Welcome to a chapter of the e-book Disaster Investigation.
'The situation, that somebody will not accept the results of the investigation, does not mean that the investigation must be done again.'
Johan Franson, Swedish director of safety at sea, to Ms Mona Sahlin (s), deputy minister of transport, 990218
Part 1. How Survivors and Relatives were misinformed 1994-1998
1.1 A prime Example of Falsification of History
This is an enlarged and up-dated edition of the book 'Lies and Truths about the M/V Estonia accident' that was published hard-copy in February 1998 (1) and which demonstrated that the 'Estonia' sank due to leakage below the waterline. The book described clearly that the cause of accident of the Commission was impossible. The information of the book was told to the Commission 1995-7, but it saw no reason to consider it 3.19 - as it should as per UN resolution IMO A.849(20). The book got good reviews by several newspapers and technical magazines and nobody has shown that the content is incorrect. That was 1998.
The objective is to publish a more comprehensive analysis, based on proven facts, about the 'Estonia' accident and particularly about its investigation. One purpose is to start a factual and constructive discussion about what the Commission thought happened aboard the 'Estonia' on 28 September1994 in order to improve safety at sea in general and safety on ferries in particular. The investigation, conclusions and the Final Report itself by the Commission are wrong from A - Z. The work for safety at sea suffers.8
The Swedish government and its national maritime administration have decided - so far successfully - to cover up the Truth in a well-planned disinformation campaign. Nobody wants to factually discuss the 'Estonia' sinking in Sweden today.
It is the writer's hope that this book can be used teaching naval architects and master mariners an example to learn from accidents, even if - in this case - a completely false Final Report (5) was issued in 1997 which prevented serious discussion for several years.
Evidently this book shall be used by students of risk analysis and safety management, when analyzing the 'Estonia' accident. These students will face an interesting task - to compare the official Final Report (5) with the observations in this book.
Only one Cause of Accident announced and investigated
The Commission confirmed its sequence of events of the accident and its most probable (only) cause, already announced on 4 October, on 17 October 1994, only nineteen days after the accident and one day before they, reportedly, had found the visor 1 570 meters West of the wreck 1.11 and before they hade investigated the wreck by divers. No 'less probable' causes were ever investigated.
Never has the cause of a big maritime accident been confirmed in such a short time. And no evidence was ever produced - then or later - for the alleged cause and its consequences. It was quite cleverly done - immediately after the accident the public was presented by TV and media numerous emotional stories about the accident including the visor story. In such a way the visor story was etched into the minds of the people as "truth" without giving them a chance to query it in a rational manner.
The Estonian chairman of the Commission, first Mr Andi Meister, later Captain Uno Laur, repeated the same story several times, i.e. that the crucial event which caused the accident on 28 September 1994 was that the 14 years old locks of the bow visor of the ferry were incorrectly designed and manufactured in 1979. It had led to seven initial events leading to the sinking (the eighth event) on 28 September 1994 shown below.
It will be demonstrated in this book that there is no evidence for any of the events (i)-(viii) and that the ship probably sank earlier than stated.
The commission has produced a video MS Windows MediaPlayer v.7 CIF 352x288, 256 Kbps, 6,9 Mt of (i - viii) above. There is no evidence for any essential statements in the video. Normal waves do not even lift the visor! That the port side lock failed first is not proven. That the visor can pull open the ramp is not proven - the ramp is locked. But if the visor is lost and the ramp is down and the speed is forward, water evidently enters the superstructure - it is well shown. Then the 'Estonia' should have capsized, turned upside down and floated. Not sink as shown in the video.
The Commission met for the last - 20th - time at Helsinki
on 12 March 1997 and agreed a 228 pages Final Report in
English (5), which then was published on 3 December 1997,
i.e. 38 months after the accident. The Swedish edition of
the same report was issued in December 1998, one year later,
50 months after the accident. All essential facts in the
Final report are false and cannot be proven. All the
presented evidences are false or falsified!
The Final report (5) investigates only
one cause for the sudden listing -
water on top of the car deck
superstructure - and states
erroneously that the 'Estonia' then sinks slowly
during 30 minutes instead of capsizes immediately,
when the angle of list is 40 degrees to float
upside down, 1.9
on the undamaged, watertight hull
- fig. 1.1.1. The Final report (5) therefore cannot explain
why the ship sank without capsizing after the
alleged 'accident' due to the visor locks.
The evidence for the 'accident' - the lost
visor - is very poor and does not convince an
intelligent observer. There is in fact no evidence
that the visor fell off the ship prior to
The Final report (5) investigates only one cause for the sudden listing - water on top of the car deck inside the superstructure - and states erroneously that the 'Estonia' then sinks slowly during 30 minutes instead of capsizes immediately, when the angle of list is 40 degrees to float upside down, 1.9 and 1.15, on the undamaged, watertight hull - fig. 1.1.1.
The Final report (5) therefore cannot explain why the ship sank without capsizing after the alleged 'accident' due to the visor locks. The evidence for the 'accident' - the lost visor - is very poor and does not convince an intelligent observer. There is in fact no evidence that the visor fell off the ship prior to sinking!
The Final Report (5) does neither mention nor describe the availability of bilge pumps aboard 1.24 nor the watertight doors/bulkheads inside the hull, which shall be closed at sea 1.23 to prevent sinking due to hull leakage and flooding one compartment. That the 'Estonia' could only have sunk due to leakage of the hull below the waterline and flooding of several compartments is not mentioned and is thus not investigated.
Ships normally sink due to leakage - leakage of the 'Estonia' was never investigated 1994-1997 - and the responsible parties will not investigate leakage today.
The Final Report does not mention that the life saving (rafts) equipment under davits were lacking 1.33 at the deck house- and that it meant that the so called approved evacuation plan required that 1 196 persons aboard had to jump overboard (sic) and to swim ashore or to a raft thrown into the water to survive 1.34, which naturally was not an approved method of evacuation in 1994 on an open, often ice cold sea. The result was that many drowned or froze to death. The 'Estonia' was evidently never seaworthy on the Baltic (31).11
The Final Report (5) is only a badly written report about an alleged faulty visor on the 'Estonia' and faulty visors on other ferries.
The Commission refused categorically during 38 months to discuss its invented theory about water on top of the car deck in the superstructure as no honest naval architect would support it. The investigation was completely secret from September 1994 to December 1997 (some reports were even secret until March 1998) and the Commission refused to answer any questions from outside experts. There is no evidence that a proper accident investigation actually took place. Most time seems to have been used to fabricate the false Final report (5). Extracts of video films of the wreck were provided 1994-1997 but the extracts were edited as part of the disinformation. The Final Report is quite a clever labyrinth of contradictions, which is difficult to describe, but an attempt is done in this book. The reader has to accept that many observations are repeated in the various chapters, the reason being that if you follow the various links you might miss some information.
After the publication of the Final Report in English the Commission was dissolved and, e.g. the Swedish Accident Investigation Board (Statens Haverikommission, SHK), does not reply to any questions about it, in spite of the fact that they signed it, 1.38 and 3.19. The reason is as follows:
The above sequence of events, which is the logical development with a fully open ramp, was evidently never reported. Most of the survivors reported 2.1 instead that there were two severe bangs before 01.00 hrs, that the ferry already at about 01.02/5 hrs first rolled a little and then heeled suddenly >30 degrees to starboard, when the survivors held on to fixed things, and then the ship up righted and reached a stable position at about 15 degrees list, 2.1, 2.12 and 3.16, so that you could escape to deck 7 during several minutes. When the ship rolled to an almost upright position, it was possible to get out. Then it took a fairly long time, 20-30 minutes, before the ferry was at the side - 90 degrees list - at about 01.30 hrs and sank on the stern a few minutes later between 01.32-01.36 hrs. Why did the 'Estonia' lose stability and sink in such a way?
The writer thinks the 'Estonia' sank due to a severe leakage of the hull below the waterline starting at 00.55 hrs - inflow 100 m3/minute, that water spread into several compartments of the hull through open watertight doors on deck 0 (tank top), that the initial stability was suddenly lost due to large free water surfaces in several compartments on the tank top, so the ship heeled and that a new equilibrium was reached at about 15 degrees list. The leakage may have started at the stabilizers, which had been installed eight months earlier, and which had never been tested in rough weather. The lying crew probably discovered that the 'Estonia' was leaking prior to the sudden listing.
The open Starboard Pilot Door
When more water then leaked into the hull the vessel didn't upright so that 10-15 minutes later deck 4 aft starboard was under water and the superstructure/car deck 2 started to fill from above through openings aft (ventilators on deck 4 - inflow say another 100 m3/minute) causing stern trim and an increased list 90 degrees at 01.30 hrs and that the ship then sank quickly stern first at 01.32-01.36 hrs. This is the only logical explanation.
The Final Report (5) does not mention the possibility of leakage of the hull at all. The Commission has also made great efforts to hide all films and observations of the open starboard pilot door that was visible down on the wreck above the mud line. Films have been cut/edited and sand has been deposited on the wreck to hide the pilot door.
Classic Example - the 'Herald of Free Enterprise'
There is a classic example how a car ferry capsizes with water on the car deck without sinking - the 'Herald of Free Enterprise' - outside Zeebrügge in Belgium on 6 March 1987 in fairly calm weather. She had no visor but a normal bow door - of steel - in the front bulkhead of the superstructure above the car deck. Through negligence the door was not closed at departure, which was not detected due to bad control routines. When the ferry with bow trim accelerated just outside the harbour entrance, the bow wave moved straight into the superstructure car deck space, the ship started to heel and turned out of the dredged fairway and capsized one minute later outside the fairway with 500-1.000 tons of water on the car deck a few hundred meters outside the harbour. The weather was fair. Luckily the water was shallow (15 meters) and the 'Herald of Free Enterprise' ended up on the side on top of a sand bank but 188 persons drowned. Had it been >20 meters depth the ferry would have turned upside down and floated keel up and probably all 540 aboard had died. The whole accident took two minutes.
Disinformation about the 'Herald of Free Enterprise'
In (25) the 'Herald of Free Enterprise' accident is described completely different (for Swedish readers) by the so called Swedish Analysis Group appointed by the government - free translation from Swedish:
"The 6 March 1987 at 19.08 hrs the car ferry "Herald of Free Enterprise" left Zeebrügge to sail for Dover. There were 540 persons aboard. When the ferry after 20 (sic) minutes voyage changed (sic) course, it capsized and water flowed into the open bow door. The ferry came to rest on its port side on top of a sand bank - two thirds were below the waterline. 351 passengers could be saved".
The above is evidently pure disinformation! The writers of this misleading description of the 'Herald of Free Enterprise' accident are listed at 1.36. One of the writers - Christina Jutterström - was later (June 2001) appointed head of the Swedish public television.
A lot of people lying for the Swedish government about the 'Estonia' have later been appointed to - given - high positions in the administration.
The responsible parties for the 'Herald' accident were later identified - both crew onboard and management ashore - and were sentenced in court. A responsible party for the 'Estonia' accident has still not been identified.
The official explanation is that the 'Estonia' sank ('capsized' the Commission says) due to water on the car deck 2,5 meters above the waterline in severe weather, Beaufort 7 and >4 meters waves. The water had reportedly ended up on the car deck inside the superstructure on top of the hull, as visor locks and hinges had broken, the visor had fallen off, the ramp protecting the superstructure had been pulled fully open and the forward part of the superstructure was wide open, so that (a little? - the Commission says 33-55 tons/minute) water came in every time, when the bow dipped into four, five metres high waves and when the ship moved forward at unchanged speed (14 knots).
That sequence of events is not possible according to above description what happens, when the ramp is pulled fully open. The reason is that any water temporarily loaded on the car deck inside a superstructure in an otherwise undamaged ship with an intact hull only creates a heeling moment that tips the ship upside down. It goes fast - 1 500 tons should have been sufficient to tip the 'Estonia' upside down in severe weather - capsize.
The capsize occurs, when the heeling moment of water in the side of the superstructure exceeds the ship's normal righting moment of the hull due to buoyancy. Then the ship turns turtle! The ship then floats upside down. A heeling moment cannot sink a car ferry. It is elementary!
Ships only sink when they lose buoyancy (leak) of the hull or are overloaded, when the old and added weights exceed the available buoyancy of the hull, which is never the case with water on the car deck in a superstructure. With water in the superstructure ferries capsize and float upside down before overloading occurs - the extra weight of the water in the car deck then flows out.
The Commission had apparently no idea about these simple facts, when it met for the first time on 28-29 September 1994 and started to spread the incorrect water-on-the-car-deck-in-the-superstructure-theory 2.16. Or they knew and decided to censor the fact at the request of their chiefs.
The Falsification of History started on the same Day of the Accident
That is normal. Millions of people were shocked and it was extremely easy for the Commission to manipulate everything. Nobody could think clearly. Somebody - on the day of the accident - planted the disinformation that the visor had fallen off and this impossible suggestion was supported by the lying crewmembers. The writer was however at sea in the Mediterranean and got very interested - could it happen to his ferries? Therefore this book is necessary. A factual review how the Commission 1.5 - the nine investigators and several experts and observers of three nations and their maritime administrations - manipulated everybody including the International Maritime Organization, IMO. It is now seven years after the accident, but it is never too late to present the Truth, which is very easy to verify. Appoint a new investigation and investigate the real facts!
Ask the lying crew what really happened.
It is a grave error. The hull of the 'Estonia' on decks 1 and 0 was divided into 14 watertight compartments below the (car/bulkhead) deck 2. The various compartments were in too many locations connected by watertight, sliding doors in the bulkheads. On deck 0 there were ten watertight doors.
Two watertight compartments on deck 0 could only be accessed by opening a watertight door; the stabilizer compartment and the compartment forward of the stabilizer compartment. If it were a leak inside the stabilizer compartment you could only reach it by opening a watertight door. This arrangement was incorrect and very dangerous.
On deck 1 there were five watertight doors in the passenger accommodation, one watertight door to the engine control room and several doors elsewhere aft. Access to the engine control room was via two watertight doors! - albeit with a vertical emergency exit ladder to the car deck 3 meters above.
The number of W/T doors was too large and not as per the SOLAS 1.23. The 'Estonia' was therefore incorrectly built and certified and not seaworthy for the open Baltic. She was once 1980 only built for protected, coastal trading.
All watertight doors shall be closed at sea. It was impossible on the 'Estonia', because i.a. the public toilets for passengers on deck 1 were in the second and fifth watertight compartments. That the doors were open have been confirmed by passengers and also by the Estline inspectors Karl Karell and Tomas Rasmusson to the Commission (acts A60f, g*), and by the Swedish NMA inspectors.
The Final Report does not mention nor describe the watertight door system at all.
That is another grave error. Water could spread to several compartments in the hull, which caused sudden listing >30 degrees at 01.02 hrs. Passengers saw water on deck 1 forward before 01.00 hrs.
The bridge was probably informed that the ship was leaking and that the engine crew had started the bilge pumps and may have closed some watertight doors. One survivor - Sillaste - has informed that the bilge pumps were running 1.3. When and why were the bilge pumps started?
The Final Report (5) does not even describe the bilge pump system and especially the fact that the bilge pumps suck from the bilge on deck 0 of the hull, which is six meters below the car deck, not from the car deck 2 and the superstructure, which is >two meters above the waterline 1.24.
One survivor (the patrolman Linde) has told the Swedish daily Dagens Nyheter and testified before the Commission that passengers noticed water noticed on deck 1 prior to the accident (the listing). The situation was thus critical. It is probable that the watertight doors on deck 1 at that time were open. But as described in 1.23 the control and indication of the watertight doors on the bridge were unclear - and you could open the watertight doors from the bridge! It is thus possible that watertight doors in the hull, e.g. the doors closed by the crew on deck 0 to isolate the damage, were opened from the bridge and that it contributed to the accident.12
The defective watertight Door System contributed to the Accident
It is a sad fact that the accident could have been prevented at any time between the first heel at 01.02 hrs and until the superstructure started to fill from deck 4 above at say 01.20 hrs by just closing all the watertight doors and starting the bilge pumps at full speed. At that time the damaged and leaking ship was still floating, albeit with >1 500 tons of water on deck 0. If the watertight doors had then been closed, the leakage would have been isolated in one hull compartment, which would have filled up 100%, while the water in the other compartments could have been pumped out. Probably, after first having closed some watertight doors, and then accidentally having opened the doors, there was no more hydraulic power in the system - and the watertight doors could not be closed.
Leakage of the hull as cause of accident was never investigated. The watertight door system is not described at all. The investigation was manipulated from the beginning with a false cause of accident - the visor protecting the ramp of the superstructure.
8 The writer thinks it is hard to understand why the Commission and its sponsor, i.a. the Swedish government refuse to even discuss the content of the Final Report. The Analysis Group, which was appointed to review the actions of various Swedish institutions 1.36, should according to its instruction not review the work of the Commission.
9 Estonian times.
10 The decision not to blame the crew was taken early and is not explained in the Final Report. It was part of the Swedish-Estonian deal to cover up the true cause of the accident.
11 Two Swedish NMA inspectors from Malmö, Åke Sjöblom and Gunnar Zahlér 1.33 surveyed the 'Estonia' the 27 September 1994 at Tallinn. They found many defects. See supplement 223 in the Final report (5) and (31). Sjöblom was asked to shut up and change his early testimonies. Later he was appointed chief of the Swedish Southern and Western Ship Safety Inspection regions. He was paid extra money by Franson to continue shutting up. Now he is retired - but he still shuts up.
12 The writer will in this footnote describe why and how he believes the investigation was manipulated. The ship sank due to leakage and open watertight doors of the hull. The ship was unseaworthy. The visor and the ramp were damaged before the accident. They could not be locked properly and were kept in place by temporary means. When the ship sank, the visor was still attached to the ship, which was confirmed, when the wreck was filmed. However, the films showed the old damages around the visor and these were used to blame the accident on the visor design and manufacture. Later the Commission was told - ordered - only to investigate this cause of accident. But as the visor was still hanging on to the bow (and the ramp was closed), Mr Kari Lehtola told the media a false wreck position and ships guarding the wreck was moved to the false wreck position 2 100 meters Northeast. Then apparently the visor was detached from the wreck under water by divers and fell to the bottom. On 18 October the Commission stated that the visor had been found one mile West of the wreck. No position was given. Later the Swedish navy lifted the visor up from the bottom - naturally at the wreck. No position was given. Later the Commission corrected the false wreck position and informed the alleged visor position - 1 570 meters West of the wreck. This very complicated charade was necessary to be able to blame the accident on the visor. The Commission apparently thought that they could write a completely false accident investigation report by moving wreck and visor around.