By Anders Björkman, M.Sc, Naval architect, Managing director, Heiwa Co
Paper read at the Lloyd's List Maritime Security and Safety Conference, London, 12-13 February 2003
A common approach to marine casualty investigations - the IMO resolutions
Reliability, validity, disclosure and significance of accident investigations to improve safety
Case studies - Exxon Valdez 1989, Estonia 1994, Erika 1999 (Prestige 2002)
Lessons to be learned - the IMO to take the lead
You expect that the marine industry really wants to learn from accidents to achieve better safety.
Accidents occur every day at sea. Do we learn anything from the investigations? Are the corrective measures right? Three very big accidents come to mind - the Exxon Valdez grounding in 1989 (35 000 tonnes of crude oil spilled), the Estonia sinking in 1994 (at least 852 dead) and the Erika sinking in 1999 (>10 000 tonnes of heavy fuel spilled). What do these three accidents have in common? One answer is that the casualty investigations were not done as agreed by the IMO. The IMO has adopted resolutions about how accident investigations shall be done since more than 40 years. The early resolutions were recommendations; the latest is a Code for the Investigation of Marine Casualties and Incidents. If the spirit of the resolutions is followed, there should be no problem. The resolutions are sometimes not followed. Independent innovators of better safety at sea like Heiwa Co have difficulties.
1.1 Heiwa Co - European Agency for Safety at Sea
Heiwa Co assists ship owners, charterers, underwriters and administrations with ship safety, projects and ship management audits. Safety is the probability of no accident: a technical, economic, human and, lately, a political matter. High safety of ships starts with good structural design, intelligent arrangements of water tightness, leak protection and escape, easy to use procedures, equipment fit for purpose and means to maintain and operate the ship and to evacuate crew and passengers to minimize effects of human errors. Safety at sea is then a human question - to keep up the good arrangements and to follow the procedures.
The cost of high technical safety is small - it is just to get the arrangements right from the beginning, e.g. the Coulombi Egg tanker. Right arrangements and equipment then simplifies for the ship's crew to maintain high safety. Heiwa Co has a lot of experience in these important fields of ship design, particularly oil tankers and roro-passenger ferries, and operation including crew training and motivation.
Heiwa Co has been involved with roro-passenger ferry design, safety, conversions and upgrading since 1988. Heiwa Co has converted and upgraded numerous ferries to higher standards (introduced after the Herald of Free Enterprise accident 1987) and has inspected a large number of ferries for purchase.
Heiwa Co isn't and doesn't want to be a Recognized Security Organization, i.e. an organization with expertise in security and anti-terrorism matters recognized by any Administration or Designated Authority as such, and therefore has little comments on the new SOLAS XI-2 Ship and Port Facility Security rules. Heiwa Co works with safety at sea and tries to educate politicians about it.
Safety is not just rules! Safety is also new facts about past accidents that surface long afterwards, which many administrations tend to neglect. Heiwa Co investigates new facts about past accidents to innovate better safety; thus the Titanic accident 1912 is still of interest and this is the reason for the Heiwa Co looking into the Estonia accident 1994 and the Erika accident 1999 and past tanker accidents.
1.2 Collision Scenarios - Collision Bulkhead - 250 Tanker Collisions
At the time of the 1966 Load Line Convention, the most likely area where oil tankers and any other ships were expected to suffer damage due to collision was forward. The IMO had long recommended a collision bulkhead as protection. Since 1967 however the introduction of traffic separation schemes changed the way in which tankers encounter other ships. In congested waters the chances of meeting another ship head on are virtually eliminated. Instead, close-quarters situations develop more associated with same direction travel. This phenomenon has been verified by a review of encounters in various routing systems, e.g. the English Channel, the Danish Belts and the Malacca Straights. The net effect of this is a greater risk of damage to the tanker cargo tank body section because of interaction, when ships manoeuvre too close during overtaking, or by errors in turning calculations, when intending to pass astern.
It can be shown that a slow moving oil tanker is potentially more likely to be victim of collision during overtaking than a faster ship, such as container ship, which is more likely, because of its speed, to be overtaking. Fine lines of faster ships make them a projectile with greater penetrating power than the bluff-bowed bulk carrier or tanker. Oil tankers in particular are therefore highly susceptible to side penetration in the cargo part of the hull, if a close-quarter situation develops into a collision. It can also be shown that a large oil tanker in a collision will result in more catastrophic consequences. Being proportionately less manoeuvrable, it is at the mercy of the 'giving for' by a watch officer of this 'giving way' vessel. Being the larger target reduces the possibility of a near miss and increases the possibility of a hit. The consequences of being struck will almost certainly be the penetration of the upper part of the single or double hull followed by oil spill and fire. A typical example is the Baltic Carrier run down by the bulk carrier Tern between Germany and Denmark 29 March 2001.
There are many areas associated with collision risk in traffic separation schemes:
- where there is a high density of crossing traffic
- where a scheme encounters a corner. The larger tanker will inevitably have a deeper draught and be slower. Faster ships will therefore constantly overtake her. When she encounters a corner she is fully entitled to turn. She is then dependent on the overtaking ship being alert to the change and making the necessary alteration to her own course
- where a scheme converges on a special route. The tendency of larger, deep-draught tankers is to cut across the headings of other ships navigating too close to the separation zone; they have little other choice. This increases the risk of these large targets falling victim to the faster projectiles overtaking them.
In 1988-1989 Heiwa Co studied about 250 accidents, where a ship had struck a tanker in collision, which confirmed the above. Most collision structural damages occurred in the tanker side. Even more surprising - about 50% of the major, high energy, damages were only located in the small freeboard area above the waterline of the stricken tanker which makes up only 20-25% of the side. In about half the collisions oil was spilt. The IMO or any national accident investigation board had not noticed this and neither had recommended better topside protection. The area of highest risk of an oil tanker is the freeboard above the waterline! All other ships - non-tankers - do not suffer greatly from damage above waterline. It was the beginning of the Coulombi Egg oil tanker - the tanker that does not spill oil in collisions, groundings or due to structural failures and with small risk of fires and explosions and structural failures.
1.3 The Coulombi Egg Oil Tanker
The Coulombi Egg tanker design is the only alternative to Double Hull tankers approved by the IMO in accordance with Marpol I/13F(5) and the EU. The Coulombi Egg tanker spills much less oil in collision and grounding accidents than the IMO/USCG/OPA 90 Double Hull tanker proposal. Oil spills due to structural failures were not considered by the USCG/IMO when mandating double hull 1990/1992. Single hull tankers are apt to fracture due to corrosion, fatigue or workman defects and thus spill oil (e.g. the Erika, Kristin, Castor, Prestige, etc.). Standard double hull tankers with a 2-3 meters wide double hull and minimal corrosion protection are even more apt to fractures and corrosion as the double hull is thinner steel and higher stressed structure. The Coulombi Egg tanker is on the other hand much more robust than both single and double hull.
The Coulombi Egg oil tanker would hardly have been approved by the IMO unless the Exxon Valdez had run aground in 1989. In 1989 the IMO considered that a hydrostatically loaded single cargo tank bottom and lower single sides and topside ballast tanks on a tanker provided no protection against oil spills. According to Marpol 1973 and its Protocol 1978 the Coulombi Egg had zero protection against oil spill. The IMO had simply not drawn the correct conclusions of the casualty investigations available at the time.
In 1997 the IMO however considered the same arrangement better protection than double hull as Marpol had been amended! The IMO had learnt about the result of 250 oil tanker collisions.
2. A common Approach to Marine Casualty Investigations
The IMO has agreed how its members shall investigate accidents at sea.
2.1 The IMO resolutions A.637 (16) and A.849 (20)
IMO resolution A.637 (16) (and IMO resolution A.440 (XI) long before that) was about the free exchange of information and public hearings, etc., and about Cooperation of the Investigation of Marine Casualties. Resolution A.637 (16) had recommendations according to the United Nations Conventions on the Law of the Sea, 1982 (art. 94(7), art. 217(5) and art. 223)). An investigation of a marine casualty should, e.g. be public. Resolution A.637 (16) was replaced in November 1997 by A.849 (20) - the Code for the Investigation of Marine Casualties and Incidents and it should be the basis of all investigations. In the latter Code the (IMO) Assembly notes that:
...the safety of seafarers and passengers...can be enchanted by timely and accurate reports identifying the circumstances and causes of marine casualties...
and it is further RECOGNIZED that the
... need for a code (is) to provide ... incident investigation with the sole purpose of correctly identifying the causes and underlying causes of casualties ...
Therefore the Code states in 1. Introduction:
1.3 By introducing a common approach to marine casualty investigations and the reporting on such casualties, the international maritime community may be better informed about the factors which lead up to and cause, or contribute to, marine casualties. This may be facilitated by:
1.3.2 Defining a framework for consultation and cooperation between substantially interested States.
Further the Code states in 2. Objective:
The objective of any marine casualty investigation is to prevent similar casualties in the future. Investigations identify the circumstances of the casualty under investigation and establish the causes and contributing factors, by gathering and analysing information and drawing conclusions. Ideally, it is not the purpose of such investigations to determine liability, or apportion blame. However, the investigating authority should not refrain from fully reporting the causes because fault or liability may be inferred from the findings.
Further the Code states in 5. Conduct of marine casualty investigations:
5.1 Where an investigation is to be conducted, the following should be taken into consideration:
5.1.1 Thorough and unbiased marine casualty investigations are the most effective way of establishing the circumstances and causes of a casualty.
5.1.2 Only through cooperation between States with a substantial interest can a full analysis be made of a marine casualty.
5.1.3 Marine casualty investigations should be given the same priority as criminal or other investigations held to determine responsibility or blame.
Further the Code states in 7. Responsibilities of the lead investigating State:
The lead investigating State should be responsible for:
7.1 developing a common strategy for investigating the casualty in liaison with substantially interested States;
7.2 providing the investigator in charge and coordinating the investigation;
7.3 establishing the investigation parameters based on the laws of the investigating State and ensuring that the investigation respects those laws;
7.4 being the custodian of records of interviews and other evidence gathered by the investigation;
7.5 preparing the report of the investigation, and obtaining and reflecting the views of the substantially interested States;
7.6 coordinating, when applicable, with other agencies conducting other investigations;
7.7 providing reasonable logistical support; and for
7.8 liaisons with agencies, organizations and individuals not part of the investigating team.
Further The Code states in 11. Personnel and material resources:
Governments should take all necessary steps to ensure that they have available sufficient means and suitably qualified personnel and material resources to enable them to undertake casualty investigations.
Finally the Code states in 13. Reopening of investigations:
When new evidence relating to any casualty is presented, it should be fully assessed and referred to other substantially interested States for appropriate input. In the case of new evidence, which may materially alter the determination of the circumstances under which the marine casualty occurred, and may materially alter the findings in relation to its cause or any consequential recommendations, States should reconsider their findings.
The above principles, especially paragraphs 7.8 and 13, are very good but unfortunately they are not applied fully, when a big accident occurs at sea.
It is not emphasized that the results shall be available to innovators trying to improve safety at sea. It would be very easy to provide a database on the Internet with maritime accident data - causes of and means to avoid accidents and improve safety in order to liase with agencies, organizations and individuals. It is also obvious that new evidence altering the findings in relation to its cause must be fully assessed in a separate, new investigation.
2.2 European Union Implementation of the IMO Resolutions
The IMO-resolution A.849 (20) has been adopted into EU-law by directive 1999/35/EC of 29 April 1999. According to article 21 the directive entered into force when it was published in the official EU newspaper, which took place 1 June 1999. The reference to the IMO-resolution is in article 2(p) and then accident investigations are detailed in article 12. The responsibility of an EU member state is, e.g. described in article 12 point 4, i.e. a member state:
"conducting, participating in or operating with such investigations shall ensure that the investigation is concluding in the most efficient way and within the shortest possible time taken into account the Code for the investigation of Maritime Casualties",
where the Code is IMO-resolution A.849 (20). According to article 9 the EU-directive should be implemented in national law by 1 December 2000 and if not done, it was regardless in force from that date.
The newly, 2002, formed European Commission Maritime Safety Agency assisting the Commission in the effective implementation of Community legislation on maritime safety need not develop, in cooperation with the Commission and the Member States, a common methodology for investigating maritime accidents and to analyse existing accident investigation reports - it already exists - IMO resolution A.849(20).
2.3 What to expect from a Casualty Investigator - IMO res. A.884 (21)
The skilled marine casualty and incident investigator is the person best suited to conduct all but the most specialized aspects of an accident investigation.
An investigator should have appropriate experience and formal training in marine casualty investigation. The formal training should include specific training in the identification also of human factors in marine casualties and incidents. Resolution A.849 (20) has been further improved by resolution A.884 (21) to assist the investigator in this respect.
In 1997 an OECD conference considered the following seven general and rather obvious 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 them 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.
The above ethical behaviour and principles are a prerequisite for any investigation conducted "without fear or favour" in the interests of maritime safety.
3. Reliability, Validity, Disclosure and Significance of Accident Investigations to improve Safety
An accident report made in accordance with IMO resolution A.849 (20) by trained accident investigators of high ethical principles has still no value unless it is reliable and valid and discloses all significant facts about the accident and how any conclusions were reached. ( 13)
Reliability may be defined as follows -
"an independent analyst ought to reach the same conclusions as the investigators in their Final report" and
"the reliability and completeness of the official data should not be affected by the investigator's understanding of the purpose and scope of the database".
Validity may be defined as follows -
"the found causes must be true causes and be predictive".
Disclosure may be defined as follows -
"ability to distinguish between events and underlying causes" and
"ability to reflect the sequence of effects and their interactions" and
"ability to identify a causal relation between different levels of explanation" and
"ability to distinguish between human error, technical failure, and environment" and
"ability to relate failures to the basic system modules: Technical, human, etc", and
"ability to identify tasks or operations not performed" and
"ability to identify tasks or operations performed below standard".
Significance may be defined as follows -
"ability to identify preventive measures" and
"ability to identify consequence-reduction measures" and
"ability to formulate recommendations for prevention" and, finally,
"ability to formulate recommendations for consequence reducing measures".
A quick look at the accident investigations of the Exxon Valdez accident 1989, the Estonia accident 1994 and the Erika accident 1999 shows that they simply lack reliability, disclosure, validity and significance in many respects.
4. Case studies - the Exxon Valdez 1989, the Estonia 1994, the Erika 1999
Investigations should identify the circumstances of the casualty under investigation and should establish the causes and contributing factors, by gathering and analysing information and drawing conclusions. Let's look at three examples.
4.1 The Exxon Valdez 1989
The proximate cause of the Exxon Valdez grounding 1989, as far as the writer is informed, was the human factor in combination with bad or non-existent bridge procedures. While the tanker was loaded the Master and the Chief Engineer were apparently ashore (sic) and they rejoined the tanker shortly before departure. A pilot boarded the tanker at departure and assisted it out into the fairway and then left. The tanker soon after changed course in the fairway to avoid ice and never changed back to the correct course. The navigation officer apparently forgot to order the correct course change and the helmsman didn't notice anything. A third person on the bridge may have disturbed the navigation officer in her duties. The Master was allegedly in his cabin. So the tanker continued for 30-60 minutes on wrong course until it ran aground 6-8 miles off course. Who was at fault? The ship owner blamed the Master and fired him. The authorities later arrested the Master and never challenged the ship owners for faulty bridge procedures. The accident investigators apparently blamed the single hull design (sic) to have contributed to the accident but had the single hull tanker been hydrostatically loaded the oil spill would evidently have been quite small. It seems that the confusion and uproar due to the oil spill prevented a proper technical accident investigation. By firing and dismissing the Master, who was later arrested, the possibility to find out the true cause was evidently minimized, e.g. faulty bridge procedures and slack shore management.
4.1.2 U.S. Oil Pollution Act 1990
The result of the grounding is the famous US Oil Pollution Act 1990, OPA90, about, e.g. financial guarantees to cover clean up costs/damages and double hull for new tankers entering US ports.
It seems that the OPA90 financial penalties and sanctions, which are punitive in nature and not insurable, has encouraged the creation of more one-tanker companies (compare the Erika and the Prestige, etc) and limited asset based oil-trading companies. This makes investigations of tanker accidents/spills more difficult as the real tanker owner and responsible party cannot be identified.
OPA90 has also led to the introduction of arbitrary and theoretical calculations of environmental damage due to oil spills that are often based on highly theoretical models and questionable science. They have less to do with compensation and more to do with fines or penalties. Experience in the US and OPA90 is that there are armies of lawyers and 'experts' employed arguing the issues. This only means that those who have suffered genuine loss, as a result of an incident, suffer delays and reduction in the level of compensation received, as they compete with claims for highly theoretical damages to the environment from opportunists.
It seems there is consensus that a double hull would not have prevented the Exxon Valdez oil spill and naturally not the grounding itself, but regardless the IMO followed the US lead and amended the Marpol 1992 to the effect that new tankers should have double hull or be of an alternative design providing equivalent protection in collision and grounding. The US as only IMO member didn't approve the IMO Marpol I/13F amendment, i.e. the U.S is not a party to Marpol any longer. However, the 1992 Marpol I/13F regulation suddenly allowed the Coulombi Egg tanker arrangement to be considered for approval.
Why is double hull not the best collision protection for oil tankers? Formal Safety Assessment gives the answer. By studying tanker collisions, as already described above, you find that 80% of all minor damages and 50% of all major damages are only located above the waterline. As the area above the waterline is less than 20-25% of the total side of the tanker you realize that the probability (density) of damage above waterline (only) is much higher than below the waterline. A uniform collision protection - double hull - from weather deck to the bilge is sub-optimal. In high-energy collisions double hull tankers will still spill plenty of oil. The optimal protection is instead to arrange the protection above and a little below the waterline. You do not need any collision protection at the bilge; it can be single hull. The Coulombi Egg oil tanker was developed 1989-1994 based on the above FSA and it improves tanker collision protection four times compared with double hull. It was one major reason why the IMO, in 1997, and the EU later approved it as the only alternative to double hull as per Marpol I/13F(5).
4.1.3 The Coast Guard Authorization Act of 1998
The US have not accepted this logic. The OPA90 actually mandates regular review of oil tanker safety arrangements, etc., but it has never taken place. In 2001 the U.S National Research Council's (NRC) Transportation Research Board (TRB) developed a rationally based approach and method for assessing the environmental performance of alternative tanker designs relative to the double-hull standard  but no alternative design has been assessed by, e.g. the USCG.
The Coast Guard Authorization Act of 1998 mandated the Secretary of Transportation to commission the Marine Board of the National Research Council's (NRC) Transportation Research Board (TRB) to develop a rationally based approach and method for assessing the environmental performance of alternative tanker designs relative to the double-hull standard. The result is TRB Special Report 259 'Environmental Performance of Tanker Designs in Collision and Grounding: Method for Comparison'  issued by the TRB. The Coulombi Egg tanker had previously been discussed at the US Congress but was not mentioned in the report.
Under the auspices of the Marine Board, the NRC convened an 11-member Committee on Evaluating Double-Hull Tanker Design Alternatives with appropriate scientific and technical expertise in risk assessment, tanker design, tanker operations, crashworthiness of ships, and costs and damages (including environmental damages) related to oil spills. The committee as a whole met five times between June 1999 and January 2001 but it did not contact Heiwa Co to find out the latest developments about the only alternative design approved by the IMO as per Marpol I/13F(5) - the Coulombi Egg tanker - from its designer and developer.
It is stated in the report that a number of organizations have submitted proposed alternatives to double-hull designs to either the USCG (for the United States) or IMO (representing the international community) both of which have developed regulations addressing minimum tanker design standards. As far as the writer is informed only one alternative tanker design has been submitted (1992/1995) to the IMO for approval - the Coulombi Egg tanker - and approval was granted 1997. The committee states that several other concepts have been developed in the United States but none has been submitted to the IMO for formal assessment and possible approval.
The NRC committee however developed a rationally based approach for assessing the performance of alternative tanker designs on the basis of their relative ability to prevent environmental damage from oil spills following collision and grounding accidents. This methodology can be used as a tool by regulatory authorities in determining whether to approve an alternative to the double-hull tanker design. This is extremely good. Unfortunately the committee didn't assess the only IMO approved alternative. It would have been even better if the method also considered oil spills due to structural failures but that is for the future.
4.2 The Erika 1999
The Erika accident outside Brittany the 11 and 12 December 1999 has provoked questions. The single hull tanker Erika broke apart on 12 December and spilled > 10 000 tons of heavy fuel oil. Why? Like the Exxon Valdez master the Erika master was arrested after the accident. Did the master cause the accident? What was the cause of accident?
4.2.1 Maltese Causes of Accident
According to Malta Maritime Authority (MMA) October 2000 there were many concurrent causes: "The loss was the result of several factors acting concurrently or occurring simultaneously ... The most likely (sic) reasons for the loss were corrosion, cracking and local failure, vulnerabilities in the design (sic) of the ship, and the prevailing sea conditions. ... In 1998 the tanker underwent repairs at the Bijela shipyard in Montenegro. ... The quality of the Bijela repairs could have contributed to the initial local failure, leading to the final collapse ... The ship's managers were in attendance when these repairs were carried out, yet they failed to identify and/or address areas of significant local corrosion, nor did they monitor the repairs correctly."
The official flag state investigation has thus explained - in very vague terms without evidence - why the Erika broke apart, but the real cause could have been a fracture in the recently repaired single hull side shell structure caused by fatigue and cyclic, heavy wave loads on the side. Oil then started to leak and the tanker asked for assistance. However, the leaking and damaged tanker was apparently denied a port of refuge and had to stay at sea in the heavy weather for another day. The fracture therefore developed upwards to the main deck, which in turn fractured across the full beam, due to the continued bad weather. Then, on the 12 December, the fracture developed downwards through the two longitudinal bulkheads and the side shell on the opposite side of the original damage and the section modulus of the cargo tank body became zero - the only structure connecting the two parts was the bottom plate, which was ripped apart. Thus, we know how the Erika broke apart.
Unfortunately we have not been told why the tanker was denied a port of refuge to stop the small fracture to develop into a disaster.
The Malta Maritime Authority puts serious blame on the ship's managers too - they failed in their duties. To do proper repairs of an allegedly corroded tanker is not easy. Evidently severely corroded parts are renewed and the repairs stop, where the original steel is intact. The extent of the repairs is agreed between owners, ship's manager, shipyard and class. During removal of corroded parts you may discover new damaged areas and the extent of repairs is extended. Evidently you should not or cannot weld new steel to original, severely corroded steel.
It is the ship manager's or owner's supervisor who has ultimate responsibility but the yard and the class must share total responsibility. If the managers supervisor is an ex chief engineer with limited welding experience of steel hull, he (or she) must rely on the shipyard and class that the steel work is done properly. The quality of repair is most likely to suffer due to less favorable working conditions than those under which the original weld was made. Consequently, a potential danger exists of introducing new defects. These may be more harmful and less readily detectable. One lesson to learn is that all repairs affecting tanker's hull plating must be recorded properly.
4.2.2 Italian Protests
In December 2000 the Italian classification society RINA responded to the allegations about corrosion. RINA stated that the last special survey in 1998 did not give evidence of accelerated corrosion in the ballast tanks. Hull thickness measurements were taken. During the 18 months that then passed until the accident RINA did not receive any information about problems and the vessel passed several oil company vetting surveys and two port state controls - no problems! RINA suggests six other causes, which could have contributed to the accident to be inspected further. Nevertheless, Italy did not insist on Malta following IMO resolution A.849 (20), § 13 (see 2.1 above).
4.2.3 French Removal of Oil
All oil from the Erika was removed during the summer of 2000. It would have been extremely helpful to find the exact cause of the accident and that the fractured parts would have been filmed at this time.
Did in fact the alleged fracture start in the interface between new/repaired and old steel and where - in a ballast or cargo tank - and how could it develop into a disaster, whereby the tanker split into two? Did corrosion play any part? By close-up filming of the ripped apart edges we might have found the answer. Unfortunately the charters, Elf-Total-Fina, who paid for the removal of the oil from the wreck, did not apparently film the fractured edges of the two parts!
4.2.4 Design at Fault - but no Pictures of the Defect
The Malta Maritime Authority puts blame on the tanker design, but it was a standard single hull tanker with two longitudinal bulkheads. That the shell plate in tankers (and other ships) fractures locally due to fatigue, corrosion or a hidden defect is fairly common, but that the whole tanker then splits into two is extremely rare. It is strange that the underwater pictures of the two parts of the wreck have not been made available for examination of the fracture surfaces.
4.2.5 French 'Experts' and new Causes
The French appeal court judge Dominique de Talancé asked 2001 two 'expert' naval architects to determine the causes and the responsibilities of the accident. They concluded (Le Figaro 5 October 2001) that the trading certificates were issued on 21 November 1998 and had not been renewed on 21 November 1999, i.e. the tanker was trading without certificates. However, that did not cause the tanker to split into two. As the Class was still valid and the trading certificates rely on Class regarding hull strength, out-of-date trading certificates cannot have caused the accident.
The 'experts' also concluded that the tanker was not popular with the oil majors 1993-1998 and that it had been detained twice - corrosion of bulkheads on 11 December 1997 and corrosion of the hull on 20 May 1998. It would appear that the Erika then went to dry-dock in Montenegro May 1998 and carried out the necessary repairs under RINA supervision and then traded another 18 months before the accident.
The 'experts' state that BP rejected the Erika in 1999. However, a rejection by oil major is not the cause of an accident, and we are not told why the tanker was rejected. And according to RINA other oil majors and two PSCs passed her and she was always trading. The 'experts' blame the charterers Elf-Total-Fina for having chartered a sub-standard tanker, but it is not clear how Elf-Total-Fina according to the 'experts' should have been able to, e.g. inspect the hull and cargo tanks structure of the tanker. When oil majors 'vet' a tanker, it checks many items, but evidently the vetting surveyor cannot inspect all the structural details of the internal hull in cargo and ballast tanks or the quality of recent repairs.
The 'experts' do not explain why and how the tanker split in two or how the charterer (Elf-Total-Fina) should have been able to recognize that risk or possibility a week earlier. The 'experts' do not mention that the responsibility of seaworthiness and cargo-worthiness of a tanker rests with the ship owner - not the charterer or the cargo owner. The historic reasons why cargo interests are not made directly liable for oil pollution damage include their inability to inspect or otherwise check the internal condition of the tanker that will carry their cargo and that they have no direct control over the care or operation of the vessel. Breaking the existing division of responsibility, which has been progressively achieved over the years, will ultimately lead to a dilution of the tanker owner's responsibility and will be a disincentive for insurers to take a pro-active interest in the condition and operation of the vessels they insure. It leads to a lowering of standards.
The 'experts' rightly blame the French (Brittany) maritime safety authority (Premar) for having misjudged the first Mayday and the request for a port of refuge. Premar did not consider the first request from the Erika on 11 December seriously and no emergency procedures were activated on 12 December. In that time a small fracture in the side apparently developed into disaster and the tanker splitting into two parts. Nevertheless, also France did not insist on Malta following IMO resolution A.849 (20), § 13 (see 2.1 above).
Malta did not cooperate with various French or Italian investigators and the objective seems to have been to attribute responsibility to the charterer instead of establishing the proximate cause of the accident. How can then anybody come up with a solution of the problem? Better surveys and inspections? Better control of structural maintenance?
4.2.6 ESP, CAS, CVI and PSC
New methods to stop tankers breaking up seem to be the Enhanced Survey Program, ESP, and the Condition Assessment Scheme, CAS, of single (and double) hull tankers. ESP and CAS are only more careful and extensive Class surveys.
Small cracks in the tanker structure or welding repairs are very difficult to spot at these surveys in spite of increased close-up visual inspections, CVI. The cracks can develop after inspection and all structure is anyway not CVIed. Furthermore it is highly probable that double hull tanker structure will be subject to even more cracks due to corrosion and fatigue than single hull in the future and that ESP and CAS will not spot them either. The conclusion is then that elderly double hull tankers will cause more structural failures and oil spills. What about more frequent Port State Controls, PSC? A PSC inspector is not a Class ship (structural) surveyor and will not be able to spot any potential structural defects in the tanker at all. The solution is evidently to mandate single hull Coulombi Egg tankers as the international basic standard as it is inherently more tolerant against structural cracks, etc. in the first place and much easier to inspect - CVI - and maintain than double hull tankers.
4.2.7 The Prestige 2002
One further, recent example of a superficial accident investigation is evidently the Prestige sinking outside Spain November 2002. The accident seems very similar to the Erika. Both tankers were single hull and had been subject to extensive repairs and survey 18 months before the accidents. Both tankers suffered a fracture in the hull. Both tankers listed when an empty ballast tank was flooded. Both tankers were refused a port of refuge and forced to remain in the heavy weather area. Both tankers broke apart and major oil spills followed. It seems that 40 meters of side shell fell off the Prestige before her breaking apart. Both Masters were arrested preventing a proper investigation, etc.
Hopefully the Prestige accident investigation will conclude that, had the Prestige been a Coulombi Egg tanker, no spill would have occurred, even if a hull fracture had developed. A hull fracture would only cause water to enter the cargo tank, while the cargo was not leaking out but pushed to an undamaged ballast tank. Thus the damaged tanker would have floated on its cargo and could have been brought to a port of refuge without worry about an oil spill. It seems that the real solution to a problem is always overlooked when oil is spilt at sea as the victims of oil pollution rage at alleged terrorists at sea causing pollution.
4.2.8 Political Solution
The Erika accident has led to new demands 2000-2002 of phasing out all single hull tankers and the use of double hull only or approved alternative design (i.e. the Coulombi Egg), even if the cause(s) of the Erika accident is (are) still not resolved as per the IMO/EU resolutions today and even if new medicines like CAS, ESP and PSC have been ordained.
There are about 683 single hull tankers >60 000 dwt and the EU proposal is that about 30 of these tankers a year are stopped from entering EU ports until 2015, when the last 214 (sic) single hull tankers are stopped in one go.
There is no valid disclosure in the EU proposal signifying that future oil spills due to fractures in tanker side structure will be eliminated by refusing older tankers entry to Europe. The side structure of a double hull tanker is generally higher stressed than single hull due to the void inside side space - no cargo pushing from inside against the side. The whole side is a ballast space and many double hull tankers have very poor corrosion protection there! A lot of old, >15 years, double hull tankers will replace the single hull tankers between 2007-2015. The solution should be to apply the Polluter Pays Principle and not force away existing tankers.
4.2.9 The Polluter Pays Principle
The intention of the Polluter Pays Principle, PPP, as developed by the OECD and the EU as understood by Heiwa Co, is to promote a civilized system that effectively protects the environment while preventing the occurrence of pollution. The PPP is simply the idea that it should be more economical not to pollute than to pollute. Investments in new and less polluting oil tankers, imposed by new legislation (e.g. Marpol I/13F in 1992), is evidently a correct implementation of the PPP.
The scope of the PPP is not to define a responsible person, legally obliged to pay a fine to the state or compensation to the victims of pollution (a posteriori), but, to prevent pollution at the source (a priori) by, e.g. encouraging, less polluting oil tankers like the Coulombi Egg tanker.
In this respect it is questionable to promote double hull tankers as means of better protection against oil pollution due to structural failures, as double hull was only introduced to provide better protection against oil spills due to low energy collision and grounding, while oil spill due to structural failure (or explosions, for that matter) was not considered. Oil spill due to structural failure is evidently prevented by better structure less prone to failure and improved inspection routines to spot any defects in time. In a majority of cases structural failure is due to corrosion and fatigue and/or to bad workmanship at repairs (e.g. the Erika and the Prestige) but not to design itself.
4.3 The Estonia 1994-2003 - the IMO Resolutions were not to be applied - the whole 'Investigation' was a Scam
On 28 September 1994 at 00.36-01.36 hrs (local time) the roro-passenger ferry Estonia sank in the Baltic and at least 852 persons died or disappeared. The accident evidently interested Heiwa Co . Immediately in the morning the Estonian president decided that an Estonian commission was appointed to investigate the accident. However, the same day the prime ministers of Sweden, Finland and Estonia instead decided that a joint Commission should do the investigation. Sweden put diplomatic pressure on the Estonian government that Sweden should chair the Commission. Furthermore the investigation was to be secret - the public should have no insight - and all evidence, other material and analysis were to be confidential until the end of the investigation. The IMO resolutions about marine accident investigations were not to be applied! The media was immediately fed - and published - stories how and why the ferry had sunk. In retrospect it is easy to show that all essential information was false. The Commission intentionally announced a false position of the wreck to start with! A week later, on 4 October, the Commission confirmed the early findings - the bow visor (sic) fitted to the superstructure had caused the accident - the bow visor had fallen off and the inner ramp protecting the superstructure had been forced partly (sic) open. Water leaking into the superstructure had then sunk the ship. How and why was not explained then and it was never done.
Two weeks later, on 17 October, the day before the visor itself was allegedly found at the bottom of the sea far away (1 560 meters West from the true wreck position or >3 000 meters from the false position), the Commission reconfirmed the first findings about the visor and the ramp. Water on the car deck in the superstructure then allegedly completed the disaster - sinking. The Commission never explained when or how fast or slow the water had entered into the superstructure and why water in the superstructure would cause the sinking of one 'in principle' unsinkable ship with an undamaged hull and in the end it was never clarified.
The visor was officially found on 18 October 1994, allegedly one mile West of the wreck, and, in a secret operation directed by the Swedish Navy (sic), the visor was salvaged mid-November 1994. However - there is no evidence whatsoever that the suggested position of the visor or that of a red buoy - a mile West of the wreck of which a false position had been announced earlier - was true. The visor had probably been found at the wreck early October and was thus salvaged at the wreck mid-November 1994 and this was the reason for the false wreck position!
A sloppy and completely unprofessional dive examination of the wreck took place 2-4 December 1994. It was made by an American offshore and underwater service company appointed by, and under the control of, the legal counsel of the Swedish Maritime Administration (sic). The public had no access and there are no records, logs or reports of observations during the diving.
The Commission met again on 15 December 1994 and confirmed for the third time that the bow visor had caused the accident and that divers had noted no other damages. But now the investigators had modified the accident scenario and invented new events!
4.3.1 New Explanations of the Accident
In the new explanations it was clearly stated that, based on the divers' findings, the ramp had been locked before the accident and that all ramp locks had been ripped apart by the visor. The visor had pulled the inner ramp of the superstructure fully open. Large amounts of water had entered the superstructure and caused the sudden listing at 01.15 hrs - and the sinking 35 minutes later at about 01.50 hrs. These statements are today proven mendacities. The ramp was not even locked (!), because it was twisted, so the locks did not fit. The weather tight ramp was always leaking. The ramp had not been pulled fully open by the visor. The ramp was found stuck in its frame and could not be moved as it had been secured with ropes in port.
However the Commission concluded that it was the visor locks (sic) that were incorrectly designed and manufactured 1979 by the shipyard - a design fault. At the end of December 1994 the Commission announced the correct wreck position - 2 111 meters Southwest of the previously announced, false position!
The Estonia was allegedly doing 15 knots in head seas of Beaufort 7 with 4,3 meters waves when the superstructure bow ramp two meters above the waterline was suddenly ripped fully open. The opening was 5,4 meters wide and 6 meters high. You would then have expected that the first wave entering the superstructure at 15 knots speed contained 180 tons of water. It would have smashed everything inside the superstructure and trimmed the ship on the bow. It is unlikely that the ship would have pitched up above the waves again. However, if it did, it would pitch down again six seconds later below water and scoop up another 180 tons of water. Then the ship would never pitch up but would list and capsize like the Herald of Free Enterprise 1987. The superstructure would quickly fill up with water in less than 60 seconds, the ship would turn turtle and ... float upside down on the air of the watertight and dry hull below the superstructure. It would have taken one minute.
But this true, correct and realistic scenario was never presented to the public. The Commission instead started to present outrageous, stupid lies about water in the superstructure slowly listing and sinking the ship (the hull). These lies are still official Truth and explanation why the ship sank. To confuse the public the Commission mixed up capsize/sinking and hull/superstructure and presented some 'experts' to explain that ferries sink with water in the superstructure.
The Swedish government (sic) decided the same day, on 15 December, that neither wreck nor dead bodies should be salvaged. The legal counsel of the Swedish Maritime Administration had previously explained that it was too difficult and expensive (>US$ 150 millions) to do the job and a Swedish Ethical Advisory (sic) board had agreed. In conjunction with Finland and Estonia an international agreement was later signed and national laws adopted to the effect that nobody could ever examine the wreck of the Estonia - the wreck was to be covered up by concrete. The preparatory legal work was completed on 30 March 1995.
4.3.2 The Estonia Part and Final Reports
On 3 April 1995 the Commission published its Part report  reiterating for the fourth time that the defective visor locks had caused the accident. Every essential statement in the Part report can in retrospect be proven false - but few reacted - 99.9% of the public believed the disinformation of the Commission. The Commission said that the Final report  - with all relevant information - was a formality to be published in a few months.
The Swedish law went into force on 1 July 1995 and the Swedish work to cover up the wreck started: >300 000 tons of rock and sand were deposited around the wreck. The international treaty to the same effect did not come into force until August 1995. The work to cover the wreck was cancelled in 1996.
On 21 October 1996 the Swedish government appointed the Board of Psychological Defence, SPF, to handle communications of information to the relatives of the victims. The SPF told all Swedish authorities not to discuss any questions concerning the Estonia in, e.g. the printed press, by outside experts (like Heiwa Co) e.g. how and why the ship had sunk.
For more than three years the Commission stated at infrequent media contacts that the Estonia was correctly certified with correct lifesaving equipment and completely seaworthy, etc. and that a design fault of the visor locks caused the accident, the capsizing and the sinking. This was all the public had to know.
On 3 December 1997 the Final report  of the accident was published after more than three years of secret deliberations. In the meantime two investigators had died and five others had been dismissed or resigned and replaced by 'experts'. No real investigation was ever done! There exist no records of any interviews and evidence gathered by the investigation. No essential fact can be supported by evidence! All essential facts in the Final report  are false, and that is one message of this paper. Never in modern history has such a dishonest and untruthful document been published to explain - cover-up - a big maritime tragedy. Immediately after the Final report was published the Commission dissolved itself and never replied to any queries. Nobody is today accountable for the Estonia accident investigation.
4.3.3 All essential Facts are false
If you bothered to check, e.g. the ship's certificates, it was obvious that they were not correct and that, e.g. the lifesaving equipment was not as per SOLAS. Further verification of the published data - which has taken Heiwa Co several years - then showed that every essential fact in the Final report  was falsified, often based on manipulated investigations, to hide the fact that the ship was un-seaworthy. How and why the ferry had sunk due to water inside the superstructure was evidently not explained then or earlier. Why somebody decided to cover up the Truth is still not clear.
The large majority said nothing neither in 1994 nor 1997 or 2001! Silence. There were a few critical voices - but it was considered normal - and the officials, the SPF and the media wrote them off as unintelligent, unscientific and unreasonable amateurs or conspiracy freaks. The IMO said nothing but appointed an 'expert' panel that accepted all false statements of the Commission.
The Estonia accident thus took place in September 1994 and the Final report  of the accident investigation was published in December 1997. Several attempts have been made to have the investigation re-opened to review new proven facts never examined by the official investigation as per IMO res. A.849 (20), § 13 but to no avail.
4.3.4 Factual Faults of the Investigation
Reference  is a description of a surprisingly large number: twenty-two factual faults, falsifications, lies, disinformation, cover-ups, etc. of events and conditions in the Final report  that Heiwa Co has found.
· Salvage of the victims - all dead bodies could have been recovered during the first week
· Seaworthiness - the ship was not seaworthy
· Watertight subdivision - was not fit for purpose or as per the SOLAS - see 4.3.8 below.
· Life saving equipment - was not fit for purpose or as per the SOLAS - see 4.3.7 below
· Port State Control by Sweden - manipulated several times to hide un-seaworthiness 
· Visor - it was attached to the ship, when it sank (the Atlantic lock was probably damaged earlier)
· Ramp - the bow ramp was never open during the accident (the locks were undamaged)
· Wave forces on the visor - model tests and simulations falsified to show much higher forces
· Water inflow through an open ramp - falsified published figures
· Speed and course - falsified published figures
· Intact stability - the ship should have capsized immediately with 2 000 tons of water in the superstructure. Official calculations are false - see 4.3.6 below
· Sinking - the ship could not sink due to water in the superstructure
· Plot of accident - the plot is a falsification - shows an undamaged ship turning and drifting - see 4.3.5 below
· Testimonies - survivors' testimonies were changed
· Dive investigation December 1994 - no proper records - results are manipulated
· Damage to starboard front/collision bulkhead - not reported by the Commission
· Destroyed evidence - several objects salvaged December 1994 were thrown into the sea
· Visor damage before the accident - used as cause of accident to hide the Truth
· Major hull modification work done 8 months before the accident - stabilizers were fitted
· Tank top swimming pool built into the double bottom - the space had been flooded earlier
· Cargo - all cargo has not been identified
· The visor was blown off under water after the accident using explosives.
There were many deficiencies and defects on the Estonia prior to accident - the ship must be considered sub-standard and totally unsafe - and, when the ferry then sprang a leak, they all contributed to (caused) the disaster. It is obvious that the investigators connived to hide the real facts by, e.g. removing the visor attached to the ship after the accident!
4.3.5 Estonia - Sequence of false Events
The Commission established already on 4 October 1994 the sequence of alleged events five days earlier: first loss of the visor, then a partly open ramp and water on the car deck in the superstructure, later increasing list from 01.16 hrs and finally slow sinking until 01.48 hrs. The Commission also stated that the ship capsized. On 15 December 1994 the Commission changed the sequence of events - the ramp had been pulled completely open at 01.14-01.15 hrs, followed by a sudden water inflow and listing, later by a closed (!?) ramp, so that the water inflow was reduced, and the ship sank later at 01.55 hrs. No proven facts supported any suggestions then, 1994, or today, 2002. No event of the official sequence is possible (see chapter 1.9 in ) in its context. The plot is a falsification. That the Commission could not have analysed all facts and causes already the 4 October 1994 is self-evident. Probably the Estonia sank already at 01.32-01.36 hrs after leakage of the hull that started at 00.30-00.40 hrs, which caused the sudden listing at 01.02 hrs as noted by a majority of survivors. The ship never turned or drifted.
A complete analysis was not done later because the investigators did not want to admit that the alleged sequence of events from the 4 October 1994, based on four crew members untrue testimonies - particularly the time of the listing at 01.15 hrs - was an invention, i.e. no analysis could be made 1994-1997: the Commission only wrote a report, which tried to prove the first suggested, false sequence of events with fabricated causes.
4.3.6 Estonia - Stability after Accident
The investigators never analysed how a stable condition developed after the sudden listing. The Estonia was evidently leaking below the waterline before the listing developed. The whole ferry was shaken - it was observed by many survivors before 01.00 hrs. Later there were two more impacts noticed by many survivors - water spread into several compartments, which resulted in the sudden listing - duly noted by all survivors at about 01.02 hrs - (see chapter 2.1 in ). Then water spread everywhere through open watertight doors below the car deck. The ship sank slowly but in a stable condition and the visor was dislodged but still attached, when the list was very great.
The Commission however published (Figure 4.19 in Supplement 504) completely false stability calculations assuming that the hull was undamaged and dry and that the deckhouse above the water filled superstructure was watertight (sic) and dry on the lee side preventing capsize.
Figure 4.3.6 - Figure 4.19 of Supplement no. 504 (Figure 4.19 in Supplement no. 504 of (5) thus shows a floating condition in equilibrium (sic!), when decks 4-5 (and the superstructure space - decks 2-3) are filled with water (shaded), i.e. the windows on decks 4 and 5 starboard are broken, but decks 6-8 are completely watertight - the windows on decks 6 and 7 and the side doors to deck 7 starboard below water (!) in the figure above are intact and closed watertight!)
The Commission ignored the obvious fact that with only 2 000 tons of water inside the superstructure, the Estonia would have capsized and floated upside down. Evidently a deckhouse is never watertight. On the other hand the Commission cleverly stated that the ship had in fact capsized.
4.3.7 Estonia - Incorrect Lifesaving Equipment
The Estonia was certified to carry 2 000 passengers and 188 crew but had only lifeboats for about 700 persons. The passengers were supposed to jump overboard, when the ship was evacuated or abandoned, and to swim ashore or to about 60 life rafts that somebody (sic) was supposed to drop into the water. This wet evacuation system was totally illegal and not fit for purpose. Therefore the crew could not train and practice abandonment of the ferry.
4.3.8 Estonia - Incorrect Watertight Subdivision
The Estonia had 22 doors in the watertight bulkheads of the hull below the superstructure. This was an illegal and stupid arrangement. The doors could even be opened and be kept opened (sic) from the bridge, which was another totally illegal arrangement. The watertight integrity of the Estonia hull in case of leakage could be considered non-existent. Water could spread anywhere. Even more surprising - some hull spaces on deck 0 could only be reached via watertight doors on the tank top, i.e. could not be reached from the bulkhead deck 2. To inspect a leaking hull compartment below the waterline you had to open a watertight door on deck 0 .
4.3.9 Estonia - The Hole in the Superstructure caused by Explosives
Private divers examined the Estonia wreck in August 2000 and found a big hole in the fore part of the superstructure. It is quite obvious from pictures taken of the hole and from analysis of test pieces taken from the edge of the hole, that the cause of the hole is an explosion. Heiwa Co thinks the damage was caused when the visor was removed from the wreck under water after the accident. The Estonia accident investigators claim that the area is undamaged. When the film with this hole was shown on Swedish and Estonian TV in November 2000 the sequence with the hole was cut out/censored. Invited 'experts' then discussed the film and concluded they could not see an external hole or any unreported damage of the ship!
4.3.10 Estonia - Proven Facts and Government Excuses
All proven facts above have been advised to the Swedish, Finnish and Estonian governments, the Swedish NMA and the Commission during 1995-2001 and ignored. The Swedish government dismissed the first request for a new investigation 1999. In proposition no 1:1999/2000 to the Swedish Parliament it stated that a new investigation should not be done. The responsible minister reasoned: 'There were some evident deficiencies in the investigation or persons that put up questions about it, but my judgement is that they are not serious enough to demand a new investigation', (Swedish news agency TT 990927). By this stand the Swedish government supports various conspiracy and sabotage theories and increases the secondary trauma of relatives and survivors (see, e.g. chapter 1.36 in ).
The re-opening of the Estonia accident investigation has been discussed several times in the Swedish Parliament, latest at a debate 30 May 2002, when Björn von der Esch, MP, said the following:
' ...by manipulations ... (of the casualty report) ... the conclusions have become totally opposite to the real ones. The natural reaction to such a revelation in a nation governed by law must be that the government immediately decides to investigate the circumstances around the manipulations. Instead it puts the lid on. Can this be compatible with the demands of a nation governed by law? Self-evident questions that now do not get any answer are therefore: Why has (the casualty report) been manipulated? By who has (it) been manipulated? On whose behalf has it been done? Who knows the client? Why is the government against investigating the manipulation? By leaving these questions without answer the Estonia matter has developed into a bigger legal scandal than the Bofors affaire (the illegal sale of guns to India in the 1980's) at its time. Then the government assured that the laundry should be washed. Now however that didn't happen - but they admitted that there was dirty laundry to wash. In the Estonia affaire they pretend it is not the case. Once again the citizens feel how the nation of law stops functioning when fears of suspicions of crime are pointing in a troublesome direction for the government.'
4.3.11 The IMO was fooled - Deadly, fast Rescue Boats - Idiotic anti-flooding Doors in the Superstructure
The International Maritime Organization, IMO, has accepted all the false information about the Estonia presented by Estonia, Sweden and Finland 1994-1997 and later and has modified international rules for safety at sea based on the false information. Most of the safety amendments after the accident are nonsense (see chapter 5 in ).
The Estonia accident investigators were clever. They knew the weaknesses of the IMO - bureaucracy, lack of technical expertise, the ease to manipulate the Assembly and Committees, etc. - and the IMO complied. The IMO did not dare to question the findings of the Commission supported by so many 'experts'. Another tragedy. International safety at sea work suffers.
Figure 4.3.11B - Movable 'watertight door/bulkhead' in the side of the superstructure - not fit for purpose
5. Lessons to be learned - the IMO to take the Lead - Estonia, Finland and Sweden to explain their Manipulations
Big marine accidents are often not investigated properly according to the IMO Code and EU law. The reason is apparently political as politicians see an opportunity for change - not improvements.
In this situation any means are permitted. The investigator can lie, falsify and manipulate, as he/she likes. The risk of detection is small and the media will not react.
One victim is future safety at sea. It cannot be based on incomplete, false or manipulated marine accident investigations, but as there are no safeguards against the manipulations of accident investigations, safety at sea is actually made worse. Future accidents, loss of life and oil spills will prove this sad conclusion right.
Large independent organisations involved with safety at sea like classification societies, universities, model test tanks, trade unions, etc. are not likely to criticise this situation as they are too closely associated with the various administrations and often financially dependent on them (e.g. research grants).
Strangely hull and P&I underwriters do not seem terribly worried that accident investigations are not done correctly. Why the pay false claims is an enigma.
The small, truly independent company, like e.g. Heiwa Co or individual working to improve safety at sea has no chance in this game. Serious analysis and improvements are easy to destroy with the normal means of the public servants and politicians in charge.
So there are many lessons to be learned from accident investigations concocted by unscrupulous IMO members. One obvious way forward is that serious IMO members and the EU really query the allegations and questionable information presented by less serious members (or individuals representing those members) in various accident investigation reports. The IMO members Estonia, Finland and Sweden shall not get away with presenting outrageous lies to the IMO about the Estonia accident 1994-2003.
Safety development and rule improvement can only be based on reliable and valid facts, which disclose all circumstances and provide significant information. The EU, or rather the European Commission Maritime Safety unit, should support the IMO in this work.
The IMO and the EU should thus support international demands that Estonia, Finland and Sweden re-open the Estonia accident investigation as per IMO resolution A.849 (20) - §13 to investigate the newly published facts and findings.
But the IMO should not only improve their reactive procedures. Proactive steps are even better:
+ Establish an IMO lead supervisor council of accident investigations
+ Impose penalties in the form of fines or sanctions by the supervisor council on countries that fail to abide by the IMO rules and resolutions
+ The IMO to reopen the Estonia investigation or verify old and new facts and conclusions
Heiwa Co thanks all persons who have contributed with information, observations, suggestions, ideas and analysis of various matters of this paper and the continued investigation of the Estonia cover-up and for constructive discussion, often per e-mail, with interested parties.
Heiwa Co is solely responsible for any factual errors in this paper and conclusions and suggestions. Now is the time for other experts - in other fields - to take over the continued examination of the reliability, validity, disclosures and significance of, e.g. the Estonia casualty investigation. No new public investigation will probably be permitted within the next 20-30 years by Sweden. The problem is not the Estonia - it is, e.g. the Swedish maritime administration as summarized by Mr Johan Franson, Director of Safety at Sea, one of the chief instigators of the Estonia cover-up, and president of the IMO Diplomatic Maritime Security Conference at London 9-13 December 2002 and newly appointed Administrative Board member of the European Maritime Safety Agency, in the Swedish daily FinansTidningen, March 1999 (see also chapter 3.12 of ):
"Mr Björkman has bombarded the world, at the limit to maniac energy, with his basically conspiratorially founded opinions about the (Estonia) Commission and the cause of the sinking. ... Representatives of Swedish safety at sea, among them myself, chose to work with matter that we consider more important for the safety at sea, than to discuss with Anders Björkman."
1. ESTONIA JOINT ACCIDENT INVESTIGATION COMMISSION, 'Part report about technical questions in connection with the sinking in the Baltic on 28 September 1994 of the passenger ferry MV ESTONIA', April 1995 (Stockholm).
2. ESTONIA JOINT ACCIDENT INVESTIGATION COMMISSION, 'Final Report about the M/V Estonia accident', December 1994, ISBN 951-53-1611-1
3. BJÖRKMAN, A, 'Disaster Investigation', 2001
4. STENBERG, B & RIDDERSTOLPE, J, 'Urkundsförfalskning för att dölja bristande sjövärdighet', June 1999, ISBN 91-630-8637-9
5. BJÖRKMAN, A, Lies and Truths about the M/V Estonia accident, 1998, ISBN 2-911469-09-7
6. TIKKA, K. and others 'Environmental Performance of Tanker Designs in Collision and Grounding: Method for Comparison', Report no. 259, Transport Research Board, U.S. Academy of Sciences, 2001