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Welcome to a chapter of the e-book Disaster Investigation.


1.11 The second false Cause of Accident 17 October 1994. No Passengers interviewed!

The Commission also presented the cause of accident at the meeting (7) on 17 October 1994. It was stated that defective visor locks was the proximate cause of accident.

It is not known how the Commission could have established this amazing cause so quickly based only on some video films and some interviews with crewmembers. The visor had not been found. Nobody had taken close-up photos of the locks. No details of the locks were avaliable.

No dive inspection had officially been carried out. The rumours that Swedish divers had visited the wreck early October and removed the visor have not been confirmed but need be investigated.

The visor had officially not been found and naturally not been examined. The visor locks had not been investigated.

No damaged parts of the wreck, e.g. the ramp or the visor locks had been salvaged and examined.

The sequence of events of the accident 1.9 had not been clarified. They had not even been put together. We know today that that official sequence, made up, negotiated, long afterward, is false.

The statements of the 137 survivors had not been analysed, experts had not been appointed, no stability calculations had been done, etc. Several survivors had e.g. stated that water had been seen on deck 1, down inside the hull below the car deck (no. 2) before the sudden listing. There were also rumours about water in the engine room. These statements were obviously ignored, censored, by the Commission.

No testimonies confirmed water up on the car deck in the superstructure high above the waterline, unless you believed 3/E Treu down in the ECR on deck 1, who said that he had seen it on a TV-monitor. The possibility that Treu lied 1.48 is conveniently not considered in the Final Report (5).

Blame the Accident on a technical Fault - e.g. some Locks

Historically, the international maritime community has approached maritime safety from a predominantly technical perspective. The conventional wisdom has been to apply engineering and technological solutions to promote safety and minimize the consequences of marine casualties and incidents. Accordingly, safety standards have primarily addressed ship design and equipment requirements. Despite these technical innovations, significant marine casualties and incidents have continued to occur.

Analyses of marine casualties and incidents that have occurred over the past 30 years have prompted the international maritime community and the various safety regimes concerned to evolve from an approach which focuses on technical requirements for ship design and equipment to one which seeks to recognize and more fully address the role of human factors in maritime safety within the entire marine industry. These general analyses have indicated that given the involvement of the human in all aspects of marine endeavours including design, manufacture management, operations and maintenance, almost all marine casualties and incidents involve human factors.

In the 'Estonia' disaster human factors didn't play any role - except some stupid naval architects and shipyard workers making defective visor locks 14 years earlier ashore!

One way the maritime community has sought to address the contribution of the human factor to marine casualties and incidents has been to emphasize the proper training and certification of ships' crews. It has become increasingly clear, however, that training is only one aspect of human factors. There are other factors, which contribute to marine casualties, and incidents, which must be understood, investigated and addressed. The following are examples of these factors relevant to the maritime industry: communication, competence, culture, experience, fatigue, health, situational awareness, stress and working conditions.

Human factors which contribute to marine casualties and incidents may be broadly defined as the acts or omissions intentional or otherwise which adversely affect the proper functioning of a particular system, or the successful performance of a particular task. Understanding human factors thus requires the study and analysis of the design of the equipment; the interaction of the human operator with the equipment and the procedures the crew and management followed.

It has been recognized that there is a critical need for guidance for accident investigators, which will assist them to identify specific human factors, which have contributed to marine casualties and incidents. There is also a need to provide practical information on techniques and procedures for the systematic collection and analysis of information on human factors during investigations.

This book should result in an increased awareness by all involved in the entire marine industry of the role human factors play in marine casualties and incidents. This awareness should lead to proactive measures by the marine community which in turn will result m the saving of lives, ships, cargo and the protection of the marine environment, improvements to the lives of marine personnel and more efficient and safer shipping operations.

However, during the 'Estonia' accident investigation the Commission carefully ignored all human factors aboard and blamed the accident on some people ashore that 14 years earlier made mistakes designing and manufacturing visor locks.

Meaningless Discussion

In April 1997 the writer contacted Forssberg for some clarifications of obvious manipulations during the investigation. Forssberg, surprisingly, replied that he never was going to comment on the Final Report (5), which he then had worked with for almost three years and which then was finalized. One month later Forssberg was dismissed from the Commission by the Swedish government (or he resigned at his own request) after having 'lied' about an old letter. Forssberg was then appointed as an advisor at the Swedish Ministry of Transportation and wrote, again, spontaneously to the writer 30 October 1997 the following:-

"... (it) is meaningless to start a debate about the cause of the sinking of the 'Estonia' before all documents are on the table, i.e. when the Final Report of the Commission is public. I want however emphasize that behind the content of the part report was a united Commission with access to highly qualified experts in your field of technology".

Forssberg, whose trustworthiness is in severe doubt, has since never explained how he managed to establish the cause of accident so fast in October 1994 and what he thinks about the statements of 3/E Treu.

It is thus not known if and how the Commission analysed other causes than the one presented on17 October 1994 as 'one of the most probable causes of accident'.

There is no evidence for the alleged cause of accident announced on 17 October 1994. All other available facts indicate that this cause is false. To blame the accident on innocent persons ashore 14 years earlier is simply ridiculous!


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