Welcome to a chapter of the e-book Disaster Investigation.
'Marine casualty investigator means a person or persons qualified and appointed to investigate a casualty, or incident, under procedures laid down in national legislation for the furtherance of marine safety and protection of the marine environment'
IMO res. A.849(20) 4.7
1.5 The Conspirators of the Commission appointed 10 October 1994
Regardless of the fact that an Estonian only or a joint Commission was decided on 28 September and that a 'Commission' started to work informally already on 28/29 September and that the Commission had already announced a possible cause of accident on 4 October, the names of the members of the Commission were not announced until 10 October 1994 at 17.00 hrs (GMT+2) by the Estonian government, as per table 1.5 (3) below.
Many and varied contributory factors can play a significant part in the events preceding a marine casualty or incident. The question of who should be charged with the responsibility for investigating and analyzing human factors therefore becomes important. The skilled marine casualty and incident investigator generally is the person best suited to conduct all but the most specialized aspects of human factor investigation.
An investigator should have appropriate experience and formal training in marine casualty investigation. The formal training should include specific training in the identification of human factors in marine casualties and incidents.
In some cases, a human factors specialist may be of significant value in the investigation.
None of the appointed investigators of the Estonia accident had appropriate experience and formal training in marine casualty investigation.
Table 1.5 - Original members of the Commission 1994
Those members marked with * were members of the
Marine Accident Investigators International Forum,
MAAIF, who must follow the UN resolutions
about marine accident investigations. During the investigation the Commission did not
follow the codes of the UN at all! The Swedish
members also did not follow Swedish law (1990:712)
about accident investigations.
Those members marked with * were members of the Marine Accident Investigators International Forum, MAAIF, who must follow the UN resolutions about marine accident investigations.
During the investigation the Commission did not follow the codes of the UN at all! The Swedish members also did not follow Swedish law (1990:712) about accident investigations.
Experts and Observers
Other experts and observer were also appointed to assist the Commission.
The NMAs of Norway, Estonia, Sweden and Finland got observers, but Germany, where the ferry was built, was excluded from the Commission.
The Danish observer Niels Mortensen was replaced in November 1994 by Knud Skaareberg Eriksson; footnote 1.14.
Norwegian observer was Tom Getz.28 He too never attended any meeting. Finnish observer was Tom Sommardahl. Estonian observer (or expert) was Kalle Pedak, head of the Estonian NMA.
But none of the Danish, Norwegian and Finnish observers ever participated at any meeting of the Commission 1994-1995. Why appoint an observer that does not observe?
Swedish observer was Sten Anderson*, member of the MAAIF, Swedish NMA.
A new Finnish NMA observer was appointed and started attending the investigation one year later.
Sweden appointed mid-November 1994, tekn. dr. Mikael Huss from the Royal Institute of Technology (Kungliga Tekniska Högskolan), Stockholm, as stability expert, psychologist Bengt Schager, Halmstad, as expert to review testimonies, and Captain Olle Noord (nautical expert).
Finland appointed Captain Simo Aarnio 1.3 of the Finnish NMA as expert from the start. Other Finnish and Estonian persons were appointed as experts.
It must be recalled that, when the Commission was announced on 10 October 1994, the (only!) cause of accident had already been established six days earlier. Not one member or expert of the Commission has ever publicly disagreed with it. In retrospect it is quite surprising how in total fifteen members29 and more than ten experts and observers during three years never discussed or investigated any other cause, e.g. leakage.
In the Final Report (5) page 14 the Commission says that
"the members ... did not receive any directives from their governments ... but only represented themselves".
It means that the Commission was 'private' and not as per any UN resolution or national legislation. But even if the Estonians only represented themselves, there was a serious conflict of interest 1.7, and even if the members said that they only represented themselves, several members were later dismissed and new ones appointed by the Estonian and Swedish governments 1.20.
The Commission decided - or somebody instructed the Commission to decide - immediately that the whole investigation was going to be secret and that all evidences were not going to be available for the public during the 'investigation'. The public media did not protest - it was content to publish what the Commission announced at regular intervals without critical review 1.44.
The main weakness of the 'investigation' commission was that witnesses could not be questioned under oath.
The crew could say whatever they liked - or what they were told to say - and nobody could protest.
In fact, the Commission hearings of the crew members were just 'discussions' - no protocols were made and tape recordings were of bad quality. Later the Commission could conveniently refer to various statements of the crew that suited the alleged cause of events. No serious party was ever permitted to question the crew.
The observers were only from the three national maritime administrations of Estonia, Finland and Sweden. These administrations had committed serious errors in the past about the ship, which evidently was unseaworthy, and they were naturally interested that this fact was not made public. This will be described in later chapters.
What can you say about the other members of the Commission and the 'experts'? They were supposed to bring their particular knowledge to the investigation, but it seems that they all were manipulated only to produce material supporting the alleged cause of events, which will also be described later.
In 1997 an OECD conference considered the following seven general ethical principles for accident investigators:
· Selflessness Accident investigators should act solely in terms of the public interest. They should not do so in order to gain financial or other material benefits for themselves, their family, or their friends.
· Integrity Accident investigators should not place themselves under any financial or other obligation to outside individuals or organizations that might seek to influence them in the performance of their official duties.
· Objectivity In carrying out public business, including making public appointments, awarding contracts, or recommending individuals for rewards and benefits, accident investigators should make choices on merit.
· Accountability Accident investigators are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office.
· Openness Accident investigators should be as open as possible about all the decisions and actions that they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands.
· Honesty Accident investigators have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest.
· Leadership Accident investigators should promote and support these principles by leadership and example.
Ethical behaviour and principles are a prerequisite for any investigation conducted "without fear or favour" in the interests of maritime safety. This is in the interests of the public in general, seafarers, ship owners and the maritime industry in general.
None of the appointed investigators and experts followed the above seven principles.
Let's face it! All the investigators were totally corrupt and served particular - not public - interests. No central archive of information was therefore made - all info was scattered around at various places in three different countries so that the participants could negotiate the result. The 'experts' evidently had no possibility to check any information concerning their particular field held by another party.
Even if the UN/IMO resolutions are not perfect, they would have been a good base for the investigation procedures.
By immediately ignoring the UN/IMO resolutions the Commission fixed the stage for later drama - a 100% manipulated investigation report (5).
It was not the first or the last time it happened - but the 'Estonia' investigation must be considered the most shameful scam in maritime history.
28 The Danish and Norwegian observers are not mentioned in the Final Report (5). According to the protocols they never attended any meeting, even if they were formally appointed as shown.