Welcome to a chapter of the e-book Disaster Investigation.
'No one left the ship in an orderly fashion. Some were forced to jump (into the water), but most were swept into the sea by waves or slid into the sea inside or outside life rafts'
The Final report (5) chapter 16.8
1.34 "Please jump into the Water in case of an Accident" - the idiotic Safety Instructions censored
The 'Estonia' should have had an approved evacuation plan for 2 188 persons aboard, which showed how about 1.000 passengers in cabins on four decks and 1 000 passengers in other spaces on several decks and 188 crew members should be mustered on deck 7 by the crew and then escorted to lifeboats and life rafts for a dry abandonment of the ship. That was an absolute requirement of the SOLAS 1974 chapter III, rule 4. The 'Estonia' had no such plan since 1993 in spite of statements to the opposite Appendix 7. At the last inspection on 27 September 1994 both the safety and the muster plans were missing on board (31). It is also certain that when the 'Estonia' sailed under Finnish flag the same deficiency existed. To evacuate 2 000 passengers is a formidable task - if there were only 10 lifeboats for about 692 persons.
Rule 4 (a) states that all life saving equipment shall be immediately available at an accident.
Rule 4(b) states that the equipment shall be safely and quickly launched and that it shall be possible to embark into lifeboats and life rafts quickly and in good order.
It means that all 2 000 passengers shall be able to step into the lifeboats and life rafts at the 7 deck - the embarkation deck - where the passengers are mustered. The lifeboats and the life rafts shall then be lowered into the water - it takes only a minute.
Evacuation Tests and Trials
The Final Report (5) page 52 says that
'The safety organisation was tested during the port state control in February 1993 (see 3.2.10)'
and 3.2.10 of (5) says
'Technical Port State inspections were carried out in February ... 1993. The first inspection was in connection with the start of traffic on the Tallinn route and did not give rise to any remarks'.
The Swedish NMA at Stockholm (i.a. inspector Tom Evers) inspected the 'Estonia' 1993/4 at least five times without finding any defects. At the inspection at Tallinn 27 September 1994 the safety and muster plans were suddenly missing (31). Evidently the safety and evacuation system was exactly the same between 1980-1993 when the 'Estonia' was named the 'Viking Sally' with Finnish flag. The defective system had been approved by the Finnish NMA 1980 and Swedish Port State Control 1980-1993.
The first Swedish NMA inspection and test of evacuation of the 'Estonia' took place at Tallinn 26 January 1993 and not in February as stated.78 As there were only 692 seats in the lifeboats and 300 seats in the rafts under davits, 1 196 persons had to jump overboard and swim ashore, when the ship was abandoned. Why the Swedes made this test on a ship that already had been sailing to Sweden for 13 years is not known - to test the Estonian crew?
The Final report only states that all passengers should be collected by eleven evacuation groups on board - what happened then is not stated. The writer met Johan Franson and Sten Anderson of the Swedish NMA at a shipping conference September1998 - The Stockholm Port day! Informally the writer asked how the NMA thought that the passengers on the 'Estonia' should have had to abandon ship with the Solas B80 or 60 throw-over-board rafts. Franson, the Swedish NMA safety director, replied
"Simple, you throw the life rafts overboard and the passengers climb down the rope ladders at the sides and then they jump into the water and swim to the rafts".
Franson has in a letter to the Swedish daily Svenska Dagbladet also stated that the lifesaving equipment on the 'Estonia' was correct (and that the information of the writer was incorrect).
The crew and the experts of the Swedish NMA, which tested and approved the system, must have been totally incompetent having approved such a system. Of course the system was wrong since 1980!
It is probable that the Final report (5) does not mention the above defect to protect the crew and the Swedish, Estonian and Finnish NMAs. In stead the Commission blamed the accident on a visor 'design fault' made 1980 and stated that there were no other, obvious defects on the ship.
The evacuation was made more difficult by the fact that the 'Estonia' was listing and rolling. Plenty of persons were trapped, when stairs and floors tilted and prevented evacuation. The Final report states on the last page 228 that simple modifications of the design could have eliminated these deficiencies.79 But no simple modifications are described.
The survivors have stated that no information about safety equipment, evacuation paths, alarms and similar were given to the passengers just prior to or after departure. It was the same procedure as on coastal trading to Åland, which was given on the 'Estonia', i.e. nothing at all. The crew evidently could not suggest to the passengers to jump overboard, when the ship was abandoned, so they said nothing. The Final report has no comments.
The big Investigation Scandal
The Final report (5) chapter 16.8 has only the following to say about how to abandon a ship:
'No one left the ship in an orderly fashion. Some were forced to jump (into the water), but most were swept into the sea by waves or slid into the sea inside or outside life rafts'.
No analysis follows the conclusion. And no criticism has been voiced. It is quite mad. Johan Franson, Swedish NMA director for safety at sea, has of course told the media that the evacuation plan was 100% correct. And in the Swedish daily FinansTidningen March 1999 he says:
The international accident report about the Estonia makes a well considered and professional impression. I have not at my contacts with foreign maritime administrations heard any criticism of the report. ... Representatives of Swedish safety at sea, among them myself, chose to do other things that we consider more useful for the safety at sea, than to discuss with Anders Björkman.
Swedish and foreign maritime administrations have disqualified themselves - they do not care about the most basic requirement - that you shall be able to safely abandon a ship at sea.
The evacuation plan was defective and contributed to the high number of victims. The Commission was fully aware of these facts but decided to ignore them - in the Final report (5) the evacuation plan was considered to be perfect.
78 It is quite sad, according
to the writer, to note that the 'Estonia' did not have a
safety organisation to evacuate all persons aboard and that
the Swedish NMA had never pointed out this defect. That the
Commission without evidence concludes the opposite is a
7. The approval by the
Swedish NMA of the evacuation system aboard the 'Estonia' is
shown in chapter 6.5.2 annex no 127 in the German Final
report. The ship owner and the Swedish NMA made a 'test' on
26 January 1993 at Tallinn. They said that 850 passengers
were aboard + an unknowns number of crew.
79 If you ask the Commission what they mean, you get no answer.