37.2
Activities to the End of 1994On 30 September 1994 the Swedish and Finnish JAIC members met again in Turku and according to a memo attached as Enclosure 37.2.447 they dealt with the following matters:
1. Olof Forssberg: Discussion concerning the distribution of the areas to be investigated between Estonia-Finland-Sweden, the forthcoming operation/ organisation: partly help from Swedish side.
Cargo : Estonia and Sweden, possibly controlled by Sweden
Passenger list : Finland
Rescue services: Finland
The Swedish part of the JAIC will hear the Swedish helicopter crews and rescue services.
Weather : Estonia (however each country will obtain weather information from its own weather office).
2. Fax exchange between Finland/Sweden concerning important matters.
3. Next meeting proposed to be in Helsinki after the wreck has been filmed, thereafter preliminary report.
4. Each country keeps a separate protocol for its own file.
5. Estonia's concern about NATO/Russia's interference with the wreck.
6. Dealing with media.
7. Keeping record, archive.
8. Swedish JAIC members shall visit N&T the following day. Stowage plan.
9. Swedish JAIC members shall visit 04.10. Karppinen shall attend on behalf Finland.
10. Heimo Iivonen informed about air rescue in Finland. The Swedish part of the JAIC, LFV had informed the Swedish Rescue Services that they had questions as to the rescue services and the control center.
11. Heimo Iivonen has a good contact to Estonia: Kalle Pedak.
12. Börje Stenström points to the importance of hearing the masters' from 'Silja Europa' and 'Mariella' plus the 3rd engineer of the 'Estonia', Margus Treu.
13. Discussion concerning guarding the wreck.
14. Definition of the term "Skylight": Warning for the crew only (no warning for passengers).
15. Pirjo V. informed that the Finnish part of the JAIC had access to the 'Estonia' drawings.
16. Finally: A Helsinki newspaper is reporting that one of the Estonian JAIC members is involved in a weapon affair!After the meeting the Swedes went home while Kari Lethola and his team stayed in Hotel "Marina Palace" in Turku.
In the late afternoon the wreck was located by the Finnish survey vessel "SUUNTA" and Kari Lethola advised (only) the Swedish part of the JAIC by fax on the same day:"The wreck has now been located:
Latitude 59°23'
Longitude 21°42'
The wreck lies with the port side on the bottom. M.S. 'HALLI' with ROVs tries tomorrow at 10.00 hours to begin the work."The complete fax is attached as Enclosure 24.393.
1 October 1994 :
DAGENS NYHETER :"'Estonia' located at 70 m depth.
'Estonia' is apparently resting on her side at 70 m depth. The vessel was already located 2 hours after the survey vessel 'SUUNTA' commenced her search on Friday (1.10). A ROV can be sent down at the earliest on Saturday (2.10). ...
The master of the F.B.N. survey vessel 'SUUNTA' refuses to analyse the sonar pictures of the wreck. ...
The wreck was found pretty close to the casualty area.
As soon as the wreck has been video-filmed, the commission shall meet in Helsinki to analyse the films. According to Kari Lethola the video films will not be shown to the public until the commission has completed its analysis carefully and quietly.
Lethola does not make definite statements, however admits that a lot indicates the visor to have been the cause of the casualty. "We have a lot of indications pointing to this but no evidence. This we will only get after the wreck has been filmed on video. ...
The commission has finalized the taking of statements from the survivors. On Friday they concentrated on collecting all thinkable information which might have a relation to the casualty. There is eyewitness evidence drawing the investigators' attention to the bow door. However Lethola does not exclude completely the possibility that the cargo might have shifted. "The many reports about banging noises from the car deck could indicate that the cargo did move", Lethola replied.
The Swedish and Estonian parts of the commission have gone home and the commission shall first collect everything concrete to work with.
"Now our work aims at filming the wreck. With the help of the video films we hope to be able to analyse and draw conclusions about the casualty", said Olof Forssberg. "Further investigations are required before we take position concerning possible diving." A preliminary report might come within a week after the JAIC has studied the video films .... . "
The central criminal police in Turku have also been busy with trying to get a hold of the 2nd master Avo Piht who had been onboard the vessel. He was at first stated to have been among the survivors ,but it is now most likely that also he lost his life. The commission has a special interest in hearing Piht's version of the catastrophe. ..."In the evening the Finnish part of the JAIC sent by fax sonar pictures of a large object - see Chapter 24 and Enclosure 24.394 - to the Swedish part of the JAIC only. Attached was also the radar plot of the Finnish Navy showing the tracks of 'SILJA EUROPA' as from 00.12 hours, 'MARIELLA' as from 01.16 hours (which is still before the "official" Mayday) 'SILJA EUROPA', 'TURSAS' and even of two unidentified vessels, however, of ESTONIA only at one position, namely the casualty position. - See Subchapter 22.3.
2 October 1994
DAGENS NYHETER:"Pictures Can Give the Answer.
In Finnish newspapers it was reported on Saturday (01.10.94) that 'Estonia' may have had problems already one hour before finally the alarm was transmitted. The vessel may have deviated from her normal course and may have had problems with manoeuvring as well as with establishing the position and for a full hour deviated from her normal course.
The Finnish JAIC member, Kari Lethola, denied very determinedly that the JAIC should work with such a theory. According to Lethola there was no "normal" route for the 'Estonia'.
"Vessels do not always move on the direct line between two positions. Good seamanship requires the selection of the most advantageous route", said Lethola.
"There are no indications that 'Estonia' should have deviated from her course or should have had problems establishing her position already that long time before the catastrophe. The misunderstanding was probably initiated by the vessel having been one hour behind schedule ... .""Water Penetrated from the Car Deck.
The JAIC puts big confidence on the failure of the visor that caused the casualty. (The JAIC strongly believes that failure of the visor caused the casualty.)
Water from the car deck penetrated the cabins on deck 1 below ...
This was reported to the JAIC by the watch A.B. Silver Linde.
This new evidence supports the theory that water rushed on to the car deck past the bow visor and past the inner bow ramp.
"We are pretty sure that this is the way it must have happened. Otherwise the development of the accident could not have been that quick", said the observe for Sjöfartsverket, Sten Andersson. ... Linde returned to the bridge, where everything was normal when one of the telephones rang. The mate said, that some unknown person, maybe a passenger, reported that something had happened deep down in the vessel.
Note: A passenger cannot phone the bridge. Silver Linde was sent down at once. Down on the lower decks he met passengers rushing up and heard persons shouting that water had entered into the cabins below the car deck.
Note: Water on 1st deck before the big heel. "It was so congested that Linde could not go deeper, thus he turned round and rushed to the information desk to telephone the bridge."
Note: What about his walkie-talkie? "When he was standing there, however, the 'Estonia' heeled and took a heavy list." ... "At about the same time the watch engineer and the technician Henrik Sillaste were in the engine control room. On a monitor they saw water streaming past the bow ramp."
Note: The bow ramp was still in place though slightly open after the big heel.According to Sten Andersson they also saw water on the car deck. ... Sten Andersson refused to speculate about what caused the failure of or damage to the visor. The JAIC does not yet have sufficient documentation to draw secure conclusions. It is hoped, however, that the video films from the wreck will allow this.
"We hope that the films shall bring us the final evidence", said Sten Andersson.
Note: On this day the ROVs filmed the wreck officially for the first time. See Subchapter 25.1.
Sten Andersson: "By the end of next week, if everything goes according to plan, the commission shall complete a first preliminary casualty report."
Note: The above information about the initial testimony of Silver Linde must originate from the first questioning by the commission of the three crew members Linde, Treu and Sillaste in Turku on Thursday, 29 September 1994, which was abruptly ended by Andi Meister. Obviously Sten Andersson in his capacity as observer for Sjöfartsverket did already attend this first hearing (as well as all the following ones).
3 October 1994
DAGENS NYHETER:"New Pictures from the Wreck Point to the Visor.
Everything points to the visor located in front of the bow ramp to the car deck to have been the cause for the casualty. Dr. Jouko Nuorteva, who analysed the sonar pictures taken when 'Estonia' was located, could give them on Sunday a new interpreta-tion. According to Nuorteva the vessel is turned towards East, i.e. not in the course direction as it was believed in the beginning.  The object could according to Nuorteva be the damaged visor or part of the visor. The video pictures shall deliver the information in case the visor should have sustained such a big damage. The investigators now have access to as many video films as still pictures from 'Estonia'. The pictures were taken in black/white and colour.
"The pictures are of a high quality, so much we can say," said Kari Lethola.
"At first the JAIC shall come together to analyse the pictures and thereafter we shall decide what can be published", Lethola said. "After weather improvement we shall try to film as many details as possible. We are going over the vessel 'screw by screw' ", Lethola advised.
The JAIC decided already yesterday to meet in Turku, today, Monday. ... "
"Estonia is Prepared to Exchange the Chairman of JAIC.
Estonia's President, Lennart Meri, is fully prepared to exchange the Estonian Transport Minister Andi Meister, who is jeopardized by Sweden and Finland in the joint investigation of the 'Estonia' casualty. There must not remain the slightest doubt that Estonia wants complete certainty about the catastrophe."
This was stated by the President in an interview last Sunday in Stockholm ...
The 65 year old President has taken it very personally that there was so much mistrust against the Estonian crew and the Estonian JAIC members expressed recently by several Finnish and Swedish civil servants.
He listened politely to the questions, nodded but did not want to become polemical about them. He said slowly, very slowly and with very much self-control after having pointed to all the flags outside the hotel being put on half-mast:
"There was the best trained personnel one can think of on the 'Estonia'. They did their work exemplarily and did everything to avoid that panic broke out. Captain Arvo Andresson, this experienced sailor, stood all the time on his bridge and never left it. He followed the vessel also into the depth. Everything went so fast."
The last days had added doubts about the Estonian Transport Minister Andi Meister as chairman of the JAIC. Among other things the Swedish sea safety experts questioned his competence.
"In this context I can only say that in case there should be indications of a conflict of interest for any Estonian person, we shall exchange him", Lennart Meri replied.
Confidence
He pointed out spontaneously that he himself had appointed a personal representative (for the JAIC), who, with his 40 years in the sailor profession, stood for competence and experience. He has the President's full confidence and he is member of the JAIC.
Note: He means Uno Laur.
The President explained that two Estonian representatives had already left the JAIC and were replaced. He added that they had wished to leave ... ."
Note: These were Toivo Ninnas, Managing Director of ESCO, and Yrjo Saariinen, Traffic Manager of Estline.
See Subchapter 36.2.
LLOYD'S LIST reported on the front page:"'Estonia' Visor Broken Away Evidence of catastrophic failure as submersible finds bow 15 m from sunken ferry
By Jim Muluran, Shipping Editor
Sonar images of the wreck of the 'Estonia' last night suggested the ferry may have sustained catastrophic damage to her bow doors. Pictures transmitted to the Finnish government vessel "HALLI" from an unmanned submersible suggested the visor bow door was lying 15 m from the hull. The underwater survey tended to confirm fears that the failure of the outer visor may have caused the casualty. There was still no indication as to whether there had also been a devastating failure of the inner watertight doors."The JAIC met in Turku on this and the following day and viewed the video material produced by the ROVs from the "HALLI". It has to be assumed that it was then decided that the visor had to be considered "not yet found", although somebody must have told Lloyd's List before that the visor had been found. The reasons for such a tactical manoeuvre are obvious: The visor next to the wreck implies a longer sequence of events and rules out a rapid development undetected by the crew until it was too late. The visor close to the wreck also rules out the possibility that the visor might have pulled open the bow ramp when the vessel was still at full speed or, at least, making headway.
4 October 1994
DAGENS NYHETER:"Film Pictures Show the Visor to Have Been Torn Off
Video pictures show that the whole visor was torn off 'Estonia' ... and that the watertight ramp at its inside was about 1 m open. Therefore the car deck became quickly water-filled and the vessel capsized. .... The experts cannot say whether a heavy wave or fatigue of the material have caused the catastrophe. The video pictures demon-strate without doubt that is possible on a modern ferry that the whole visor weighing many tons can simply be torn off. This could be the explanation for the 2 bangs many survivors have heard. ...
The visor was pushed upwards with such force that it broke loose from its hydraulic locking devices and left big holes in the steel plates. ...
The visor has still not been found although ROVs have been used in addition. The reason for this is certainly that the visor fell off more than on hour before the vessel sank. The bow ramp is in position but its locking devices are also damaged. The bow ramp has to ascertain/maintain watertightness even if the visor is damaged, however, it is about 1 m open. The JAIC draws the conclusion that the water quantities which ingressed through the open ramp were sufficient for the vessel to loose the stability and to capsize.
Why the visor was torn off and why also the locking devices of the bow ramp are damaged the JAIC cannot say for the time being. "We need time for us to find the answers why the visor became loose", said Olof Forssberg. According to Forssberg this could be for example a heavy wave, too high speed under the prevailing conditions and too high load.
The JAIC members warned not to draw conclusions with regard to other car/passenger ferries. They would now investigate whether the 'Estonia's' construction would deviate from the construction of other comparable ferries. According to naval architect Börje Stenström, JAIC member, it is already clear that the ferry traffic shall have to face serious consequences even if the answer to the question what caused the casualty should not be found.
"It has to be emphasized that the Atlantic lock of the 'Estonia', which is an additional locking device for heavy weather, had been engaged," said Stenström.
Failure of Material Far-fetched
Stenström does not want to speculate completely about the causes why the lock mechanism failed, however, he stated that failure of the material seemed to be far-fetched. "Then you may rather imagine overload."
Technology Doctor T. Karppinen ... stated that the sea state had influenced the tearing off of the visor. According to Karppinen the pictures of the open bow ramp did support the reports of two engineers that water ingressed through the bow ramp. That they had seen on a monitor."SVENSKA DAGBLADET:
"Estonia's Visor Torn Off
Pictures of the wreck of 'Estonia' published Monday evening by the JAIC do confirm that the bow visor had broken off the vessel ... .
Thereby the theory is supported that the damaged visor caused the casualty ... . The JAIC gave some preliminary explanations of the video pictures taken during the first ROV examination, but was careful when commenting the cause of the accident. "Today we are able to say what approximately happened, but we are far away from being able to state why it happened", said Olof Forssberg."
"Olof Forssberg: "Today we can approximately answer the question: What happened? However, we cannot answer the question: Why did it happen?"DAGENS NYHETER:
"Norwegian Mini Submarine Can Help
A Norwegian special-purpose vessel for deep sea photography can be engaged for the examination of "Estonia".
The vessel's name is "Seaway Commander" and it is equipped with 3 remote-controlled mini subs. It is one of the most modern vessels of this type in Northern waters.
The vessel arrived Monday p.m. in Nynåshamn after having left Haugesund on Friday.
"It speaks a lot for the vessel to proceed to Hangö during the night", said Leif Aspen, operations manager of the Norwegian offshore company Stolt Comex.
According to Aspen they are in negotiations right now with the Finnish Coast Guard and the JAIC to obtain the order to examine "Estonia".
The 3 mini subs differ in dimension. The two bigger ones weigh ca. 4500 kg each and the small one just 200 kg.
"The two big ones are equipped with cameras and manipulators, these are special robots with claws that can pick up objects from the sea bottom", said Leif Aspen."
Note: The "Seaway Commander" left the area after several days of futile waiting because the Finns and Swedes engaged exclusively government respectively navy vessels in the operation until the visor had been recovered and whatever else had been clarified.SVENSKA DAGBLADET:
"Officer's Statement Supports Video Film
Six days after the catastrophe the only surviving officer having been on duty spoke at a press conference in Tallinn. The 3rd engineer and watch-keeper Margus Treu was in the engine room of the vessel at the time of the casualty. In the case that his evidence is true it is once and forever established that "Estonia's" sinking was caused by the tearing loose of the bow visor.
In spite of Treu being an experienced sailor it was difficult for him to explain what actually happened.
- "At 01.00 hrs. I saw on my monitor in the engine room that an AB sailor went his control round and that he was just forward at the bow ramp."
This information, however, does not conform with the statement that AB sailor Silver Linde made during earlier interrogation by the Commission. Linde testified there that he had completed his round already at 00.30 hrs. by turning a control key behind the bow ramp.
Heard Hard Bangs
Between 01.12 and 01.15 Margus Treu heard 2 to 3 strong bangs in the vessel.
"These were not the waves. They did not sound like from waves even if the waves are very strong. I thought that trucks had started to move and crashed against the shell plating."
He switched his monitor to the effect that he could see the truck. Thereafter he changed the camera and had a look at the bow area. "There I saw that water rushed onto the car deck. Then the vessel had already taken a list. Simultaneously the mate called from the bridge asking: "Can we restore the balance of the vessel again?" Treu tried to pump water over to the other side which failed. The mate asked again:
"Is it possible to pump out freshwater to regain the balance?" Treu replied:
"This is not possible, this is technically impossible."
The Engines Were Running
He also denied information that the engines had stopped long before the vessel sank. No water entered the engine room as long as he was there.
"At 01.25 hrs. I tried to start the port one but it failed. The starboard engines kept running for some minutes more. Then they also stopped."
Washed into the Sea
Thereafter he crept up to the 8th deck and pulled himself to the aft just when the sinking was interrupted.
- "Then I was washed into the sea by a giant wave. I succeeded in pulling myself up into a lifeboat."
From there he saw that the bow visor had disappeared when "Estonia" disappeared into the deep.
After the press conference Margus Treu criticised the interrogations by the Estonian police. The Estonians went very far with their ambitions to clarify the causes for the casualty.
On Friday (30 September, i.e. 2 days after the casualty) all passenger lists and Estline's complete documentation concerning "Estonia" were confiscated by the Estonian Security Police.
Note: On 5 October N&T declared the withdrawal from the Stockholm-Tallinn ferry service (which remained a decla-ration only for the years to come because they continued until 1998). On Monday, 03.10., also Sten-Christer Forsberg, technical director of N&T, went very far when he strongly attacked the Swedish Ship Engineers' Association:
- "Their categorical allegations against the Estonian engine room crew is shameless and insulting. The purpose is to make use of the situation for own policy."LLOYD'S LIST reported among others:
"Asked whether the video tapes would help to establish the cause of the disaster, Kari Lethola said: "I hope so, but this is not the only method we use."
Speculation that the bow door had been torn off... heightened yesterday with a Finnish News Agency report that sonar pictures of the 'Estonia' showed a large object lying 10 to 20 m from the wreck. Tuomo Karppinen said: "We have not seen that kind of large object." Marine geologist Jouko Nuorteva, who located the wreck on Friday (30.9.) using a sophisticated sonar device, told the Finnish News Agency (STT) yesterday: "The observation of a large object is certain. It was seen on all the 4 sonar pictures that were taken from 'Estonia' on Friday."
5 October 1994
LLOYD'S LIST reported among others:"Swedish JAIC member Olof Forssberg said the film showed what had happened, but did not say why. "The hardest question remains to be answered: Why did the locking mechanism fail? The big question is, why did the bow visor break off. Before that is known, we cannot establish the cause", he said. "We are at the start of a very long road. We still don't know where the visor is. We will start looking for it immediately." Questioned about possible causes why the visor became loose, Lethola said: "They can be technical, they can be human, but they can be also because of the sea conditions with extremely high waves."
SVENSKA DAGBLADET published an article with the headline:
"Sabotage Theory Written Off Mate reports about last hours onboard. Tallinn, SvD."
a copy of which was faxed to the Finnish by the Swedish JAIC upon instructions of Olof Forssberg. On his request Gunnel Göransson (the Swedish administra-tor) wrote the following remark on the faxed copy: "I want this evidence to be followed up! Olof." See Enclosure 37.2.448.
The article reads as follows: "'Estonia' had a problem with the bow visor already before departure from Tallinn harbour. Such a theory can be found in the investigation material of the Tallinn police according to the experience of SvD made in Tallinn. However according to mate Einar Kukk, who was trainee onboard the 'Estonia', those in command on the bridge did not receive any information that this should have been the case. Kukk was on the bridge between 20.20 hrs. and 00.40 hrs. local time. "During this time a possible failure of the visor was not discussed", said Einar Kukk to SvD. The Tallinn police have interrogated 58 survivors, of whom 33 are crew members. Many of them state that they heard a distinct metallic noise before 'Estonia' got the list. "But none of them took the view that this resulted from a collision", said the investigator Väino Karmi. The investigation by the police, which runs parallel with the investigations by the International Commission and the Swedish police, indicates that the theory about sabotage can be probably written off. "No such information did come up", said V. Karmi. He is upset about accusations that the Estonian security police did try to hide important witnesses. "When the survivors of the catastrophe arrived at Tallinn Airport we guided them away from the intensive shadowing by the media. Even you journalists have to understand that people having just escaped a tragedy should not be exposed to questions."
Fraud with Cargo Weights
Väino Karmi is well acquainted with MV 'Estonia' since the Tallinn police initiated an investigation into fraud with cargo weights earlier this year. The trigger off factor was the smuggling of 64 Kurds who were hidden in a Swedish truck. Karmi is of the opinion that many freight forwarders systematically stated lower values to avoid high customs fees. "Each time the Estonian customs made spot checks they found wrong declarations." SvD did scrutinise the "Estonia's" cargo manifest. The 39 trucks contained everything from furniture and timber to frozen fish and fashion clothes. Two trucks were declared empty, but the Tallinn police has no confirmation of some rumours that refugees should have been onboard.
Note: There were actually 40 trucks onboard. See Chapter 17.
Trainee Mate
Mate Einar Kukk was onboard the 'Estonia' to gain practical experience before taking up his normal duty as 2nd mate on "Estonia's" sister vessel 'Vironia,' the previous 'Diana II'. 'Vironia' shall take up the traffic at the beginning of November. Kukk reports about the last hours onboard:
- "I left the bridge at 00.40 hrs. Then everything was under control. I went to bed just before 01.00 hrs. After ca. 5 minutes I heard a strange noise which I had never heard before at sea."
Kukk went up to see what happened. When he was still in his cabin the vessel started to heel over seriously. Kukk's statements also indicates that 'Estonia' took a list already 30-35 minutes before the casualty. .."DAGENS NYHETER :
"Vessel's Command Criticised by the JAIC "
After the visor broke off the 'Estonia' was doomed if the vessel was not turned rather quickly which was not done." That's the way Tuomo Karppinen expressed himself. The JAIC came out with a preliminary report about what caused the casualty after their meeting in Turku on Tuesday.
According to the JAIC the casualty one week ago had been caused by water on the car deck which ingressed via the forward ramp. Why the visor broke loose is not explained. The JAIC declared that it could have been caused by fatigue as well as by one single overload of the locking devices. Thereafter the visor broke off and the inner bow ramp was exposed to such wave loads that the locking devices gradually gave way and the ramp opened some meters.
This had been sufficient to take in so much water on to the car deck that the vessel became unstable, heeled to starboard and capsized. How fast this developed after the visor broke off the JAIC is unable to say.
One A4 Page
It is also unknown "which information about the immediate danger did exist on the bridge", as they expressed themselves. One A4 page with short factual comments is all that the JAIC has achieved so far in the investigation of the human tragedy without comparison in Europe after the war.
Many of the experts and members of the JAIC to whom DN spoke did agree in one matter: It is considered to be more or less impossible that ferry proceeded on against the prevailing sea conditions with the 15000 ts heavy ferry without noting that the visor and also parts of the foreship were torn/broken off.
"They should have seen from the bridge that the visor had disappeared", said T. Karppinen.
"It is for me not understandable that one can proceed against 8-10 m high waves without noting that the visor has disappeared", said Sten Anderson who has sailed as master for 17 years and is now observer for Sjöfartsverket to the JAIC.
"It is very difficult to understand that they proceeded on without visor for another hour", said Börje Stenström.
All these comments mean subliminally that those in charge on the bridge after midnight were not competent. Another possibility is that the visor was torn off and the inner ramp damaged by one single wave which did not give the watch officer time to react.
Different Versions
The statements from the surviving crew members, however, do not confirm the above version of a development within seconds after which the vessel was doomed to capsize. The JAIC's hearing of the crew did clearly reveal that the watch A.B. Silver Linde made his last watch round at 23.30 hours Swedish time. At this time he had turned a key which confirms that he did make his round. Then he heard a loud bang from the ramp and had to hold himself fast not to be knocked off his feet on the car deck. He did nevertheless not draw the conclusion that something dangerous had occurred as the vessel continued to pitch in the heavy seas. Exactly this indicates that what Linde heard was a part of the casualty scenario: He was used from many times before to holding himself against the vessel's move-ments and would not have paid attention unless something special occurred.
"Everything normal".
When he came to the bridge half an hour later there were the 2nd and the 4th mate. At the same time also Captain Arvo Andresson appeared. According to Linde everything was normal on the bridge. Thereafter the phone rang and somebody advised that there was something wrong down in the vessel. Apparently now large quantities of water were penetrating.
Only 24 minutes after Linde and the master came up to the bridge the emergency call "Mayday" was sent. About 20 minutes later the vessel disappeared from the radar screen of "Mariella". If the heavy bang heard by Silver Linde on the car deck at 23.30 hrs. had been caused by the breaking off of the visor, the vessel must have proceeded on for at least half an hour without bow visor and also without those on the bridge noting what had happened. Ab-solutely clear is that the master really tried to save his vessel after he understood what had happened, it is however unclear when this was.
- The pictures from the wreck show that the rudders are almost on hard astarboard and the propellers are in a position indicating that the speed had been reduced, said Tuomo Karppinen. It is, however, unclear when this manoeuvre was made and how long the speed had been reduced. Sten Andersson pointed to the fact that the reducing of speed in the prevailing wind and sea conditions was the only professional way to handle the vessel.
- However none of the surviving crew members from the engine room talk about speed reduction for any longer period of time. It is extremely important to adjust the speed, this is of particular importance for a vessel with bow visor. According to Sten Andersson the crew "did not judge the circum-stances properly" during that night. Karl-Johan Hagman drew attention to the fact that Estonian vessels with 'Estonia's' engine power are unusual.
- The crew probably did not realize how dangerous it is to proceed with full output of 24000 hp against the heavy waves, an output that was needed to break half meter thick ice.
If the visor should be found near the wreck everything points to a very quick development. The visor then broke loose shortly before the vessel took such a list that all 4 main engines stopped due to lack of oil pressure.
If, however, the visor should be found a longer distance away from the wreck, this would indicate that the vessel proceeded for some time against the heavy waves without visor. The competence of the crew has to be questioned. Then the JAIC's chairman, the Estonian Andi Meister, does not believe anything of this at all:
- According to my opinion the catastrophe was caused by a material failure. "I cannot blame the crew".
Note: When being interviewed by Jutta Rabe on 01.05.97 Andi Meister stated among other things that "the JAIC had decided to use this casualty to set an example by teach-ing the shipbuilding industry a lesson." This required a casualty scenario permitting a cause consideration pointing to the shipbuilder, i.e. the building yard - Meyer Werft in Papenburg.
The TÄGLICHER HAFENBERICHT (Daily Harbour Report), Hamburg published the following:"The JAIC has yesterday published a preliminary report after having analysed the video films from the wreck and after having interrogated the survivors. The report reads as follows:
1. The JAIC is of the opinion that the casualty was doubtless caused by an accumulation of water on the car deck.
2. The JAIC is also convinced that the water penetrated the car deck through the forward ramp.
3. It was established that the bow visor was lost at a certain time. The bottom lock has been identified by ROV. The lock turned out to be broken. It could not be established however whether the failure had been caused by fatigue or overload.
4. After the visor had fallen off, the inner ramp was exposed to the pressure devices of the ramp to fail in steps and the ramp did open to some extent. Thereby water could penetrate the car deck. It could not be verified whether the locks of the ramp were out of function, i.e. were damaged or whether the ramp moved forward out of a locked position. It has not been possible to clarify whether the damages to the hull in consequence of the tearing off of the visor did cause further leakages.
Note: Item 3b of the Smit Tak report after the diving survey in December 1994 reads: "b. Construction damage. Except for some minor buckles in the superstructure at the stern near deck 8, damaged/broken railing and broken davits on the deckside, the lost bowdoor and damaged forward ramp some broken windows/ port-holes including the cuts made by the divers during the internal inspection, there is no constructional damage to the ship observed." As the videos were cut at the relevant areas the conclusion is unsupported by evidence, leave alone that the mudline video shows holes, however not caused by physical impact but by corrosion. See Subchapter 29.5.
5. The development in time of the different occurrences could not be determined.
6. It has not been established whether faults of the hydraulic of the locking devices could explain why the locks of the ramp did open at a particular time.
7. It could not be established so far which information about an immediate danger had been available on the bridge before the casualty and which measurements had been incurred onboard.
8. No signals from the EPIRBs of the vessel were received. It could not be established whether the transmitters in some way fell off the vessel or if the lists prevented their functioning."
Note: At the time of the writing of this 'preliminary report' the Estonian JAIC members knew that the EPIRBs had been found along the Estonian coast in "switched off" condition. This information was, however, passed to the Finns/Swedes only 21/2 months later. The preliminary report dated 04.10.94 is attached as Enclosure 37.2.449.
6 October 1994
Kari Lethola reported to Olof Forssberg (only) about the search for the visor - see Chapter 24 - and was requesting the assistance of Swedish navy vessels. The Norwegian vessel 'SEAWAY COMMANDER' was still in the area and the public apparently was demanding from the Finnish and/or Swedish Governments to make use of this very sophisticated vessel, which was obviously not planned, but increasingly caused concern to Kari Lethola and his colleagues.
Lethola also reported that debris was found near the wreck which indicated the drifting direction of the ESTONIA. Also on his fax of 06.10. the area then searched is marked, i.e. 1 nm to the West, 2 nm to the East and 1 nm to the South. As the visor was finally "found" according to the logbook entries of the 'NORDICA' about 1400 m to the West of the wreck, the visor must have been in the above described area.
Otherwise SvD reported about complaints of the Tallinn police about the lack of co-operation by the Swedish police in the following article published on 6 October:SVENSKA DAGBLADET :
"Estonians Not Satisfied with Swedish Police
The Estonian police require new information and help from Sweden to be able to carry out the work necessary to investigate the 'Estonia' catastrophe. The highest police management is disappointed that no better assistance is provided by the Swedish police and other autho-rities. Finland, however, has supported the Estonians on different occasions already without the Estonians having to beg for it.
Priit Männik, Deputy Manager of the Central Intelligence Department of the Estonian police said that he hoped for an improvement during next week. Then the leader of the preliminary inquiry by the Swedish police, Chief Prosecutor Birgitta Cronier, shall come to Tallinn together with several Stockholm police investigators. Männik, a powerful guy ... has his desk in the head office at Piikgatan, where also previously the head office of the KGB had been.
Difficult to get Information
- It has been difficult to obtain information from Sweden and the Swedish police did not get in contact with us up till now. The Finnish police, however, have been much more active, said Priit Männik. The information he is lacking deals among other things with the passengers who had been on board and who were delivered into Swedish hospitals, with 'Estonia's' technical equipment and with information from the Swedish Shipping Inspection (Sjöfartsverket).
- We have no access to the Swedish inspection made before the last departure here in Tallinn on 27 September in connection with the training of Estonian inspectors, he said. Transport Minister Andi Meister, chairman of the JAIC, criticised for not having allowed the first hearing of survivors to be performed the way required, said on Wednesday that the Estonians had still not been informed who is in Swedish hospitals although many days have passed since the 'Estonia' casualty.
Invitation to the Swedish Police
Police chief Männik would like the Swedish police to come to Tallinn and participate in the investigation. He and his investigators have now taken the statements of all 61 Estonian survivors. On Wednes-day they commenced analysing the statements. They are working in accordance with 3 main theories why 'Estonia' could have sank, but Priit Männik is like a clam if he is asked questions in this regard.
- I have agreed with the JAIC not to go public before their preliminary results are clear. The technical aspects have to be carefully considered in our investigation. Estonia has so far not put forward any suspicion for a criminal offence.
- According to Männik the witness statements from the surviving Estonians are very contradictory. One of the problems is to find the time when what happened.
- He sighs about the confusion which continues to exist about who had really been onboard of the 'Estonia' and refuses to state any number: "This is changing every day."
7 October 1994
On this day INTERPOL Tallinn sent out by fax an urgent message to the INTERPOL offices in almost all the European capitals to search for and locate the missing 2nd master of the ESTONIA, Captain Avo Piht.
Note: This INTERPOL initiated search implies that Avo Piht must have been saved and that he had evidently been ashore.
The message with photo of Avo Piht is attached as Enclosure 37.2.450. Also the expert for military operations in the Swedish JAIC, Rune Lundin, informed the Finnish JAIC about the names of the Swedish mine hunters being on standby in case the Finns wanted to use them.Furthermore DAGENS NYHETER reported:
"Debris from 'Estonia' Found
The crew of 'Tursas' has found small pieces of metal debris from 'Estonia' when analysing the sonar pictures taken on Thursday.
- The pieces, however, are so small that they hardly show the way 'Estonia' was drifting. The visor we have still not found, said Kari Lethola. When the search was discontinued on Thursday 'Tursas' had been between 1 and 11/2 nm distant from the wreck. During the search 'Tursas' had found a wide ranging area with a very thick layer of mud. ...
Object Squeezed into Ramp Opening
Films from the wreck show some sort of red material near the open bow ramp through which water ingressed to the car deck. The object looks like a mattress. "This is a mattress which you see on the pictures", said Kari Lethola.
"We have discussed this and came to the conclusion that something is jammed in at the bow ramp. This detail has to be filmed again."
"We have studied the drawings and there is a bed-clothing store located right inside the bow ramp." Kari Lethola does not dare to say whether somebody has tried to seal the gap between ramp and bulkhead by means of mattresses or if the mattresses visible on the video film could have floated up and got squeezed in after the vessel sank."Also SVENSKA DAGBLADET reported :
"Damage to Visor Locks is the Main Question
The JAIC is now focusing on the question whether the locking device systems holding visor and bow ramp in place were faulty or damaged.
"This is one of the main questions we are concentrating upon", said Uno Laur. As soon as the weather permits the 'Suunta' shall send the ROV's down again, this time for a special documentation of the locking devices. The combination of the broken off visor and the open ramp confuse the experts, simultaneously it does point to the locking systems being a weak point in the sequence-of-events.
"The visor broke off completely or in parts which could have been caused by damaged locks. Thereafter huge water quantities were smashing against the bow ramp, the inner door. This has to be watertight and has strong hydraulic locks.
According to Johannes Palmgren, expert in Shipinspec., the ramp should withstand the waves, even if the visor should be gone - at least for the time it takes the crew to realize that the visor has disappeared.
The videos from the sea bottom show that the ramp is about 1 m wide open at the upper side. The gap continues at both sides and narrows continuously.
"Nowhere do you find an answer to the question why different locking systems failed almost simultaneously", said Uno Laur. On Thursday the experts of the Estonian part of the JAIC com-menced looking at the 16 hours of video film available. SvD received permission to join the marine experts while viewing the videos.
Sharp pictures.
Remarkably sharp pictures from 'Estonia's' propeller triggered off an intensive discussion. The question what speed was she making on her way to disaster is most relevant. The 15 kn which were the rule in heavy weather could have been too much. Nevertheless, what happened after the crew discovered free floating water on the car deck?
Was the speed reduced to minimize the water ingress or did it come too late?
"There are relations between the angles of the propeller blades which indicate the speed of 'Estonia' just before she sank. On the film a rather small angle is visible which indicates rather low speed", said Uno Laur.
However the picture of the propellers do not say anything about the earlier speed. Most important: Did they lower the speed after 3rd engineer Margus Treu had reported to the bridge that there was water on the car deck just after midnight (Swedish time), i.e. 35-40 minutes before 'Estonia' sank?
The Angle Controls the Speed.
- Those in charge on the bridge can reduce the speed directly by changing the angles of the propellers (blades). The engineer has nothing to do. The four main engines can continue with unchanged revolutions, Laur pointed out. It is nowhere documented that those in charge on the bridge actually did reduce the speed after Treu's alarming them, said Laur. The combination of the damaged or torn off visor, open ramp and excessive speed might have been the death sentence for 'Estonia'.
No Questions from the Owners
The Estonian part of the JAIC, of which Uno Laur is the member directly representing the President has difficulties receiving the required information quickly which is probably due to the politicians trying to influence the investigation heavily. Already on the 29th September they requested drawings, sketches and calculations for different parts of the 'Estonia'.
After six days, yesterday was Thursday, there was still no reaction. From B.V. the JAIC received a letter on Thursday with the offer to help. The letter was sent by normal mail and was thus only received after 6 days.
Finally fax contact has been established with Paris and the Estonians have requested all relevant information from the classification society B.V., which surveyed 'Estonia' in the beginning of 1993, which included also the visor and the bow ramp.
"They are frustrated that nobody has access to the drawings of visor and locking devices", said the marine engineer Heimo Jaakula, one of the Estonian experts and advisors. ..."
9 October 1994Kari Lethola sent by fax the following message to the Swedish JAIC:
"Message: Good morning! Due to bad weather the search for the visor was discontinued during the whole day, but now Nuorteva has further analysed the pictures. At the location on the sea bottom, where "Estonia" on basis of the object did capsize, there is a 10 m long and 5-7 m broad object on the bottom. It is probably of metal. The form fits well with the visor. Depth is 70 m, the bottom is hard. Karppinen, Aarnio and the ROV I team go onboard of "Tursas" at Nagu at 11.00 (Finnish time) and the work starts at ca. 13.00 hrs. They shall video film at first the "large object". Attached please find a sonar picture including an enlargement of it."
Note: Again they indicate that the visor is lying next to the vessel and even that ESTONIA on basis (or because of) the object (the visor) did capsize. For details see Chapter 24.
10 October 1994
Kari Lethola to the Swedish JAIC:
"Message: Good morning! The large object turned out to be a steel plate. The search for the visor has again been discontinued due to strong wind. Nuorteva is of the opinion that is it not useful to continue the search without having drawn up a probable plan. It does not make sense to drive around at sea into the blue. It takes a few days to make up the plan. This is the reason to consider whether the Swedish vessels should come along. What do you think about it?"
Note: Now the probable visor next to the ship is a steel plate of 70 m² adjacent to the wreck. How did it get there and why, is it never mentioned again?The Swedish JAIC replies as follows:
"Thanks for the fax. From Sweden Hans Rosengren, Sten Andersson and Börje Stenström are coming to Turku. ... Concerning the question about the participation of Swedish vessels Olof shall revert soonest. He is in a meeting right now."
The reason for the trip to Turku was the arrival of 'DIANA II' at the Turku Repair Yard where she was prepared for flag change from Swedish to Estonian flag and name change to 'VIRONIA', which was subsequently changed to 'MARE BALTICUM'. Onboard of 'DIANA II' were some of the ESTONIA survivors and a number of members from ESTONIA's 2nd crew. Moreover 'DIANA II' was a near sister to ESTONIA with more or less identical visor and bow ramp constructions including the locking systems. All this was to be closely inspected by the Swedish and Finnish JAIC members and the Sjöfartsverket observer Sten Andersson. The detailed photo documentation existing in the files of the Swedish JAIC was made during those days.
Tuomo Karppinen sent the following fax to Börje Stenström:"Börje, Thanks for your fax and the good pictures of visor and ramp. We changed our plans and went out already on Sunday because we thought that we had found the visor by sonar. We could not find the visor by ROV. We filmed again visor and ramp by ROV. A summary of our observations is attached. I will have the video film with me and we can look at it on Monday evening at Nådendal if this should suit you."
Note: This is confusing because Karppinen states on the one hand that they could not find the visor by ROV, but says on the other hand that they filmed again visor and ramp.In Stockholm the Swedish JAIC members met with the prosecutor Birgitta Cronier and her assistant.
11 October 1994
The Swedish JAIC sent by fax to the Finnish JAIC the following information:
"Good morning, Kari. Here comes a fax from the embassy in Tallinn with information about the newly formed Estonian commission and its members."
The fax from the Embassy reads as follows:
"To the Foreign Ministry,
re: M.S. 'Estonia':
Estonian average commission The Estonian Government decided on Friday, 7 October, that the government commission under Transport Minister Andi Meister shall be dissolved. He had been instructed by the government to co-ordinate all operations in connection with the sinking of the 'Estonia'. At the same time another average commission was formed which shall represent Estonia in the joint Swedish-Finnish-Estonian Commission. Also the newly formed commission is headed by Transport Minister Andi Meister. The other members are:
The Tallinn Harbour Master Eduard Hunt
The General Director of the Border Control Tarmo Kouts
The Managing Director of CMM Uno Laur
The General Director of the Sjöfartsverket (E.N.M.B.) Kalle Pedak
The Under Secretary in the Foreign Ministry Indrek Tarand
The Vice General Director of the Rescue organisation Kalev Timberg
The Director of the Labour Inspection Mati Jarvis"The note by BNS dated 07.10.94 is attached as Enclosure 37.2.451.
12 October 1994
Fax Kari Lethola to Olof Forssberg:
"Message: Heimo Iivonen has now investigated the possibilities of continuing the search for the visor. We are ready to commence the search on Monday, 17.10. We will receive assistance from Navy forces. Dr. Nuorteva is employed by them. If it suits you, we are requesting that Sweden sends an expert in mine searching by Friday, 14.10. He could come along with the Finnish reconnaissance vessel and simultaneously he could prepare himself for the situation, in case assistance from Swedish vessels should be required. Assistance might become actual at the beginning of week 43, i.e. as from 24.10.94.
If our proposal suits you, we kindly ask you to inform us of the name of the expert and contact details."
Note: Now they receive assistance from the Finnish Naval Forces with whom the sonar expert Dr. Nuorteva is employed. Nevertheless they need the help of a Swedish mine hunting expert already by Friday, 14.10.94, although the search for the visor was scheduled to commence only on Monday, 17.10.94.In Stockholm the Swedish JAIC informed the heads of the Ship Owners Association and other shipping organisations about the information then available.
Up to now the extensive exchange of information or rather a more or less continuous stream of information just went from Finland to Sweden, Estonia was bypassed. Only on 12 October, when the Finnish and Swedish experts were already onboard of "DIANA II" Olof Forssberg informed Kalle Pedak, General Director of the Estonian Sjöfartsverket (E.N.M.B.), by the following fax:"MV ESTONIA Accident
I am assuming that you are the coordination point for the communi-cation about accident investigation matters and I am therefore forwarding the following information to you.
Note: Forssberg knew of course that Andi Meister being the chairman was the point of entry but politeness is not known to be one of his virtues.
1. A few technicians of the Swedish and the Finnish parts of the investigation board are visiting the shipyard at Nådendal in Finland on 11 October to study the Diana II, sister ship to Estonia. The visit is primarily for general familiarization, including study of ramp detail. The bow visor is unfortunately welded shut so the visir and ramp function cannot be examined in detail."
Forssberg then continued with other matters: "
2. We understand from newspaper articles from Tallinn that you are disturbed by Nordström & Thulin not providing you with desired technical information. According to our agreement on division of the work the Swedish side has the responsibility to collect drawings, technical reports, etc.
Please let me know what information you are looking for an we will provide such information if readily available to us.
3. We understand from various information sources, primarily newspapers, that some additional crew members, besides the four we knew about on 29 Sept, were rescued. We would appreciate if you can confirm if that is the case and give details for our general information.
4. We would appreciate if you could send reports of the hearing of Estonian witnesses. We will make the translation."In response Pedak advised by phone that two professors from the Tallinn University would also attend on the 'DIANA II' and that they had been promised by B.V., Paris that they would supply them with the required documentation.
In summary of the information submitted so far on the previous pages, it can be concluded that the Finns and Swedes co-operated quite closely in matters concerning the wreck, the visor and whatever else might have been on the bottom of the sea in this area, however without informing the Estonians at all. On the other hand, the Estonians did withhold information, at least as long as possible, in all matters throwing a bad light on the ferry, the crew and/or the E.N.M.B. and the ESCO/Estline organisations including possible explosions onboard. Thus already from the very beginning the JAIC was split into two groups of interest, i.e. the Finns and Swedes on the one side and the Estonians on the other, and it is quite obvious that it would be most advantageous for both sides if a casualty scenario and a cause consideration could be found which was simple to understand, close to reality and which did not affect the interest spheres of any of the three countries represented in the JAIC, but could be used "to set an example by teaching the shipbuilding industry a lesson" (Andi Meister).
13 October 1994
On the day the Swedish JAIC met Sjöfartsverket in their Norrköping head office. Details are unknown.
14 October 1994
Kari Lethola reported to Olof Forssberg by fax:
"Message: Good Morning! Attached please find the morning news from Finland. I hope they are legible, it is a question of fax to fax.
Regards Kari
1. Attached I am sending you the previously mentioned summary of the Kikuts interrogation.
2. As Börje certainly did report the crew of "Vironia" (previously "Diana II") is now here in Nådendal. There are dozens of persons having for one year or so worked onboard of "Estonia". They know a lot about the vessel's matters. Among others there is also mate Kukk, who shall possibly be heard by us in Tallinn. "Vironia" shall stay at Nådendal for 2 weeks. Is it useful to hear these men by the Commission, e.g. by the end of next week? Will you be sending a representative from your side to here? Part of the men only speak Estonian. We could arrange for a proper tape recording at Nådendal. (Handwritten note on the left side: To be taken up in Tallinn 17.10.)
3. I have asked an expert at PCIMA, a teacher at the Institute of Technology Kotka, Seppo Rajamäki, to help us analyse the radio communication which took place here in Finland. He is teaching radio communication to ship officers. It is the intention that to begin with he will correct the original transcripts of the tape recordings which were typewritten and to attach a time table to the text.
4. PCIMA's expert in navigation electronic, Asser Koivisto, has met some Russians. They reported that a NAVISAILOR 2000 ECDIS chart system of Russian make had been installed on "Estonia" which registers the covered route, speed and the like. It is possible to take out data from the installation even after it has been in sea water for sometime. In case Sweden should decide for reasons of ship-technical investigations or for other reasons to have the wreck examined by divers, the above-mentioned installation should be brought up, according to Koivisto, the matter should be given a relatively high priority and should be speeded up. The Swedish pilot Benny Pettersson, who frequently piloted "Estonia" knows the exact location of the installation on the bridge.
5. We hope to make video images of the key areas on the new video films. It is our intention to send a series of colour copies to each country before Tallinn. In addition we are preparing several copies for an eventual press information. I assume that a similar number of journalists will be coming to Tallinn as were at our last meeting in Turku. The really international press will hardly come at all. Yesterday when we published the Mayday tape there was only one journalist present who did not understand Swedish and Finnish.
6. Finland's police have collected in Hangö Freeport the liferafts from "Estonia" that floated ashore and delivered by various vessels. There shall subsequently be an inspection report on each raft. FBN inspector Jan Jansson, who is also expert to PCIMA, had a look at them. There are also rafts in Estonia (some of them have already been stolen)."
17 October 1994
This was the day of the 3rd meeting of the JAIC, this time in Tallinn. At the meeting the questioning of the key witnesses from the crew was continued respectively started again from the beginning. According to the notes of Tuomo Karppinen the 3rd engineer Margus Treu, the watch A.B. Silver Linde and the trainee mate Einar Kukk were heard. As usual with this commission it was not an organised taking of statements, but the witnesses were questioned in the presence of the whole JAIC and everybody asked what he wanted to ask.
This time Treu's evidence had changed because he did not mention water on the car deck at 01.00 hours again which he previously said to have reported to the bridge, but now saw Linde at 01.00 hours on the car deck "coming from the pumping station for visor and ramp", although according to his own statement Linde was at 01.00 hours on the bridge and according to Kukk the vessel abruptly heeled to starboard at this time. It is unknown whether this remained unnoted by the audience or whether attempts were made to clarify these differences. The 2nd Interim Report of the JAIC reads as follows:"At its meeting in Tallinn on 17 October 1994 the Joint Accident Investigation Commission (Sten Andersson did not attend) reviewed new information available to it as a result of additional video films taken from the sunken ship and confirmed the following conclusions of the First Interim Report:"
Note: The visor was still not found "officially".
"I The bow visor was lost underway."
Note: The JAIC believed that the visor was lost when the vessel was proceeding at full power against 4.5 m significant wave height which includes 8-9 m seas. This position was maintained all the time and is part of the scenario of the Final Report.
"II Water entered the car deck at the forward ramp."
Note: This is true because it was observed by Treu, Kadak and Sillaste on the monitor and the ramp was found to be open at the wreck.
"The Commission also assumed the following positions regarding the details and one of the most probable causes of the accident:
1. The bow door (visor) has separated from the ship as a result of failure of all three locking mechanisms. According to the observations made by members of the crew this happened at about 01.15 when water was simultaneously observed on the TV-monitor, entering the car deck from openings along the vertical sides of the forward ramp. The failures have taken place, in case of the two side locks in the welding of the locking eye plates to the bow visor and in case of the centre lock (as previously shown) by failure of the lugs carrying the locking plunger unit."
Note: Already on the ROV videos from 02. and 09.10.94 the extremely thick welding seams of the side lock lugs are visible, which were created by cutting off/rewelding of the lugs several times as it was observed by many truck drivers - see Subchapter 12.5 - however this is not mentioned by the JAIC.
2. "Following the failure of the locking arrangements the bow visor has opened up under the wave loads. The deck mounted hinge points have eventually failed as a result of the uncontrolled movement of the 55 tons visor, leaving it attached only by the hydraulic actuating cylinders.
3. During the subsequent unrestrained movement of the bow visor it hit the bow ramp in several modes, including hits from the rear to the upper protrusion of the ramp, causing it to become dislodged from its locking arrangements and to move to a partly open position. The bow visor has ultimately separated from the ship and disappeared overboard."
Note: Apparently at this time JAIC had not yet realised the interlock between visor and bow ramp, i.e. that the upper part of the ramp was extending into the ramp house being part of the visor, which means that if the visor would move forward the ramp would get in contact with the aft part of the ramp house. As long as the visor was empty however and the ramp properly locked and secured, nothing could have happened because the empty visor was unable to break the locks and hooks of the ramp as long as they were intact. Unfortunately neither was the case. See Subchapter 29.2 and Chapter 30.
4. "Partial opening of the ramp had allowed water to enter the car deck due to the heavy sea. Collection of water on the car deck eventually led to loss of stability and capsizing of the vessel."
Note: The JAIC does not yet say that the ramp was fully open but just states "partial opening". Nevertheless, the JAIC seems to believe that the opening was big enough to allow the penetration of a sufficient quantity of water within a very short time 01.15-01.30 hours, i.e. 15 minutes from visor off to vessel on the side.
5. "After the vessel had turned over to almost 90 degrees starboard list, which is estimated to have taken place in less than twenty minutes after the damage to the forward ramp, it started to sink with the stern first. The ship disappeared from the radar screen of a Finnish surveillance station at 01.48.
6. The vessel turned during the phase of losing stability and landed on the sea bed with an almost easterly heading. It is assumed at this stage this movement was partly the result of an attempt by the officers on the bridge to turn the ship around and partly by the wave action after the ship had lost propulsion power."
Note: They did not yet say whether the vessel turned to port to starboard.
7. "The locations of the EPIRB-s have not been found during the video documentation and their status is therefore not known at the present time."
Note: At that time both EPIRB-s had been found in switched off condition already 15 days before, but this as well as the location of the visor were kept secret.
8. "Emergency MAYDAY signals were sent by ESTONIA at 01.24 and were received by ships in the area and the MRCC at Turku."The complete 2nd Interim Report of the JAIC is attached as Enclosure 37.2.452.
18 October 1994
In spite of the Report by the JAIC, which was published on 17 October, Hellberg wrote on the following day, 18 October, in DAGENS NYHETER:
"BOW VISOR TORE UP HOLES
Accident Commission convinced what cause the Estonia shipwreck. Estonia's bow visor tore up big holes in the hull, as it was torn off. Together with the partly opened bow ramp, those holes in the hull made water flow on to the car deck in such quantities, that the stability of the ship completely changed.
When the 50 to 60 ton heavy visor started to move the actuator tore traces (tracks) in the plating and holes were made in the hull, says Sten Andersson, observer of Sjöfartsverket in the Accident Commission, who was not present at the Monday session in Tallinn. Also from other very informed sources DN has received the same information, that holes in the hull contributed to water getting into the ship so quickly (...)
According to Sten Andersson the three visor locks, two on the sides and one at the bottom, was ripped off. This can be seen from the new underwater pictures taken.
DN's source, with very good insight in the ship's construction, has difficulties to believe that the sturdy lock at the bottom - the Atlantic lock - could have been ripped off by a force directed upwards. I rather believe that the visor attachments on the deck has broken and that the 54.5 ton visor fell forward and broke the Atlantic lock." "According to the source of DN this scenario gives "violent mechani-cal damages and big holes in the hull". Those holes will then be situated under the water line in the heavy sea."See Subchapter 36.2. As stated before at least the Swedish and Finnish JAIC members knew what Sten Andersson assumed, namely that there seems to have been a "big hole" in the side of the vessel which, of course, would have influenced the sinking. Nothing thereof however was mentioned to the public by JAIC.
On the same day the visor was found by the Finnish Coast Guard vessel "TURSAS" about 1 nm to the West of the wreck. See also Chapters 24 and 26.
19 October 1994
Börje Stenström apparently had been interviewed by CNN the other day and told his scenario based on the visor position being East of the wreck. After the visor had now been found West of the wreck he hastened to assure that this, of course, had no effect on the main reason for the accident, being the failure of the locking devices of the visor.
He wrote:"CNN, London - 19 October 1994 - Fax nbr 00944 71 637 6868
Attn Ms Margaret Lowrae -
ESTONIA Accident
Further to our exchange of information yesterday, you have probably noticed that the bow door has now been found and identified. It is located on the seabed about 1 nautical mile west of the wreck itself. This seems to indicate that the captain has attempted to turn the ship around at an early stage of the development of the accident, however without success in the end result. This will slightly change our picture of the sequence of events during the first 15 minutes but not the main reason for the accident as such. The above may have some bearing on the article you are writing."24 October 1994
The Swedish JAIC met the insurance company which had insured ESTONIA - Trygg Hansa - and subsequently Nordström & Thulin at their office.
Börje Stenström wrote a Status Report (not for publication) which was distributed only to the Swedish members and Sten Andersson. The administrator Gunnel Göransson was about to fax the report also to Kari Lethola and Andi Meister, but was stopped by Olof Forssberg - see Enclosure 37.2.453.
The following shall, however, be quoted:"The following is a summary of the hypothesis regarding the sequence of events judged most probable at the time of writing. It is intended to serve as a basis for verifying a joint understanding of the likely cause and for identifying known and missing facts. It is, in summary, judged that the ship's speed, the sea condition and the strength of the bow visor latching mechanism may each one and independently have been the final cause for the accident or could have been able to prevent its happening. Information/lack of information may have been a fourth parameter. Further work is needed to qualify the significance of these parameters during the actual circumstances."
Note: This illustrates how the JAIC worked: First a hypothesis is established, which serves as a basis for the verification of known or missing facts. It follows that facts which do no match the hypothesis cannot be verified.Börje Stenström finalised the Status Report on 28 October and it is interesting to note how he changed, for example item 12 referring to the stabilizer fins:
Draft Version 24.10.94:"12. The stabilizer fins were according to witness observation in extended position during the sinking, despite they seem to be in retracted position in the wreck."
Final Version 28.10.94:
"12. The stabilizer fins were according to witness observation in extended position during the sinking. The port side one seems to be in retracted position in the wreck, this could possibly be explained by the fin having retracted by gravity after failure of the hydraulic system."
The draft version states that "both fins seem to be in retracted position" while the final version states that only "the port side one seems to be in retracted position". This implies that Stenström knew that the starboard fin was not in retracted position, but apparently also not in extended position which should be the case created by gravity if the fin would have been intact. Since the starboard fin was apparently neither retracted nor extended, it has to be assumed that it was missing.
The final version of the Status Report dated 28 October 1994 is attached as Enclosure 37.2.454. It has to be noted that Kari Lethola and Andi Meister were again deleted from the distribution list, although Tuomo Karppinen stayed on.Olof Forssberg also sent the following fax to Kari Lethola:
"Attached please find my fax to Andi Meister.
I have also spoken to Johan Fransson of Sjöfartsverket about recovery of the visor. He said that it could become actual in connection with the diving inspection of the wreck in order to get an idea whether it is possible to recover the bodies. In case it should be decided to have some form of diving investigation carried out Fransson said that the investigations should then be coordinated with lifting the visor. I shall revert to this question as soon as possible. I understand from certain material that I received via the Foreign Ministry (attached) that the Estonians are interested in hearing Kikuts. As far as I am concerned the police statement is sufficient. We know that the visor came loose and through other statements also the time. If you others should consider it necessary to hear Kikuts once more I will follow you. Regards Olof"
Note: The reader may wish to consider, whether such attitude towards essential evidence complies with the duties of a leading investigator or appeal judge.Also on this day the Swedish JAIC did meet with the Stockholm pilots and subsequently with the masters of 'MARIELLA' and 'SILJA EUROPA' onboard their vessels.
As a matter of fact, when Kikuts was heard by a member of this 'Group of Experts' he stated never to have seen the visor moving up and down - see his statement Enclosure 20.246.
27 October 1994
On this day LLOYD'S LIST reported among other things:
"In an interim report the JAIC reveals that the bow visor smashed into the inner watertight ramp. The report circulated to the British ferry companies confirms that a failure of the locking mechanism of the bow visor triggered the disaster ... According to the report the initial failure to the bow visor occurred when its three locking systems failed simultaneously. ..."
Also on this day Börje Stenström and Tuomo Karppinen visited Meyer Werft in Papenburg for the first time and according to the notes made by Dr. Holtappels they informed the yard as follows:
"1. Bow visor came loose at lower end
2. Broke away upper end of ramp
3. Water came in
4. Speed 15 kn
5. Wave heights 5-6 m significant/max. 10 m
6. Wind: SW turning W
7. Wind speed 25 m/s mean value
8. max. significant weight ever measured in the Baltic was 7 m in 1983
9. Course 282° N.
10. Uneven load, despite all trimming at port still 1° starboard list when leaving, first reaction from bride more ballast on port side or release starboard freshwater
11. Hinges on deck - both sides - not torn out
12. Atlantic lock broken due to overstress, locks at the visor: movement to port but finally separated to starboard (ramp pulled out port upper side)
13. Ramp damaged upper port corner, port hinge damaged
14. Why did the visor move forward?
15. Load assumptions and design criteria for visor and locking devices required
16. Various other requests for documents"The notes are attached as Enclosure 37.2.455 and by letter of 02.11.94 - attached as Enclosure 37.2.456 - in total 32 drawings and other documents were simultaneously sent to Stenström and Karppinen by Meyer Werft.
During the month of November the Swedish JAIC spoke to:
- the previous masters of the 'NORD ESTONIA' Per Ringhagen and Sten Levander, and further with the Stockholm pilots having piloted the ESTONIA frequently,
- the employees of Sjöfartsverket's Stockholm Shipinspec office,
- the management of N&T and Estline. From 9 to 18 November the visor was searched and finally lifted by the Finnish multipurpose ice breaker 'NORDICA' assisted by the Swedish mine hunter 'FURUSUND'. See Chapter 26. During the lifting operation Tuomo Karppinen and Klaus Rahka from the Finnish JAIC were present on board of the 'NORDICA'.
The visor was landed ashore in Hangö and put on blocks in upside down condition at the premises of Messrs. Levator Oy where it stayed in the open air until it was shipped to Sweden by the Swedish Navy in December 1999. The visor was closely examined by members and experts of the JAIC from all three countries and it was subsequently decided to have the bulkhead parts in way of the torn off lugs of the hydraulic side locks cut out and transported to the Royal Technical High School (KTH), Stockholm. This was carried out after the 23 November because when representatives of Meyer Werft inspected the visor for the first time on that day these parts were still in position and are thus visible on the photos then made.
Andi Meister writes in his book "The Unfinished Logbook" about the visor inspection as follows:"On 2 December the inspection of the visor in Hangö took place. In addition to the other acknowledged experts also the scientists of the Estonian Shipping Company (ESCO) and of the Technical University of Tallinn, August Ingerma and Jaan Metsaveer, participated. It was now also established by means of squeezed steel parts that the visor had pulled open the ramp and that the ramp had been completely open until becoming partly closed again when the vessel turned upside down."
The Swedish Government had instructed Sjöfartsverket already on 3 October to develop possibilities to recover the bodies out of the wreck and it was thus decided to have the wreck examined by divers. A description of the work required was drawn up in the form of tender conditions which were sent to 14 contractors - see also Chapter 27 - and the job was finally awarded to Smit-Tak/Rockwater, i.e. Smit, Rotterdam, the world's leading salvage company. The contract was signed on 29 November and the work began on 1 December, however, was delayed due to the wrong wreck position stated in the tender conditions - see Chapter 27.
Also the JAIC was given the opportunity of having parts of the wreck examined and taken up. In order to make the necessary decisions Börje Stenström (and most probably Tuomo Karppinen) attended on board the diving support vessel 'SEMI I' while the Estonian side was represented by Aarne Valgma, the head of the Sea Safety Division of the E.N.M.B. and the man who could have prevented the last sailing of the ESTONIA (and consequently her sinking).
As the JAIC had made up their mind already what had caused the sinking of the ferry, their interest remained restricted to the bow area and to some limited extent to the bridge where allegedly three bodies had been found (although there were at least 5), which were allegedly not identified although some of them were wearing uniforms. The cabins of master, chief engineer, radio officer and the owners' cabin all located directly below the bridge were allegedly not examined. At least nothing is mentioned in the official reports. There was however another "unofficial" diving investigation going on at the same time - see Chapter 27, Subchapter 34.6 and the Disengage Report in Enclosure 34.6.434. - the result of which regrettably has never been made public. It is certain however that the work of this "unofficial" diving team was executed with the consent - if not on instruction - of a certain Swedish government authority. A number of objects from the wreck were recovered by divers and brought to the surface, among others the lugs of the Atlantic locks burnt off in a rather unprofessional way, i.e. each lug was burnt off instead of burning off the whole deck part to which the lugs were welded. Due to this way of burning, the bottom parts of the lugs - say the lower 20-30% were missing - which made the lugs look rather small. Also the sensor plate fitted next to the lugs was burnt off but thrown to the sea bottom by the diver and thus disappeared forever.
Note: The examination of this sensor plate ashore would doubtless have proven that the holes for the screws having previously held the sensors were corroded to such an extent that it would have been obvious that the sensors had been removed already several months before the casualty, a violation of the class requirements which would have forced B.V. to withdraw the class of the ferry in hindsight with substantial consequences for the owners.
In addition to the sensor plate also the sensor cables were clipped off and thrown to the sea bottom by the diver obviously for the same reason, because on the video footage it is clearly visible that these cables were cut and not broken by being torn off, of which N&T tried to persuade B.V. and the JAIC in endless argumentation and writings. Obviously with success because B.V. did not withdraw the class nor did B.V. ever criticise N&T/ESCO and the JAIC just noted on page 128, Subchapter 8.6.6 of their Final Report:"The magnetic-type position sensors for the bottom lock were not in position on their mounting bracket according to pictures taken during the ROV and diving investigations. The electric cabling that had been part of the sensor installation and the ends of the cables were visible in the area. The mounting bracket for the sensors appeared to be intact or possibly bent slightly aft. No other signs of any mechanical action could be seen on the bracket. The 12-millimetre-diameter bolt holes for the originally installed mechanical switches were empty. It is not fully clear how the magnetic sensors had been installed on the bracket. The magnet which was part of the bottom lock position indicator was after the accident visible on its mounting bracket in the locking bolt. According to information obtained from the electrical engineer who installed the magnetic sensors and the magnet in the mid-1980s they were of the Siemens 3SE6-type."
Note: According to a member of the 2nd crew the sensors had been dismounted and the cables were cut at the end of the ice winter in April 1994. The sensors were not reinstalled as the crew members had to go down anyway and open respectively close the bolt of the Atlantic lock by hammering, as this was no more possible hydraulically due to the severe misalignment and distortions of the lugs. Therefore a remote control was no more required. See Subchapters 12.5, 29.2.The Atlantic lock bolt, however, a most important piece of evidence in the JAIC's chain of argumentation, was brought to the surface but, much to the surprise of the outside world, thrown back into the sea by Stenström, allegedly after having measured its thickness and found it to be undamaged and straight, a statement, which is apparently false, as must be concluded from the rather good video footage available - see Subchapter 29.2.
It has to be assumed that Stenström very well realised from the explanations and pictures of the diver that the lugs of the hydraulic side locks could do substantial damage to the JAIC scenario when brought up to the surface and subsequently being examined ashore. The extremely thick welding seams would have proven that they consisted of several welds on top of each other, i.e. frequent cutting off/rewelding had taken place. Furthermore it would have become known that the missing bulkhead parts to cover the holes in both aft bulkheads of the visor (where the lugs had been sitting) were not attached to the lugs (apart from a tiny piece). This meant that the lugs had no more been welded to the bulkheads as original but had just been stuck through pre-cut holes and then welded on to the remnants of previous welding seams. Al this was naturally combined with a substantial reduction of the initial load carrying capacity of the locks. Stenström decided to leave the locks in the wreck.
The recovery of the visor hinge bolts which had already been ordered to the divers was stopped also. A close examination of these bolts would have brought results - see Subchapter 29.2 - for the JAIC casualty scenario.
By fax of 06.12.1994 to Andi Meister, Stenström briefly reports on the diving inspection (see Chapter 27) and concludes:"Findings in the bow area generally confirmed the earlier hypothesis of the development of the accident. Broken lugs of the bottom lock of the visor were recovered for detailed examination. One hinge for the visor was also recovered. Damages on the bow area and the ramp were documented.
The findings support the hypothesis that the visor broke loose from the ship due to high sea loads in combination with inadequate strength of the locking devices. Detailed investigation of the design and the classification society rules valid at the time of the construc-tion is being carried out.
The deck hinges of the visor broke subsequently and the visor started to move. The visor thereby forced the ramp open due to mechanical interference. The visor probably brought the ramp to fully open position at the time it was leaving the ship. The visor tumbled forward over the bow at that instant."In a memo of the same date he goes more into detail on his hypothetical assumptions:
"A. Damages
1. Ramp hinges.
Number 1, port side. Outer eye on ramp lower beam bent, inner one broken, hull mounted part intact, hinge separated.
Number 2. Both lugs on ramp lower beam broken, hinge separated.
Number 3. No damage, some play at pin.
Number 4, starboard side. No damage, same play at pin."
Note: Stenström does not state that the port outer hinge was found to be bent and misaligned, with the bolt moved to starboard, both securing plates missing and the port "outer eye" (lug) slipped off the bolt. He also failed to mention the mattresses, bed-clothing, blankets and rags squeezed between ramp and bulkhead at the port outer ramp hinge, although this had become public knowledge (see DN of 07.10., page 59 above).
"2. Ramp front side.
Heavy damage at lower end, most at starboard side.
Ramp beams damaged at lower ends and in centre line at mid length (possible contact with fore peak deck locating horn)."
Note: Stenström does not mention that the ramp is bent longitudinally, is resting on the starboard bulkhead with a gap existing between the port bulkhead and the ramp, i.e. that the ramp has been exposed to pressure from port to starboard, which had led to very severe deformations of all the transverse beams, except for the lower ones and to deformation of the longitudinal beams in the lower area which he interpreted to have been caused by contact with the forepeak deck. See Subchapter 29.2.
"3. Ramp inner side.
Some damage at top."
Note: He means apparently the damage to the port outer beam which was bent and distorted at the upper side, but the severe damage to the inner ramp plating in the upper third with burnt and distorted plates and also the distorted flaps in way of the centre line at the top and the bottom of the ramp are not mentioned. See Subchapter 29.2.
"4. Ramp actuating cylinders.
Port side one found extended, rod end failed."
Note: The videos clearly show that the port ramp actuator was sitting in retracted condition inside the bulkhead opening with the piston rod broken at the lug fitted to the lugs at the ramp side. These lugs at the ramp side were missing. The videos also show that the starboard ramp actuator was also broken, once at the lug, same as the port one, but again at the piston rod because this part was found by the diver to be jammed in between ramp and bulkhead recess. The remains of the piston rod and the actuator were noted inside the bulkhead in retracted condition. The lugs at the ramp side are missing, the fastening of these lugs was found to be blown open and distorted. See Subchapter 29.2 and Chapter 32.
"5. Ramp locking plungers.
Starboard side ones, both in extended position, mating boxes deformed. Port side ones, upper one in fully extended position, mating box deformed, lower one partly extended, no visible damage to mating box."
Note: Stenström does not mention the diver's report that there was a misalignment of 21/2 inches = 10 cm at port side between the plungers (bolts) and the mating boxes which also existed between the ramp hook and the mating lug. He also did not mention that both port mating boxes as well as the mating lug and the ramp hook were found to be intact which means that the entire port side of the bow ramp had not been secured at all upon departure from Tallinn (and numerous voyages before already). See Subchapter 29.2.
"6. Visor bottom lock.
Failed lugs on fore peak deck removed and recovered for examination of welds.
Plunger of bottom lock recovered and examined, measured general diameter 78.2 mm, 77.8 over contacting surface with visor lug."
Note: See the comments on page 81 in this respect.
"7. Visor side lugs.
Remain in front bulkhead. Estimated play, both sides, max. 10 mm. Failures in bulkhead plating around weld bead (part of bulkhead plating attached to lug bottom side but not over the entire area)."
Note: See the comments on page 70. He states failures in bulkhead plating although only a very tiny part of the bulk-head, less than 1/10 of the contact area, was found to be attached to the lugs and the diver reported that no bulk-head parts were attached to the lugs at all. "
8. Visor hinges.
Deck lugs intact, no visible twisting. Design deviates, however, from that shown on drawings. Starboard side one has been beaten by visor arm more than the port side one. One hinge bushing recovered for examination."
Note: No word about the bolts standing on the adjacent rails with the starboard one without bushing and the port one with the inner bushing attached. Both bolts could have been recovered without big problems by the crane of 'SEMI I'. At this time the cracks in the welds of the visor hinges had already been known to the Estonians for 2 months, however, the Finns and Swedish JAIC members were not informed.
"9. Front bulkhead.
Not much damage except around port side locating horn and ruptures caused by visor hydraulic rams."
Note: The starboard front bulkhead was found to be open in its upper part to such an extent that the diver could move through it and the lower side was found cracked off the hull and bulged forwards. See Subchapter 29.2 and Chapter 32.
"10. Fore peak deck.
No damage except some around centre line and in way of rubber seal."
Note: No word about the rubber packings missing and damaged in about 70% of the channels partly extending up to the front bulkheads (also noted by Åke Sjöblom and Gunnar Zahlée - see Chapter 15). Also the severely hammered stempost area is not mentioned.
"11. Bulbous bow.
Heavy scratch marks on ice breaker horn, clear evidence on front and bottom of bulb from contact with visor."
Note: This is correct, however, the marks and even damage are only proof for contact with some object, not necessarily the visor.
"12. Navigation bridge.
One Shipmate GPS navigator recovered for possible retrieval of data. The navigation PC could not be found. The engine control levers on port side bridge wing and on centre console were in full astern position."
Note: The examination of the bridge - under the aspect of acci-dent investigation - was totally unacceptable, for example Stenström failed to have the divers establish:
(a) course on the gyros which would have indicated the heading of the vessel at the time the auxiliary engines stopped;
(b) whether the auto pilot was switched on/off which would have indicated whether they were steering manually already;
(c) whether the stabilisers were activated or not;
(d) the identity of the bodies by means of their ranks indicated on their uniforms and the type of clothes of plain clothed bodies.
(e) whether any documents were still possibly legible (Stenström most likely knew that the logbook had been recovered already in the early days of October 1994 by Swedish Navy divers).
"The controls for the watertight doors were found to be push button switches and no information about ordered positions of the doors could therefore be found. The watertight door checked by the divers was in closed position."
Note: The door closed from port to starboard, thus closed anyway by gravity due to the starboard list of the wreck.
"13. EPIRB beacon.
One casing for an EPIRB beacon was found on top of the bridge, the other position was inaccessible for the diver. The casing was open and empty. The casing was recovered for further investigation."
Note: At this time both EPIRBs had already been in the possession of the Estonians for more than 2 months, but the Swedish and Finnish JAIC members were still not informed.The "likely sequence of events" followed in line with the previous statements of the JAIC. The complete memo is attached as Enclosure 37.2.457.
It is quite obvious that the JAIC was dominated by technicians, in particular by naval architects like Börje Stenström. Thus also the investigation was performed from the technical points of view of shipbuilders. It is unknown whether the master mariners Hans Rosengren and Olle Noord were always happy with the rapid development of the cause consideration and casualty scenario in which the surrounding circumstances, in particular the nautical ones, were often grossly neglected.
On 6 December 1994 Börje Stenström, accompanied by his assistant Mikael Huss, also naval architect and lecturer at the KTH, Stockholm, visited Meyer Werft in Papenburg for the second time. They had brought the starboard and centre lugs of the Atlantic lock with them for demonstration purposes. According to the notes of Dr. Holtappels Stenström explained the following:1. Bottom lock (Atlantic lock) failed due to overload, no fatigue.
2. Side locks have not taken much load due to lack of structure.
3. Wind 20m/sec., significant wave height 4-4.5 m, single waves 7-8 m; speed 14-15 kn.
4. Port deck hinge broke.
5. Visor pulled left side of ramp while still hanging on starboard hinge and in hydraulic system.
6. Banging on bow visor.
Weak welds of Atlantic lock
Ramp: first movement port side but totally torn open
Hydraulic cylinder were pulled through decks and deck beams
Trim aft onlyThe notes are attached as Enclosure 37.2.458.
This time the failure of the Atlantic lock was assumed to have been caused by overload and the side locks were considered not to have taken much load due to lack of structure, although no metallurgical examination had yet been carried out.
On 13 December 1994 the Ethic Council of Sweden recommended to the Government not to have the ESTONIA raised and instead to declare the wreck to be a permanent graveyard where private diving should be prohibited and the area should be protected respectively guarded.
On 15 December 1994 the next JAIC meeting was held and, although no examination had been carried out, Börje Stenström presented a working paper - not for publication - to the audience which is attached as Enclosure 37.2..459. The heading reads:
"M.V. ESTONIA - Summary of Technical Findings and Technical Evaluation of the Probable Sequence of Events and Cause of the Accident.
The investigation of technical facts related to the accident has continued with high priority. The findings and conclusions reported and agreed on during the meeting on 17th October in Tallinn are essentially still valid but various additional findings have been made and the related probable development of the accident has been further clarified and modified. ....
The summary below describes the technical findings and also the effect these may have had on the development of the accident.
1. All evidence found so far confirm the hypothesis that the mechanical failure started with failure of the lower locks of the visor. Most probably the bottom lock failed first. The mounting lugs for this lock have been recovered from the wreck. They indicate that the failure in the lugs has been caused by overload and also that the actual welding of the locking plunger housing to the lugs has been less extensive than presumed in the engineering calculations. The total load carrying capacity of the mounting of the bottom lock has therefore been less than intended. The internal work routines of the shipyard relevant for this condition are being discussed with the yard."
Note: 1. Failure in the lugs has been caused by overload:
The subsequent investigation by Prof. Hoffmeister - see Subchapter 34.8 - Enclosure 34.8.436 - proved that the welding seams between "locking plunger housing" and lugs were up to 90% penetrated by fatigue cracks.
2. Welding of the "locking plunger housing" to the lugs has been less extensive than presumed in the engineering calculations:
The welding seams found were about 3 mm thick while according to the Meyer yard welders having done the job, they were 7-8 mm thick originally which was also in conformity with the yard's standard welding rules when welding a 15 mm thick component to a structure. In such case each weld had to correspond to 50% of the thickness of the component to be welded. Thus it has to assumed that the welds and probably also the lugs were not original and definitely the rather poor repair welds of the starboard lug did not originate from the yard. - See Subchapter 12.5. - The JAIC was not interested and arranged for a paint analysis of the starboard lug only in December 1996.
3. The total load carrying capacity (lcc) of the bottom lock has therefore been less than intended.
According to Stenström's own calculation the lcc of the Atlantic lock had been only 70-80 ts. while actually a subsequent break test with 3 m welds revealed a break load of 220 ts. See Subchapter 34.3 and Enclosure 34.3.431."2. The side locks at the same moment or immediately after the bottom lock. Inadequate rigidity in the mounting of the lugs of the side locks have reduced the ability of these lugs to pick up load at the same rate as the bottom lock, indirectly contributing to overload of the bottom lock."
Note: The findings of the divers were apparently ignored - see page 81. The "inadequate rigidity in the mounting of the lugs", actually was always existent. It was caused by the frequent rewelding on top of existing welding seams around the 2 lugs which were just stuck through existing openings in the aft bulkheads of the visor.
"3. The hinges at the visor pivoting points on upper deck have also failed due to overload."
Note: By this time the disastrous condition of the starboard hinge having been almost penetrated by fatigue cracks initiated by deep burning marks was known to Stenström and his colleagues by their visual inspection of the broken hinges at the visor in Hangö and by examining the recovered bushing with the part of the broken visor arm still attached. According to Prof. Hoffmeister the lcc of the starboard hinge was reduced to a mere 20% of its original and this did not yet take into account the consequences of the subsequent findings demonstrated with the passenger video received in April 1996 - see Subchapter 12.5 - and Enclosures 12.5.180/12.5.181.
"8. When the visor left the ship it left behind it the ramp in fully open position, initially allowing large amounts of water to enter the car deck within a short period of time. This is believed to explain the reported rapid initial generation of starboard list."
Note: If the ramp would have been fully open it would have broken off. See Subchapter 34.10. This is in particular valid if the vessel would have continued to proceed with 14-15 kn against the waves as alleged by the JAIC at all times including in their Final Report, see Subchapter 13.2, page 171, ff.
"10. In total it is considered to be verified that inadequate structural strength in the visor locking mechanisms has been the under-laying condition for development of the accident. The sea loads on the visor generated by an irregular wave condition with occasional high waves in combination with the speed of the vessel is considered to have been the ultimate factor, triggering the structural failure in the particular instant."
Note: Not a single of these hypothetical assumptions corresponds with proven facts and/or the law of physics known to the members of the JAIC.After the meeting a press conference was held and the Press Release - attached as Enclosure 37.2.460 - was distributed. It reads in part:
"2. The Commission agreed that most of the work was still in pro-gress and needs further detailed substantiation before conclusions should be drawn and made public.
3. The Commission confirmed, however, its opinion that the strength of the locking devices for the bow visor in combination with the sea loads on the visor in the prevailing wave condition and headway of the ship is the main cause of the accident."
Note: It is apparent that the application of logic was also not one of the habits of the JAIC because 3 contradicts 2. It is stated in other words, that the locking devices of the visor were too weak to withstand forces normally encountered during heavy weather. That the vessel had traded in the area with similar weather conditions for no less than 14.5 years was simply disregarded by the JAIC. Why apply common sense?No one took notice that in item 5 the JAIC stated that "the diving investigation carried out on the wreck has revealed that the ramp was locked in closed position prior to the accident". At this time the JAIC positively knew from the videos that the complete port side of the ramp cannot have been locked prior to the accident. See Chapter 29.2.
16 December 1994
On the day before Sweden's Prime Minister explained before the House of Parliament the decision of his government not to raise the wreck of the ESTONIA for "ethical reasons".
By letter of 19 December 1994 to Meyer Werft - copy is attached as Enclosure 37.2.461 - Stenström did send a "copy of the video recording from the divers investigation of the bow area of the Estonia. The length of the film is about 65 minutes and it contains all the substantial observations made during the 10 hours of diving for the accident investigation (the remaining time being divers search for the areas to be investigated etc.)".
Stenström did not mention that the film contains all the substantial observations made during the 10 hours of diving for the accident investigation which the JAIC wanted Meyer Werft (and the public) to know. The real substantial parts were cut out respectively are not contained in these 65 minutes. Stenström wrote further:"We have initiated an examination of the lugs for the bottom locking device with regard to any signs of old cracks in the fracture surfaces or defects in the welds. We expect the preliminary investigation in this respect will be completed during this week. We will inform you about the findings from this examination."
The KTH, Stockholm confirmed that there were no old cracks in the fracture surfaces or defects in the welds, a statement which they had to withdraw when Prof. Hoffmeister presented his findings (see Chapter 30).