Nor Learning from marine Accidents - Some lessons which have not been learnt
NOT LEARNING FROM MARINE ACCIDENTS - SOME LESSONS WHICH HAVE NOT BEEN LEARNT
Anders Björkman, Heiwa Co., France
SUMMARY (as modified by the conference organizers and published in the program/invitation)
Marine accidents occur every day. Most accidents are minor and are investigated by professional hull or P&I underwriters surveyors to everyone's satisfaction. Some accidents are bigger and may be investigated by persons from the flag states accident investigation board. The results of such investigations and subsequent reports may contribute to safety at sea. Unfortunately where extremely serious incidents occur, such as large oil spills or ferry sinkings with a large death toll, there is a danger that the subsequent investigation becomes entangled with vested interests and the cause of the incident attributed may vary from the actual causes. Regrettably this can mean a deterioration in safety at sea. The author looks at some recent marine accidents and the resulting investigations.
(Original SUMMARY as submitted to the organizers in January 2002 as per the Synopsis submitted in November 2001
Marine accidents occur every day. Most accidents are small and are investigated by professional hull or P&I underwriters surveyors to everyone's satisfaction. Some accidents are bigger and may be investigated by persons from the flag state's accident investigation board (e.g. the UK MAIB, the US NTSB, etc). Sometimes the result is good and the report may contribute to better safety at sea. Real big accidents at sea - large oil spills, ferries sinking with a big death toll, etc. - are never really investigated at all. Governments, politicians, parties with vested interests take control and politically suitable investigations and causes are agreed. Then any means are possible - falsifications, lies, manipulations, etc. and the result is another disaster. But with clever political control the public may be silenced. Safety at sea suffers and gets worse and corruption develops. The paper describes some recent marine accidents that went wrong and how to improve matters. )
Mr Anders Björkman graduated from Chalmers University of Technology in 1969 with an M.Sc. in Naval Architecture and Marine Engineering. He spent a year in the Royal Navy, e.g. with planning conversions of ferries and other ships into minelayers and has worked for Lloyd's Register as a class surveyor, for Scandinavian Underwriters Agency as an underwriter's surveyor, for Mediterranean Average Adjusting Co. as average adjuster and for twenty years as group naval architect for V.Ships. Since 1989 Mr Björkman has assisted the El Salam shipping company, Cairo, Egypt to be the leading roro-passenger shipping company in the Red Sea and lately the Mediterranean with today 14 roro-passenger ships transporting > 1 000 000 persons annually. When the Estonia sank 1994 Mr Björkman started his own investigation into the sinking, as per Company ISM instructions, so that similar accidents would not occur in his own fleet. The findings have been published in book form and received good reviews by, e.g. the Naval Architect magazine and national newspapers. The findings were brought to the attention of many maritime administrations and the IMO in 1997.
Mr Björkman has developed the Coulombi Egg oil tanker system, which is the only alternative design system to double hull according to Marpol I/13F(5) approved by the IMO in 1997. It is the only ship/tanker design purely developed according to damage statistics and FSA.
Mr Björkman has made written contributions about ship's safety and works today as a ship safety consultant.
You would expect that the marine community really wants to learn from marine accidents. But is it so? Accidents occur every day at sea. Do we learn anything? The writer has very bad experiences. 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 (852 dead) and the 'Erika' sinking in 1999 (>20 000 tonnes of heavy fuel spilled). What do these three accidents have in common except that the names of the ships start with an E? One answer is that the casualty investigations were not done as agreed by the IMO. The IMO has naturally adopted resolutions about how an accident investigation shall be done already 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 problems. But the resolutions are not followed at all.
2. IMO RES. 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. The A.637(16) resolution 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. Res. A.637(16) was replaced in November 1994, after several years of discussions, at the IMO by resolution 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 liaison 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 paragraph 13, are very good but unfortunately they are never applied when a big accident occurs at sea.
2.1 EUROPEAN UNION IMPLEMENTATION
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.
3. 'EXXON VALDEZ' 1989
The proximate cause of the 'Exxon Valdez' grounding 1989 was, as far as the writer is informed, the human factor in combination with bad bridge procedures. The tanker 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 and the helmsman didn't notice anything. A third person on the bridge may have disturbed the navigation officer in her duties. So the tanker continued for 30-60 minutes on wrong course until she ran aground 6-8 miles off course. Who was at fault? The ship owner blamed the Master and fired him.
3.1 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 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. The US (as only IMO member) unfortunately didn't approve the Marpol amendment. This is sad, as evidently, double hull is not the best collision protection!
3.2 STRANGE LOGIC
Why is double hull not the best collision protection for oil tankers? Formal Safety Assessment gives the answer. By studying tanker collisions you will 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 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. The logic is therefore to arrange the maximum protection above (and a little below) the waterline in order to minimize oil spills in collision. You do not need any protection at the bilge; it can be single hull. The Coulombi Egg oil tanker was developed by the writer 1989-1994 based on the above FSA and it improves tanker collision protection four times (reduces oil spilled in collision four times) compared with double hull. It was one major reason why the IMO approved the Coulombi Egg oil tanker as the only alternative to double hull in 1997 as per Marpol I/13F(5).
The US have not accepted this logic and one reason is that the 'Exxon Valdez' accident investigation was not done as per the IMO resolutions. Actually the OPA90 mandates regular reviews of oil tanker safety arrangements, etc., but it has never taken place for political reasons. Recently the U.S National Research Council's (NRC) Transportation Research Board (TRB) has however developed a rationally based approach and method for assessing the environmental performance of alternative tanker designs relative to the double-hull standard .
4. 'ERIKA' 1999
The M/T 'Erika' tanker accident outside Brittany the 11 and 12 December 1999 has provoked questions. The 'Erika' broke apart on 12 December while underway at sea and spilled > 20 000 tons of heavy fuel oil. Why?
4.1 MALTESE CAUSE 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 reasons for the loss were corrosion, cracking and local failure, vulnerabilities in the design 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 - why the 'Erika' broke apart, but another cause could have been a fracture in the single hull side shell structure caused by fatigue and cyclic, heavy wave loads on the side on the morning of 11 December. 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 ship was denied a port of refuge to stop the small fracture to develop into a disaster.
The Malta Maritime Authority puts also serious blame on the ship's managers - 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.
The work is then supervised by the workers foreman, the shipyard's Quality Assurance team, the ship's manager's supervisor(s) and the class. It is evident that welding of the ship's hull new steel plating to existing plates needs to be checked at every step of welding and that the preparation of works is correct at every step. Only particularly qualified welders are used for this delicate work. Evidently it is the ship's manager's supervisor who has ultimate responsibility but the total responsibility must be shared by the yard and the class. If, which happens frequently, the managers supervisor is an ex chief engineer with limited welding experience of steel hull, and if the welding is done day and night concurrently with other work occupying the supervisor, he (or she) must rely on the shipyard and class that the steel work is done properly.
One lesson to learn is that all repairs affecting a ship's hull plating must be recorded properly.
4.2 ITALIAN PROTESTS
In December 2000 the 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. But maybe the fracture started in a cargo tank?
4.3 FRENCH REMOVAL OF OIL
All oil from the wreck 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 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 find the answer. Unfortunately the charters, Elf-Total-Fina, who paid for the removal of the oil from the wreck did not apparently film the edges of the two parts!
4.4 DESIGN AT FAULT
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 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.
4.5 FRENCH 'EXPERTS'
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 ship to split into two. As the Class was still valid and as 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 - black listed in 1993, rejected by TPS 1994-1995, accepted by Shell and BP in 1996, rejected by BP in 1997, rejected by TPS and Shell in 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 the 'Erika' was rejected by BP in 1999. However, a rejection by an 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 PSC's passed her.
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 of the tanker. When oil majors 'vet' a tanker, it checks many items, but evidently the vetting surveyor cannot inspect all the details of the internal hull in cargo and ballast tanks or the quality of recent repairs.
The 'experts' do not explain why the tanker split into two or how the charterers (Elf-Total-Fina) should have been able to recognize that risk or possibility a week earlier. And we still do not know why the tanker split into two.
The 'experts' do not mention that the responsibility of seaworthiness (and cargo-worthiness) of a tanker rests with the ship owner - not the charterers.
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 the tanker splitting into two parts.
4.6 POLITICAL SOLUTION
The 'Erika' accident has led to new demands year 2000 of phasing out single hull tankers and the use of Double Hull only or approved alternative design (even if the cause(s) of the 'Erika' accident is (are) still not finally resolved 2001).
However, 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! A fracture in the side of a double hull tanker will then result in the same accident as the 'Erika' (in similar, very unusual circumstances), i.e. the upper deck fractures first (because the section modulus is less at the deck - the fracture goes upwards), then the deck fractures and finally the longitudinal bulkheads and side shell members fracture down to the bottom. There is nothing to pull the tank body together, when the deck is fractured - double hull or conventional single hull. Had the 'Erika' been of Coulombi Egg oil tanker design it is highly unlikely that she would have split into half. The reason is that the Coulombi Egg tanker has a mid-height deck inside the tank body keeping it together even if the hull plate is fractured.
The 'Erika' accident investigation was not done as per the IMO resolutions. 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.
5. 'ESTONIA' 1994-2002
The international, i.e. Estonian, Finnish and Swedish, joint investigation 1994-1997 of the 'Estonia' accident 1994 must be considered the most shameful attempt in modern maritime history to cover up the real facts of a tragedy.
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. Immediately in the morning the Estonian president Lennart Meri decided that an Estonian commission was appointed to investigate the accident.
5.2 KEEP IT SECRET
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 it (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 ship had sunk. In retrospect it is easy to show that this information was as false as the position of the wreck announced by the Commission. A week later, on 4 October, the Commission confirmed the early findings - the bow visor (sic) 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.
5.3 CAUSE OF EVENTS
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 meter West) from the wreck, the Commission reconfirmed the first findings about the visor and the ramp. Water on the car deck in the superstructure then completed the disaster - sinking. The Commission never explained 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 undamaged hull and in the end it was never clarified. In the meantime a false position of the wreck had, as stated, been announced and strange things happened at the wreck.
The visor was officially found on 18 October 1994, allegedly one mile West of the wreck, and, in a secret salvage 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 two weeks earlier) - was true. The visor had probably been found at the wreck early October and was thus salvaged at the wreck itself mid-November 1994!
5.5 DIVE EXAMINATION
After a sloppy and completely unprofessional dive examination of the wreck 2-4 December - 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 Commission met again on 15 December 1994 (the public had evidently no access) and confirmed for the third time that the bow visor had caused the accident. But now the scenario of the accident had been modified by the investigators!
5.6 MODIFIED EXPLANATION
In the new explanation of the accident the visor had pulled the inner ramp of the superstructure fully open, so that 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. It was clearly stated that the ramp had been locked before the accident and that all ramp locks had been ripped apart by the visor. This statement is today a proven lye. The ramp was not locked (!), because it was twisted, so the locks did not fit so the weather tight ramp was always leaking, and the ramp was never pulled fully open by the visor (actually the ramp was found stuck in its frame and could not be moved).
However the Commission concluded that it was the visor locks that were incorrectly designed and manufactured 1979 by the shipyard - a design fault.
And - by the way - here is the correct wreck position - 2 111 meters Southwest of the previously announced position!!
The 'Estonia' was allegedly doing 15 knots in head seas of Beaufort 7 with 4,3 meters waves when the superstructure 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 later. However, if it did, it would pitch down again below water after another six seconds and scoop up another 180 tons of water. Then the ship would never pitch up again but would go down like a submarine. The superstructure would quickly fill up with water in less than 60 seconds, the ship would capsize and ... float upside down on the watertight hull below the superstructure.
But this true, correct and realistic scenario was never presented to the public. The Commission instead started to present stupid lies about water in the superstructure slowly sinking the ship (the hull). These lies are still the official Truth and explanations why the ship sank. In order 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.
5.7 COVER UP WRECK AND BODIES
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.
On 3 April the Commission published its Part report  reiterating for the fourth time that the visor had caused the accident. Every essential statement in the report was 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' raised in, e.g. the printed press, by outside experts (like the writer) 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 and the sinking. Very big wave loads on the visor had allegedly destroyed the visor locks during the night of the accident, the public was told, and the visor locks were incorrect. This was all the public had to know why the ship sank.
On 3 December 1997 the Final report  of the accident was published after over three years of secret deliberations. In the meantime two investigators had died and five others had been dismissed or resigned. All essential facts in the Final report  are false, and that is the message of this paper. Never in modern history has such a dishonest and untruthful document been published to explain a big maritime tragedy.
5.8 ALL ESSENTIAL FACTS ARE FALSE
If you bothered to check, e.g. the ship's certificates, it was obvious that the certificates were not correct and that the lifesaving equipment was not as per SOLAS. Further verification of the published data - which has taken the writer several years - then showed that every essential fact in the Final report  is 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.
But 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.
5.9 RE-OPEN THE INVESTIGATION
The 'Estonia' accident thus took place in September 1994 and the Final report  of the accident investigation was published in December 1997. Since then several attempts have been made to have the investigation re-opened to review new proven facts never examined by the official investigation.
On 20 September 1999 and 4 January 2000 the responsible Swedish minister, Ms Mona Sahlin, announced that there were no reasons for a new investigation. No new (sic) facts of sufficient value had been presented, in spite of the fact that 90% of the information in this paper was then known to Ms Sahlin.
On 16 March 2001 Ms Sahlin, after secret consultations with the heads of the political parties in the Swedish parliament, again announced that no new investigation was needed. "Maybe some technicians together with some trustworthy laymen could review the new facts (including the ones in this paper?)," Ms Sahlin thought and the heads of the other political parties did not disagree.
5.10 CAUSE AND EVENT
The head of the Finnish investigators Mr Kari Lehtola added on Swedish television the night before, that the writer - duly named - of this paper was an amateur - 'completely unable to do a proper analysis of cause and event' and that it was worrying that he "should be able to overthrow the government of an independent state".
The writer has no intent to overthrow the Finnish government, but it is interesting to note the Lehtola remark about cause end event. Mr Lehtola and his colleagues in the Commission have stated that a lot of 'events' took place when the 'Estonia' sank, but for most of these alleged 'events' there is no proven or identified cause.
5.11 EVENTS AND CAUSES
This paper is not about cause and event, but events ... and causes (and lessons not learnt).
Ms Sahlin and Mr Lehtola and the heads of the Swedish political parties were and are unfortunately not properly informed about the laws and codes for international maritime accident investigations, which Sweden, Finland and Estonia have adopted in the United Nations. UN-resolution IMO A.849 (20) and its Code for Investigations of Accidents and Incidents at Sea, paragraph 13, is clear:
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.
This paragraph is also part of the Swedish law (1990:712) how to investigate accidents.
It is as simple as that. The reason is of course that the safety at sea will be improved. The cost is minimal. If Mr Lehtola, who announced a false wreck position - believes that the writer is an amateur - "completely unable to do a proper analysis of cause and event" - he is kindly invited to prove it. Ms Sahlin cannot ignore in 2001 that new proven facts have been presented 1997-2001, which require a full new investigation - the alleged events disclosed by the Commission have different causes than concluded by the Commission or are physically impossible. In the United Kingdom several marine accident investigations ('Derbyshire', 'Gaul', 'Marchioness') have been formally re-opened (sometimes 10-15 years) later, when new facts have been presented. This has then resulted in real improvements to safety.
5.12 ERRORS OF FORM AND PROCEDURE
Several errors of form and procedure were made during the official 'Estonia' investigation 1994-1997. Without proper procedures the conclusions cannot be correct or acceptable.
The first error was that all concerned parties did not have access to or insight in the investigation. United Nation resolution IMO A.849 (20) does not permit the secrecy of the 'Estonia' investigation 1994-1998. The secrecy made it possible to hide and manipulate facts, to arrange private meetings between the investigators to negotiate what should be decided and be made public. This situation - the secrecy - is the origin of all conspiracy theories which are around.
The second error of procedure was that the draft of the Final report - both the factual and the conclusive parts - was not sent to the concerned and interested parties for comments and review before the Final report  was issued. It was a logical consequence of the first error - the secret investigation itself to prevent an open discussion. With normal procedure plenty of factual errors in the Final Report would have been easily spotted before publication.
The third error is that the investigation is not re-opened, when new proven facts are presented contradicting the official ones and modifying the analysis and the conclusions. Trade unions, survivors, relatives, the shipyard and private persons have during 1994-2001 pointed out several faults that must be reviewed - to clarify the accident and to improve safety at sea.
A fourth error was that several investigators were partial - the shipping company itself was part of the Commission and investigated itself! Errors of procedure are serious. Several investigators were members of the MAIIF1 - the Marine Accident Investigators International Forum - the rules of which state that the members shall follow the UN-resolutions, codes and laws. During the 'Estonia' investigation these investigators did not follow the ethical rules of the MAIIF and the UN resolutions. A basic requirement for an accident investigation is that all facts in the Final Report are proven and clearly described.
5.13 FACTUAL FAULTS OF EVENTS
 is a description of a surprisingly large number of factual faults - falsifications, lies, disinformation, cover-ups, etc. of events and conditions in the Final report  , which the writer 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 as per the SOLAS (Convention for Safety Of Life At Sea).
· Life saving equipment - was not as per the SOLAS.
· Port State Control by Sweden - manipulated several times 1993-1994 to hide un-seaworthiness.
· Visor - it was probably attached to the ship, when it sank (the Atlantic lock was probably damaged earlier).
· Ramp - the bow ramp was never open during the accident.
· Water inflow through an open ramp - the published figures are false.
· Speed and course - the published figures are false.
· Stability - the ship should have capsized immediately with 2 000 tons of water in the superstructure.
· 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)
· Testimonies - survivors' testimonies have been changed.
· Dive investigation December 1994 - the 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.
· The visor was damaged before the accident - and used as cause of accident to hide the truth.
· Major hull modification work was done 8 months before the accident - stabilizers were fitted.
· The swimming pool - was built into the double bottom.
An accident is often an unfortunate combination of events and existing conditions. The 'Estonia' accident is a prime example. There were many deficiencies 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. And it is obvious that the investigators connived to hide the real facts.
5.13.1 Salvage of Victims
The victims could have been brought to the surface within one week of the accident. A very reputable dive company offered its services at cost but was refused. The reason seems to have been that other divers were at that time removing the visor from the wreck - under water - so that Commission could blame the accident on the visor. Sounds fantastic? The Commission had at that time already reported a false position of the wreck 2111 meters northeast.
Several important institutions, the seafarers union ITF, the Royal Institution of Naval Architects, London, the Swedish Ship Masters Association, the Independent Fact Group, the shipyard, and private individuals have reported a big number of facts to the effect that the 'Estonia' was not seaworthy on the 27 September 1994. The Independent Fact Group has produced proof  that the protocol of the last Port State Control 940927 at Tallinn is falsified in the Final report  and that deficiencies, which should have been repaired or rectified before departure and/or stopped the vessel, have been ignored by the investigators. There are many observations that the condition and fitness of the 'Estonia' and crew training were very bad. The Commission only refers to anonymous person stating that the 'Estonia' was in perfect shape to show the contrary.
5.13.3 Watertight Subdivision
Evidence has been presented that the watertight doors in the watertight bulkheads were always open at sea and that the doors could not be closed locally, i.e. the watertight integrity of the ship was lacking (see chapter 1.23 in ) and that the ship was not seaworthy. It results in listing and sinking, if the ship is leaking. If the ship was leaking before the accident has not been investigated.
5.13.4 Life Saving Equipment
The 'Estonia' did not have lifeboats and life rafts under davits for all persons aboard (see chapter 1.33 in ), i.e. she was not seaworthy. The equipment consisted to 55% of throw-overboard-rafts (Solas-80 type), which were illegal for trade on the open seas - they remained since the ship was classed for coastal trading only 1980-1993. The Final Report comments this fact that the ship was according to the rules - what rules? SOLAS? Not possible! Furthermore the Commission states that the life jackets were of an approved type - no manufacturer or description is given - in spite of the fact that all survivors reported big difficulties - the life jackets were ripped off, when the passengers jumped into the water.
5.13.5 Swedish National Maritime Administration
It inspected the 'Estonia' at the port of Tallinn already in January 1993 - before the first voyage to see if particular Swedish requirements were fulfilled (see Appendix 7 in ). The evacuation test at Tallinn seems manipulated- it was of course impossible to evacuate 2 000 passengers aboard with the life saving equipment for 996 persons, but a test of 15 minutes 1993 - in port - proved the contrary. Hence the ship was inspected four or five times at Stockholm according the PSC protocol (the Paris-agreement) 1993/4 without any defects noted. Finally Swedish NMA surveyors at Tallinn inspected the 'Estonia' again on the day before the accident (see above), when apparently a large number of defects were suddenly noted. The Final report  does not mention any of these controls and inspections in detail. It means that there was a serious conflict of interest for the Swedish NMA. In spite of this the Swedish government asked the NMA to investigate many questions 1994-2000 - the legal position, an analysis of consequences, salvage of the wreck, if the information in this paper required serious study, etc., and to carry out several projects - a dive inspection, a report to an Ethical Advisory Board, etc. In all cases the NMA gave misleading information to the government and it was always the same person that did the work - Johan Franson - (see chapter 1.16 in ). The reason was apparently to protect the NMA.
The Commission stated in October 1994 that the visor had been ripped off by wave loads, when the 'Estonia' was upright. The visor was kept in place by, i.a. two hinges on the deck with a break strength >350 tons each. The Commission suggested that the hinges were torn apart by a sudden overload in the forward direction after the visor locks had been ripped open. How this overload developed is not clear. Wave loads directed upwards and aft cannot pull apart a hinge in the forward direction. Testimonies to the effect that the visor was attached to the ship, when it sank, have been censored. It is also probable that calculations about the wave loads on the visor have been manipulated to increase the loads (see chapters 3.6, 3.7, 3.8, 3.9 and Appendix 2 in ). The most probable theory is that the visor was attached to the ship after it had sunk and that it later was removed under water by help of explosives (see chapters 3.10 and 4.1 in ), which is based on information given to the writer not until February 2001. The assumed removal of the visor under water 2 to 6 October 1994 actually explains many strange happenings of the early part of the investigation 28 September to 15 December 1994.
5.13.7 Bow Ramp
Evidence has been presented that the ramp was never open. The Commission stated in October and December 1994 that the ramp had been forced or ripped open and permitted water to enter on the car deck in the superstructure >2 meters above the waterline. The ramp locks were ripped apart. However, pictures taken of the locks 1994 made public 1998 show that the locks are not even damaged (see chapter 3.10 in ).
5.13.8 Speed and Course
The Commission has confirmed that the speed and course were unchanged until after the listing occurred. However there are no evidences
5.13.9 Water Inflow
The Commission has informed various amounts of water inflow into the superstructure through the open bow ramp at different times, which do not add up according to the laws of physics. The writer thinks that 1 800-3 600 tons should have flowed into the superstructure and on the car deck in one minute (see chapter 1.9 and Appendix 4 in ) and that the ferry should have stopped and capsized immediately and floated upside down on its watertight hull, while the Commission reduces the inflow considerably. In two different places of the Final Report the Commission states that at the same time on the one hand only 55 tons/minute flowed into the superstructure (according to Dr. Huss - expert to the Commission) or, on the second hand, it was >666 ton/minute (according to the Commission). During two minutes around 01.29 hrs the deck house >10 meters above the waterline suddenly filled up with 14 000 ton according to the Commission, but the ship did not capsize nor stop - it floated on the deck house and drifted >1 000 metres Eastward to sink at about 01.53 hrs.
International expertise has since the accident 1994 questioned the official calculations, why the 'Estonia' did not capsize immediately due to water in the superstructure. The investigators always stated that the Final report  should give the answer. This is not the case. The Commission instead falsified all stability calculations - assuming that parts of the deckhouse (decks nos. 4-8) 10-20 meters above the waterline was 100% watertight.
As the Commission falsified the stability calculations, it could never explain the sinking of the ferry. The ferry was evidently initially floating on its watertight hull, which was properly subdivided into 14 compartments. The hull - 18 000 m3 - had large reserve buoyancy - 6 000 m3 - when floating normally on 12 000 m3, and should have survived with two compartments flooded. With 1 500-2 000 tons of water in the superstructure above the hull on the watertight car deck the 'Estonia' should immediately have capsized and floated upside down on the undamaged hull. The Commission instead stated that the hull was flooded from above (?) starting 15 minutes after the accident (the listing). The flooding of the hull then lasted for 20 minutes, so that the ship sank. No further details were given.
5.13.12 Plot of the Accident - A Falsification
The plot of the accident - figure 13.2 in the Final report  - is a pure falsification. It shows the turning and drifting of an undamaged ship that never sinks. The plot is then edited with more false information - (see chapter 1.9 in ).
The Swedish 'Estonia' survivors association 'Neptun' and the new 'Arbetsgruppen för utredning av 'Estonia's förlisning' (The work group to investigate the sinking of the 'Estonia), Agnef, have informed that survivors have not been questioned properly and that information given to the police has been edited by the Commission until it is not recognizable. The sequence of events in the Final report  does not agree with most survivors' testimonies (see chapters 2.1 and 2.12 in ). Instead the Commission believes and uses only the testimonies of four key crewmembers, which have been changed several times. At least three of them lied about what happened - it is easy to show (see chapter 1.48 in ).
5.13.14 Unreported Damages
At a private diving expedition in August 2000 big damages of the superstructure were filmed, which had not been reported by the Commission in 1994 (see chapters 1.16 and 3.10 in ). One damage - the one in the middle of the starboard collision bulkhead at the side of the ramp, probably caused by explosives after (!) the accident - shows clearly that the sequence of events of the Commission cannot be correct.
5.13.15 Destruction of Evidence
In the Swedish daily Dagens Nyheter 010311 was reported, and confirmed by the Finnish members of the Commission, that a great number objects were salvaged by divers in December 1994 and later thrown back into the sea - classified as unimportant scrap. The most important object/scrap - the locking bolt of the visor bottom (Atlantic) lock was thrown back without being photographed, measured, etc. It supports the writer's theory that the Atlantic lock was damaged before the accident and that, e.g. the bolt had not been used for a long time. It was thus rusty and dirty. But there is other evidence that the visor was damaged before the accident (see chapter 3.7 in ).
5.13.16 Major Hull Modification Work
Fin stabilizers were fitted in January 1994, i.e. openings were cut in the most highly stressed parts of the underwater hull. The matter was not investigated, if, e.g. the work was correctly done. An incorrect installation could have caused the leakage that apparently sank the 'Estonia after causing the loss of stability and the sudden listing. The 'Erika' tanker accident in 1999 were later blamed on faulty steel hull repairs a year before the fatal accident.
5.13.17 Swimming Pool in the Double Bottom
The 'Estonia' was fitted with a strange swimming pool arrangement on deck no. 0; the pool was recessed into the double bottom. It meant that the regular height of the double bottom was reduced and that the inherent protection against grounding was reduced. Survivors on deck no. 1 noted that water flowed up from the swimming pool compartment before the listing occurred indicating that the ship was leaking. The water may have come from the stabilizer compartment aft of the swimming pool. The leakage may also have started below the swimming pool.
5.14 SEQUENCE OF 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. On 15 December 1994 the Commission changed the sequence of events - the ramp had then been completely pulled 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 the suggestions then, 1994, or today, 2002. Based on the evidence in  none of the official sequences of events is possible (see chapter 1.9 in ). 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 started at 00.30-00.40 hrs, which caused the sudden listing already at 01.02 hrs as noted by a majority of survivors.
The question remains why a complete analysis was not done later? The answer is that 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 rubbish, i.e. no analysis was made 1994-1997: the Commission only wrote a report, which tried to prove the first suggested, false sequence of events with fabricated causes. The Commission does not show in the Final report  how it wrote off other possible causes of accident, e.g. leakage, which is a basic requirement in a complete analysis.
5.15 LEAKAGE OF HULL
Leakage of the hull below the waterline as cause of accident has never been investigated, e.g. due to a faulty stabilizer installation, rust below the swimming pool incorrectly fitted as part of the double bottom or repair works carried out onboard. The Final report  does not even mention the possibility. If you study all the protocols of the Commission meetings, you find that other causes of accident are only treated once the 27-28 February 1996, when the Commission decided that "Chapter 8 shall be enlarged to state that other causes of accident like explosions and collisions have been studied but found improbable".
That decision is not found in the Final report, nor why an explosion or collision was improbable and how this investigation was done. A possibility of leakage is e.g. badly supervised welding repair work in dry-dock or aboard at sea. A fact which is not reported in the Final Report, and which has never been noted in the media, is that almost the whole engine crew survived - 13 men except three officers - (see chapter 1.42 in ). The ten survivors were two officers incl. the watch keeper 3/E Margus Treu, one systems engineer (plumbing and pumps) - Henrik Sillaste, the A/C engineer and his assistant, two welders and three oilers, incl. the watch keeper, Hannes Kadak. The systems engineer - Sillaste - stated several times that the 'Estonia' was leaking (see chapter 1.3 in ) and that the bilge pumps were running. According to a report by the CNN also quoted by the Swedish news agency TT soon after the accident a crew member stood in water to his knees in a compartment before the listing occurred.
The Final report  does not say if "hot work" was carried out during the last trip. A common cause of accident is then fire or explosion, if you do not check if the surrounding is gas free. It is very strange that the Commission 1994 never interviewed particularly the welders, the repairmen and the oilers about what had been done earlier aboard during two weeks - if major works were done. 14 months after the accident the two welders and one oiler were in fact interviewed by the Estonian administration together with 23 other surviving Estonians. The 28 February 1996 the Commission wrote in its protocol that "An agreed document about testimonies had now been created". The wording is revealing.
5.16 GERMAN INVESTIGATION
After the Commission had 'created' or produced an 'agreed' document about testimonies, the German group of experts (appointed by the shipyard in 1995) sent a report 22 July 1996, (register no. B155** - made secret according to the Swedish secrecy law §8.6 until 9 March 1998 by the Commission), of 87 pages exclusive of three appendices, which completely contradicted the analysis and all public statements of the Commission at that time. The Germans showed, e.g. that the visor was badly maintained, that the visor was lost after a sudden listing occurred at 01.02 hrs and that the ship floated in a stable condition with 40-50 degrees with the funnel against the wind, etc. The Germans demanded that another ten objects from the wreck should be salvaged for complete analysis and that a further eight areas should be filmed and that the watertight doors should be studied. The German evidences were not analysed by the Commission and the demands were refused against the rules of UN-resolution A.849 (20), in spite of the fact that orally the Commission had told the Germans the opposite. By using the Swedish secrecy law SL 8.6 the Commission succeeded to silence the Germans.
5.17 STABILITY AFTER ACCIDENT
Neither the Germans nor the Commission has analysed how a stable condition developed after the sudden listing. The 'Estonia' was probably leaking below the waterline before the listing developed, e.g. the hull was damaged in way of the sauna/pool compartment or the starboard stabilizer on deck no. 0 or in some other location, e.g. the welders were working on a tank, which was not gas free and that there was an explosion causing a leak. Perhaps the work supervisor - an officer - died. The whole ferry was shaken - it was observed by many survivors before 01.00 hrs. Then they tried to do something and there was a second impact - 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 lost, when the list was very great. In this analysis all observations fit with what was observed aboard. Leakage of the hull below the waterline followed by loss of initial stability thus cannot be excluded as a contributing cause of accident. What actually caused the leakage should be investigated.
5.18 INSURANCE FRAUD
Neither the leading hull underwriter nor the P&I club Skuld has ever taken an active interest into the real cause of the accident - (see chapter 3.20 in ). They paid all claims long before the investigation was terminated when no evidence was available to prove the alleged cause of accident. That the manipulated, official investigation is part of a clever insurance fraud is today a valid consideration.
A great number of new, proven but not reported facts have been presented after the Final report  was published. The original investigations and analysis of the Final report  are incomplete. Sweden (or Finland or Estonia) is then forced according to the UN/IMO resolution and EU law to re-open the investigation, exactly as the United Kingdom has re-opened the 'Derbyshire'- and the 'Gaul'-investigations (and others) under the impartial eyes of e.g. lord Donaldson, which has contributed to real improvements of safety at sea 1997-1999.
This paper is a contribution to factual debate about the 'Estonia' investigation and a simple explanation of many questions surrounding the 'Estonia' to eliminate all lies produced by the Commission. The choice of the word lie is intentional - lie is a lie and does not become truth, if it is repeated. The former president, Mr Lennart Meri, of Estonia, the Estonian government and the former young prime minister Mart Laar (born 1962) and the former transport minister Andi Meister (see chapters 1.5 and 1.20 of ) do not seem to understand the causes how and why the 'Estonia' sank in September 1994. You still ask in 2002, why it was so difficult to investigate a simple accident at sea and why the public had no access to the investigation. President Lennart Meri is primarily responsible that the accident has not been investigated properly (see chapter 4.5 in ).
The Swedish governments under prime ministers Carl Bildt, Ingvar Carlsson and Göran Persson, ministers such as Margaretha af Ugglas, Mats Odell, Ines Uusmann and Mona Sahlin, advisors as Jan-Olof Selén, Jonas Hafström and Birgitta Wallström, and all so called 'experts' of the National Maritime Administration (Sjöfartsverket) as directors of safety at sea Bengt-Erik Stenmark, Johan Franson and Per Nordström (deputy), director Sten Anderson and certain surveyors, and all 'experts' of the Swedish Board of Accident Investigation (Statens Haverikommission (SHK)) as the directors general Olof Forssberg and Ann-Louise Eksborg, and master mariners Olle Noord and Hans Rosengren and dr. Michael Huss and psychologist Bengt Schager (see chapter 1.5 in ) seem to systematically during the past years to have given away false and misleading information about the condition of the 'Estonia' at departure from Tallinn the 27 September 1994, about why and how she sank in about 30 minutes, six hours later in the middle of the Baltic, about the condition of the wreck and why you could not salvage the dead. The Swedish NMA directors general Anders Lindström (1995-2000) and Jan-Olof Selén (2000- ) have not made things better by refusing to investigate the false information.
Deputy Swedish NMA director of safety at sea Per Nordström wrote to the author 981223, ref. 0701-9836282, which he copied to directors Johan Franson and Sten Anderson (see chapters 1.5 and 1.16 in ). Nordström considers that "the Estonia report and its recommendations are of little interest, as the work at the IMO after the loss of the 'Estonia' quickly surpassed the work of the Commission and new rules were developed, which were more comprehensive than those of the Commission". Nordström says further that "the question what 'actually' happened to the 'Estonia' will probably never be answered". This is a surprisingly uninterested and lazy position of the Swedish NMA, which according to its own ideas, wants to become the best NMA in the world with the highest safety at sea. Nordström says that the 'Estonia' report is of 'little' interest and does not clarify what happened. Then Nordström says that the Swedish NMA "has accepted the explanations of the Commission as being trustworthy". You wonder on what basis such acceptance is built?
Doesn't the NMA know that a ferry floats on its hull and that the hull need to be water filled so that the ship sinks? Hasn't the NMA noted that the Commission never explained how the ferry was alleged to have sunk? You should further note that the Commission never developed any new 'rules' in the Final Report. The Swedish NMA is responsible for safety at sea - to accept the suggestion that more than 850 persons including more than 500 Swedes died at sea 1994 due to badly designed and manufactured visor locks 1979 is to make things too easy. It is also intellectually dishonest. It is to say that wool socks grow on trees!
5.20 TOURIST ATTRACTION
One reason to salvage the 'Estonia' is naturally that the peace of the 'Estonia' will never be guaranteed. The 'Estonia' will within 10-20-30 years become a tourist attraction to be studied with a mini submarine, etc. The 'Estonia' will never rust away but will lie at 50-70 meters depth for hundreds of years, as a monument over Swedish (Finnish and Estonia) incompetence to maintain and to improve safety at sea. To prevent this, the 'Estonia' should be raised. When the 'Estonia' is raised it is easy to establish the cause of the accident - a leakage below the waterline. The visor was probably removed under water by explosive devices to support the false theory that it had been lost before the accident. The writer has no other explanation why the visor was allegedly found detached from the hull after the accident.
5.21 PROVEN FACTS
Most of the proven facts in this paper have been advised to the Swedish, Finnish and Estonian governments, the Swedish NMA and the Commission during 1995-1999. They have also visited the web site of the writer several times. All facts have been ignored. The Swedish government ignored the first request for a new investigation 1999. In proposal no 1:1999/2000 to the Swedish Parliament Ms Mona Sahlin stated that a new investigation should not be done. She added: '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).
In spite of 'some evident deficiencies' nothing is done. The contributions of Ms Sahlin support the various conspiracy theories and increase the secondary trauma of relatives and survivors, which the Analysis Group is worried about (see chapter 1.36 in ). When the Germans handed in its report to a Stockholm court of law 991230, Ms Sahlin only repeated 000104 the same statement after having the read the thousand pages German report, that: 'no new facts have been reported which require a new investigation'. Ms Sahlin and Mr Lehtola have no respect for the truth and they are afraid of the citizens. Nevertheless - the writer hopes that students of risk analysis and safety management will use this paper in order to develop better safety at sea.
The conspirators - because it was a conspiracy from the start, the first day - were satisfied. They thought they had managed to cover up the Truth. Many of the conspirators were given high offices in the Swedish administration, where they today regularly praise the work of the Commission and the content of the Final report  and ridicule the few professional marine investigators and journalists, who continue to research the accident with the aim to improve safety at sea. These persons are all charlatans. But, and this is sad, they are 'respectable' in Swedish society today. To be respectable in Sweden today is like being a good party man in a communist state - you repeat the official policy without own thinking. It is a virtue in today's Sweden (and Finland and Estonia). And a large majority of the public plays along - it has a feeling for what Truth the government wants to adhere to.
It is a tragedy for the relatives of the victims and for the survivors (and for some members and experts of the Commission). Many of the conspirators are still middle age and have years of public service to fulfil. Most of the politicians, who initiated the conspiracy, are gone from office (but alive). Many Swedish technical 'experts', who once were young honest men full of initiative and activity, have become bureaucratic servants of the Swedish NMA (still middle age) to continue the cover up - they are conspirators. They are, i.a. Sten Anderson, Johan Franson, Ulf Hobro, Dr Michael Huss, Per Nordström, J-O Selén and Åke Sjöblom, all of the Swedish National Maritime Administration.
Other Swedish non-political co-conspirators (civil servants or 'experts') are Ann-Louise Eksborg, Olof Forssberg, Gunnel Göransson, Olle Noord, Hans Rosengren and Bengt Schager of the Swedish Accident Investigation Board and professor Olle Rutgersson of the Royal Institute of Technology.
Some Finnish conspirators are Kari Lehtola, Heimo Iivonen and Tuomo Karppinen of the Finnish Accindent Investigation Board and Dr Klaus Rahka of the Finnish State Research Institute, VTT, and Veli-Matti Junnila of Ship Consultancy Ltd OY/AB.
What were and are the motives of their doings? Evidently all conspirators knew what actually happened 1994 but none has told the Truth. All has presented false versions - based on different interpretations? - but all support the official, false version as presented in the Final report  1997. You wonder if the conspirators were given orders - directives - to do what they did? Or did they falsify their work, only because they know that it had been done before for some strange reasons, and it worked then? Or did they falsify the work just as a routine - something you can do, because the risk is small to be discovered, and it serves your personal ambitions and you are paid - and you can still sleep without thinking, what you have actually done? This writer believes that most conspirators falsified the Final report  simply because they wanted to impress their masters; to show that they were good men and women - respectable - in the new Swedish or Finnish society, where Truth does not matter. Anyway - it was a big teamwork behind the shameful manipulations and it seems to help later - they can all blame the others. The SPF seems to coordinate the efforts. The Swedish media is too weak to look into the matter. The writer has no idea what is going on in the heads of the conspirators. The writer is only interested in safety at sea.
5.23 MONA SAHLIN - SPIDER IN THE NET
The conspirators are today - year 2002 - headed by the Swedish deputy minister of trade and transport - Ms Mona Sahlin. She regularly states that no new information or facts have been presented showing that the official conclusions are 100% false. She bases her false statement on other false statements of the numerous co-conspirators mentioned above. It is very evident to anybody who has studied the facts, but nothing happens. We are told that the political position of Ms Sahlin is very strong and it is not possible to move her - to get a new investigation done. Too many embarrassing questions and answers would then be presented - it is best to censor the whole affair is the official message. It is a clever strategy - every Swedish citizen including, naturally, the members of Parliament shall become a co-conspirator. It has been done before but it cannot be accepted. The Truth of the 'Estonia' accident must come to light.
5.24 THE IMO WAS FOOLED
Because the conspirators did not only falsify the investigation, they persuaded the International Maritime Organization, IMO, to accept the false information and to modify international rules for safety at sea, most of which (the amendments after the accident) today are nonsense (see chapter 5 in ). The conspirators 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.
5.25 HOW DEMOCRACY DIED
But even more serious, as one person has observed, democracy in Sweden died on 28 September 1994. Somebody - probably a Swede - ordered that the investigation should be covered up and the Swedish establishment just followed orders - no discussion. Plenty of money and other means were provided. To make ships less safe. And the establishment succeeded for many years - in spite of the corruption that followed. It explains the experiences of the writer, who met the Swedish chief technical investigator Börje Stenström already on 31 October 1994. "The writer did not understand, what it was all about". Later in April 1995 the writer in a letter to the Commission described their impossible statements - "no reply". When, probably by error, the biggest Swedish daily Dagens Nyheter, DN, on 15 August 1996 published a long article by the writer concluding that the official statements of the Commission were not physically possible, the response was immediate - "the suggestions were unscientific and unintelligent rubbish by an unreasonable person". After that DN never published any criticism of the Commission and the SPF was brought in to handle the government information. DN (reporter Anders Hellberg) had for years published disinformation about the accident and Anders Hellberg wrote a book about the accident, while the investigation was still on, confirming the false facts. One year later - August 1997 - the writer asked Dr. Michael Huss and professor Olle Rutgersson at a meeting to explain the stability calculations of the investigation. The only answer was that the writer was "conspiratorial". A few days later the new head of the Swedish Commission delegation Ann-Louise Eksborg assured that clarifications to all the writer's suggestions would be given in the Final report , and a week later the former head of the Swedish delegation, Olof Forssberg, wrote from the Ministry of Transport that "it was not possible to discuss the matter until the Final report was issued".
At a casual meeting with Johan Franson and Sten Anderson of the Swedish NMA in 1998 the writer asked, if it were really Swedish practice that passengers were supposed to jump into the water and swim ashore to save themselves from a sinking ferry. "No", said Franson, "they climb down the rope ladders at the side and swim to the life rafts that are thrown into the water by crew members". Sten Anderson had a painful look.
The Final report  published in December 1997 states that the cause of the accident 1994 were badly designed and manufactured visor locks 1979. Everything else was in order. The 'Estonia' was in excellent condition. That an alleged event 1979 causes an accident 1994 evidently has to be explained and proven. The Final report  does not provide any evidence whatsoever - not even for the alleged cause. Why more than three years of top secret deliberations were necessary to make such a simple - and evidently false - conclusion is not clear either, except that Democracy definitely died in Sweden on 28 September 1994.
The Final report  lacks reliability defined as -
"an independent analysts ought to reach the same conclusions as the Commission" 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".
This writer has not been able to reach the same conclusions as the Commission using the official data.
The Final report  lacks validity defined as -
"the found causes must be true causes and be predictive".
This writer has not been able to verify any causes of the Commission or that that they could have been predictive. On the contrary the writer has found that many 'scientific' reports to support the causes are falsified.
The Final report  lacks disclosure defined as -
"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".
This writer has not been able to make any sense of the Commission's disclosures what happened on board.
The Final report  lacks significance defined as -
"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".
The writer concludes that the official investigation of the 'Estonia' accident lacks all significance and is one simple, big lye - a conspiracy. Evidently the responsible parties will never admit to it and will never agree to a new investigation.
Big marine accidents are often not investigated properly according to the IMO resolutions and EU law. The reason is political and politicians see an opportunity for change - not improvements.
In this situation any means are permitted. You can lye, falsify and manipulate as you like. The risk of detection is small and the media will not react.
One victim is future safety at sea. It cannot be based on false and manipulated marine accident investigations, but as there are no safe guards against the manipulations of accident investigations, safety at sea is actually made worse. Future accidents 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).
The small, truly independent company 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.
The writer thanks all persons who have contributed with information, observations, suggestions, ideas and analysis of various matters of this paper and of his very personal investigation of the 'Estonia' cover-up and for the constructive discussions, often per e-mail, with interested parties. Any errors in this paper are only due to the writer. The writer will no longer concern himself with the 'Estonia' investigation but continue the work for real safety at sea. 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' disaster investigation (and other Swedish political affairs). Good luck. Nobody in the 'respectable' Swedish establishment will thank you. Therefore no new public investigation will be permitted within the next 20-30 years. Prove me wrong - and I will be glad - but a realistic view of Swedish 'democracy' is that nothing will be done to change the corruption of Sweden. The problem is not the 'Estonia' - it is the Swedish system as summarized by Mr Johan Franson, Director for Safety at Sea, Swedish NMA and one of the chief conspirators in the cover-up in the Swedish daily FinansTidningen, March 1999 (see also 3.12 of ):
"Mr Björkman has bombarded the world, at the limit to maniac energy, with his basically conspiratorially founded opinions about the Commission and the cause of the sinking. ... Representatives of Swedish safety at sea, among them myself, chose to work with matters, 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 (https://heiwaco.tripod.com/disasterinvestigation.htm )
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 (https://heiwaco.tripod.com/e7.htm)
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