12.5
Maintenance, Damage and Repairs

Generally the information available from on board is restricted to the observations of passengers as basically reported in Chapter 12.4, because the crew members had been forbidden by their employer ESCO to talk about ESTONIA at all. Only very few have talked, although very carefully, as will be explained on the following pages.
It has also been very difficult to obtain information from N&T/Hornet AB/ Estline or ESCO. Apart from the discussion with Ulf Hobro during the first meeting with the JAIC in Stockholm in February 1995, there are only some details available from the files of the public prosecutor and from those of the JAIC, which will also be discussed subsequently.

 

1. Maintenance

The vessel was drydocked at Turku between 4-8 January 1993 and the necessary inspections were carried out. At this time also some maintenance work was performed which had been partly ordered by the old owners, Wasa Line, and partly by the technical managers of the new owners, N&T, as outlined in detail in Subchapter 6.5.

Consequently in January 1993 during the time at the yard:

a) the locking devices of visor and bow ramp were neither serviced nor strengthened, and
b) the outer hinges of the bow ramp were not serviced nor were the bushings and bolts renewed, and
c) 15 m of the rubber packings of the visor and 10 m of the rubber packings of the bow ramp were not renewed.

 

As to (a):
Since the crew was unable to service and strengthen the locking devices of visor and bow ramp, they were never serviced and strengthened until the casualty. Since the crew was also unable to service the hinges of the bow ramp and to renew the bushings and bolts, in particular the port outer hinge, it is a fact that nothing was done to rectify the poor condition of - at least - the port outer bow ramp hinge. It is, however, known from Börje Stenström, head of the technical group of JAIC, that the crew had put the damaged port outer bow ramp hinge on the repair list a number of times, but that repairs were postponed by the technical managers until the next scheduled yard stay, probably in January 1995. The respective memo is attached as Enclosure 12.5.166.

As to (b):
Also the visor hinges required professional maintenance which the crew was apparently also unable to provide, because according to the testimony of the 2nd engineer Peeter Tüür in June 1996, who is responsible for the technical functioning of visor and bow ramp - the crew had problems to have the hinges properly greased and even had to add oil to the grease to ensure that the grease reached all parts to be lubricated - see Enclosure 12.5.167. Needless to say that the effect of grease is destroyed by adding oil. Due to the severely misaligned visor the hinges could no more be properly lubricated. This resulted in excessive wear of the bronze bushings which consequently had to be renewed.
Such renewal is normally effected by drilling out the steel and bronze bushing by means of a particular milling installation in order to avoid damage to the hinge plates, which would be created if the bushings would be burned out. Whereas drilling, including proper welding of new bushings, takes about 2 days in port - whilst the visor is detached from the vessel and the vessel thus has to be taken out of service - burning is much faster, however, is combined with a loss of material of the hinge plates, the creating of deep burning marks, each of which is a crack starter. It is obvious that such damage to the hinge plates reduced their weight carrying capacity and furthermore increased the propagation of fatigue cracks in the hinge plates. For further details see Subchapter 34.3. Although denied by the technical managers and crew, the steel bushings of both visor hinges were evidently burned out and replaced by new steel and bronze bushings which, however, were fitted in a very unprofessional way. This will be further explained in Subchapter 34.3.

As to (c):
On one hand the responsible inspector in the organisation of the technical managers, N&T, Ulf Hobro, stated before the JAIC on 17 February 1995:

»... we did not care for the rubber packings, we have never renewed any of them nor was it ever our intention to do so. The visor was full of water at sea and this was known to everybody.«

On the other hand, Lennart Klevberg, in charge of spare parts with N&T, did testify to the criminal police Stockholm, that

»rubber packings for the visor had been ordered but were not installed because Capt. Andresson and Tomas Rasmusson had decided to wait until MARE BALTICUM would be taken over in order to do the replacement on both ferries simultaneously.«

This does not make much sense, however, based on the underwater videos it is indeed a fact that the rubber packings of the visor were missing from forward of the Atlantic lock along the whole port side and about 1 m up the front bulkhead, whilst at the starboard side there were some rubber packings from forward of the Atlantic lock to the "corner of the mouth", which was empty up to ca. 2 m of the front bulkhead.
It is obvious that the visor was no more weathertight and thus full of water at sea up to the outboard level as evident from the watermarks inside of the visor.

 

2. Damage and Repairs

The crew also denied ever having carried out repairs to the visor, the bow ramp and/or to their locking devices. This is true as far as the major repairs are concerned which would have been necessary to bring the visor back into proper shape and alignment, but which were never carried out. The crew, however, is wrong as far as numerous smaller repairs and rectifications to the visor, the bow ramp and their locking devices are concerned which were frequently performed to avoid the worst and keep visor and bow ramp best terms possible in workable condition. This had been observed by many passengers as outlined in Chapter 12.4. and was even admitted by crew members, for example by the safety officer Ervin Roden who told Spiegel TV on 02.05.97, among other things: "Something was always being repaired on board. There was always welding work being carried out. I am uncertain whether also to the visor. But everywhere repairs were carried out, also in the area of visor and bow ramp and also by the Finns." The complete interview is attached as Enclosure 12.5.168.
Apart from the damages existing already when the ferry was taken over from the previous owners and which were not repaired by the new owners/ managers, it is quite obvious that the ferry sustained more damage to the visor and consequently also to its fixing points, the hinges and locking devices, when for example forcing ice at excessive speed as observed by various passengers. The observation repeated below is just one example:

»Observation by Henning Frederiksson on 24.03.94: It was stormy weather and "Estonia" was proceeding in open water at full speed with a following sea when she met pack ice, into which she crashed without any speed reduction. "Estonia" came fast into the pack ice with an enormous crash and had to go backwards and try again. There was 16 m/sec. storm, nevertheless, "Estonia" kept her high speed.«

 

 

The results of such reckless navigation are clearly visible on the large photo on the previous page which was taken on the following day, 25 March 1994, in Tallinn by the professional photographer Li Samuelson.
The ice damage sustained by the visor during the months of February and March 1994, when the Gulf of Finland and the Northern and Middle Baltic where more or less continuously covered by ice (see Subchapter 12.4.2), were roughly repaired by replacing parts of shell plating and bottom of the visor in Tallinn whilst the vessel remained in service. The renewed parts are still visible on the visor.

This is also confirmed by the observation of the passenger Christer Eriksson, who reported the following:

»I travelled to Tallinn on the "Estonia" on 3/4 May 1994 and left the vessel only at about 10.30 hours when all the other passengers had already gone ashore. The gangway was pulled in and I had to go ashore via the car deck and bow ramp. When I came down on the car deck I noticed a curtain of sparks falling down from the open visor on to the bow ramp and I managed to jump through it and saw on the bow ramp a giant red transformer turned 90° towards the ramp which in my opinion was Red Army surplus. Cables were running up to the port side of the forecastle deck/visor, where obviously heavy burning/ cutting work was in progress. When I returned from ashore at about 06.00 hours the workers were just collecting their tools, but the huge transformer was still on the bow ramp.«

The fax exchange reflecting the above is attached as Enclosure 12.6.169.
Although the work explained above doubtlessly falls into the category "maintenance & repair" and also could not be considered very minor, the repairs are not mentioned in the "List of Maintenance and Repair Works on M.V. 'Estonia', April 1993 - August 1994" which is Supplement No. 230 to the Report of the JAIC. Since also other visible repairs do not appear on this list, it has to be assumed that the list is incomplete for obvious reasons.

Also Lars Gunnar Nyström informed the Swedish Commission that he had made many trips on the ESTONIA. In February and March 1994 he was on board when ESTONIA was forcing ice twice and arrived in Tallinn once with a delay of 1.5 hours.
The damage sustained by the visor while proceeding at full speed through ice barriers several meters high and using the vessel as an ice breaker is demonstrated by the preceding photo and can also be seen on the video image below made from a film of 30.03.94.

 

 

As a result of the sustained severe structural damages and in combination with the different lifting speeds of the actuators and severely worn out hinge bushings, the visor became increasingly misaligned and out of geometry.
All of this led to problems - observed and reported by passengers as described in Subchapter 12.4 - during the opening and closing which also affected the locking devices and reportedly the problems became worse and took more time to be overcome the nearer the day of ESTONIA's last departure came. This is demonstrated by the following examples:

It had also been frequently observed that the lugs of the hydraulic side locks were cut off by burning and subsequently rewelded, which is confirmed by the following observations:

3. The Bow Ramp was the upper extension of the collision bulkhead above bulkhead deck and as such had to be mandatorily weathertight. Therefore the ramp required regular maintenance of the rubber packings, the hinge arrange-ment and the locking devices.
As stated before 10 m of the rubber packings should have been renewed already during the yard time in January 1993, however, this was never done up to the casualty.
The same refers to the locking devices of the bow ramp which should have been serviced and strengthened already in January 1993, which was also never done.
Whilst damaged and missing rubber packings cause a bow ramp which is otherwise in proper condition to leak, this becomes much worse if the bow ramp is visibly misaligned and twisted.
This had been the case on ESTONIA for several months before the casualty and the condition deteriorated as time went by. It is a fact that water was penetrating the bow ramp already in 1993 according to the evidence of passengers and pilots. In particular the statement of the Stockholm pilot Bo Söderman - see Enclosure 12.4.4.161 - is striking.

The following drawing clearly demonstrates that already in calm sea the water rose above the 3rd stringer inside the also severely leaking visor due to the height of the bow wave at full speed.

 

 

Since the lower part of the deck opening with the missing and/or damaged rubber packings (see arrow on drawing) was below the 3rd stringer level of the closed visor, it is obvious that water penetrated the car deck already in calm sea when the vessel was on full speed (height of bow wave ca. 2.5 m). It is also obvious that the water inside the visor rose when the vessel was pitching in head seas. The height of the water inside the visor depended on the height of the outside water level, i.e. when the ferry was taking green water on the forecastle for a certain time the visor would fill up more or less completely with respective water pressure on the leakage of the bow ramp.

Since absolutely nothing had been done to improve the condition of the rubber packings and also no maintenance to the bow ramp had taken place since the vessel was put under Estonian flag, also the condition of the ramp hinges, in particular the port outer one, deteriorated continuously. This process was being sped up by the wrong loading of the car deck through the also apparently in this respect rather inexperienced Estonian officers, because the vessel frequently had a list during loading/unloading when the heavy trucks were rolling on/off board via the bow ramp and the effect on the already pre-damaged and weakened hinges of the bow ramp was disastrous. This finally led to the complete destruction of the port outer hinge and the breaking of the inner lug connecting the ramp to the vessel, whilst the outer lug slid off the hinge bolt apparently after the securing plate was broken off. The result is explained by a truck driver who witnessed this incident as follows:

»I drove on board as one of the last trucks and after leaving my truck I saw that the crew tried to close the bow ramp, which was not possible because only the starboard side came up while the port side remained down. Only after several ups and downs of the ramp and some other things done by the crew did they finally manage to close the ramp. Ever since then the ramp was visibly twisted and when the visor opened and the bow ramp was still "closed", light fell in through the upper left corner.«

The above is based on a telephone conversation in December 1997. It has not yet been possible to take the statement of the truck driver.

This severe damage to the port outer hinge and to the ramp itself was reported by the crew to the technical managers and also put on the repair list several times according to Börje Stenström (see Enclosure 12.5.166). However, nothing was done to rectify this damage despite the fact that it constituted a severe violation of the SOLAS - and Class - requirements because evidently the open car deck was, via the leaking bow ramp, connected to the visor which at sea was filled with water.

As no maintenance took place the crew tried to seal the leaks as best they could by putting mattresses, blankets and rags into the openings between the ramp and car deck/bulkhead at the port lower corner. As a further consequence of the detached port lower side of the bow ramp the port lower securing bolt no longer fitted into the ramp pocket, whilst the upper port bolt fitted only to a limited extent and it is doubtful whether the port ramp hook was able to engage the lug at the ramp side at all.

These very severe deficiencies led to continuous problems for the crew when opening and closing the bow ramp and/or the locking devices which had been observed by many passengers, in particular by the truck drivers using the ferry twice a week or more as summarised in Chapter 12.4. These observations prove that the bow ramp as well as its locking devices had been in a very poor state of maintenance and that they no more fulfilled the SOLAS and the Class requirements.

Only since the files of the Swedish part of the JAIC and the files of the Stockholm prosecutor, Tomas Lindstrand, have to a large extent, though not completely, been opened to the public, has more background information become available, which shall be introduced as follows:

(1) Memo in one of the files of the prosecutor concerning director S.-C. Forsberg's phone call to the office of the prosecutor on the day of the catastrophe, 28 September 1994, at 14.00 hours.

(2) Explanatory letter written by S.-C. Forsberg to the Stockholm police on 01.11.1994.

(3) Statement of Inspector Ulf Hobro taken by the Stockholm police.

(4) Telephone interview of Tomas Ramusson, Hornet AB by the Stockholm police according to a transcript in the prosecutor's file.

(5) Statement of Lennart Klevberg, N&T, taken by the public prosecutor on 24.06.1996.

(6) Statements of some of the surviving crew members and of the member of a previous working team on board the ESTONIA.

The statements of

- Sten-Christer Forsberg /N&T
- Ulf Hobro /N&T
- Tomas Rasmusson /Hornet AB
- Karl Karell /Hornet AB

taken by the Swedish part of the JAIC had been classified until publication of the Final Report of the JAIC, but are now only available on tape in Swedish, thus cannot be evaluated in this report.

 

as to (1): (Phone call Forsberg)
According to a memo in the files of the prosecutor, S.-C. Forsberg had reported the following by telephone at 14.00 hours on the day of the casualty, the 28 September 1994:

"There are rumours going around town that burning and welding work has been carried out to the visor of the "Estonia". The owners do not know anything about this. It is, however, possible that the observations refer to de-icing of the visor in winter by means of burners."

Note:
In this connection reference is made to the evidence of passenger Anders who had observed in Stockholm welding being done underneath the partly open bow ramp at the Atlantic lock and of passenger Christer Eriksson who had observed burning and welding of the visor in Tallinn in May 1994 which took a full working day (see Enclosure 12.5.169).

 

as to (2): (Letter Forsberg)

The letter dated 01.11.94 written by S.-C. Forsberg to the criminal police Stockholm shall be quoted and discussed. The complete letter in Swedish together with the office translation is attached as Enclosure 5.2.110.

Sten-Christer Forsberg

- Manager of the Shipping Department of N&T
- Technical Director of N&T
- Board member of Estline AB
(CV see Enclosure 5.2.108)

a graduated naval architect of Chalmers University, Gothenburg, ex colleague of Börje Stenström, member of the JAIC, and Kaj Janérus - then managing director of Sjöfartsverket - from a mutual employment with Salén Shipping Company, Stockholm was directly responsible for the technical condition and performance of the ESTONIA and explains as follows:

»Technical Supervision of the Vessel
N&T's shipping department was responsible for the technical supervision of the vessel. Under the manager of the shipping department, Sten-Christer Forsberg, Ulf Hobro was the inspector/ superintendent of the vessel for the whole time and spent a large part of his working time on MV "Estonia". Hobro checked the condition of the vessel regularly regardless of what the master, chief officer and chief engineer did.
Tomas Rasmusson, who is one of N&T's own chief engineers, assisted the N&T operations organisation with the preparation work for ca. 2 months before take-over of the vessel and also during the following months he helped the Estonian chief engineer to update the vessel's computer based maintenance program including establishing the part of N&T's organisation concerning supervision of handling and maintenance of the engine plant.
Lennart Klevberg, employed by N&T's organisation as the purchaser, was located at the Estline Terminal in Stockholm the whole time and was responsible for negotiating and purchasing spare parts, lashing material, and other technical equipment and consumables for MV "Estonia".«

Note: According to von Tell GmbH, Hamburg the only spare part ordered by N&T in 20 months for ESTONIA was one new ice cylinder for the visor.

»To assist the chief engineer in steering, controlling, and documenting the technical maintenance of the engineer on board there was the administrative data system/program (AMOS-D) available. The system delivered information concerning particular maintenance items to be dealt with and the system registered remarkable details. The system included the recommendations of the manufacturers as well as the requirements of the Classification Society and modified continuously the gained operation experience.«

Note: Forsberg does not mention the 'Öberg-Data-System' which was installed on board and ashore and by which, among other things, repair lists respectively working lists were printed and monitored. Also the distribution of working lists is not explained,

i.e. - original to repair firm
- yellow copy to N&T
- Technical Dept.
- green and blue copies for ship's file.

Note: Contrary to his earlier statements that he had received a copy of the repair list concerning the damaged bow ramp hinge from N&T, Börje Stenström later said that according to N&T all copies had remained on board. Even if it should be true, which is very doubtful because it is neither common practice nor does it make practical sense, the original went ashore to N&T and must be available.

The letter continues:

»MV "Estonia" was taken over from her previous owners at the ship-yard in Turku, there the Estonian crew took possession of the vessel, the on-board organisation was established and the necessary work to adjust the vessel to Estline's traffic was carried out. Finnish speaking personnel from the previous owners Wasa Line (chief officer, 1st engineer, electrician and two repairmen) were hired from the start of the new traffic for between 21/2 and 5 months to assist their Estonian successors with practical advice in dealing with vessel's specific systems. This principle was always followed by the operations organisation of N&T when taking over vessels, independently of flag or nationality of crew. ...
Earlier supervision of the vessel by maritime authorities and Classification Society had been carried out by B.V. in Finland, however, since the technical supervision of the vessel was to be dealt with by N&T Stockholm, N&T demanded that the vessel in this respect should be moved to B.V. in Sweden. Thereafter mainly the inspector Anders Wirstam of B.V.'s Stockholm office carried out the on-board inspection. ...
In connection with an education program for Estonian ship inspector aspirants chief inspector Åke Sjöblom and 1st ship inspector Gunnar Zahlée from the Sjöfartsverket Inspection Office Malmö carried out an inspection on board the "Estonia" in the afternoon and evening of the 27 September 1994. Thereby no noteworthy deficiencies in relation to vessel's seaworthiness and safety at sea were discovered.«

Note: In this connection see also Chapter 15, but - in particular - it has to be borne in mind that - according to sources from inside Sjöfartsverket - Åke Sjöblom and Gunnar Zahlée very well noted the obvious deficiencies of the bow ramp and demanded rectification before the ferry should be allowed to sail on 27.09.94. This was rejected by the Estonian authorities - their trainees - whereupon the managing director of Sjöfartsverket, Kaj Janérus, was phoned and asked what should be done. The managing director reportedly referred them to the Estonian authorities who did nothing and the ferry sailed into the catastrophe.

 

as to (3): (Statement Hobro)

Ulf Hobro - CV see Enclosure 5.2.109:

»Marine engineer with 20 years experience at sea, whereof 12 years as chief engineer; has also worked as safety inspector for Sjöfartsverket for several years; employed as a technical inspector with Nordström & Thulin AB, had been responsible for "Estonia's" running maintenance, budget and finances. His office is at Skepsbronn in the old city of Stockholm. Has been engaged in "Estonia" since the plan to purchase the vessel arose, inspected the vessel before she was bought. His duty was to investigate the vessel and the vessel's general condition and to control the certificates required for the vessel. When visiting the vessel he discussed possible defects, damages, etc. with master and chief engineer on board. Defects were generally repaired by the crew, but often spare parts had to be ordered and this was dealt with by Lennart Klevberg in charge of the purchase of spare parts. In case of considerable damage special firms were engaged for the repair.
Hobro was assisted by Tomas Rasmusson who had his office at the Estline Terminal and was working as assistant inspector. He was on board the vessel to and from Tallinn on several occasions and he was the contact person between the Master and Hobro. Rasmusson was in daily contact with the vessel.
Hobro stated that since the vessel started her service in January 1993, there have been no remarks on the bow visor. There may possibly have been some hydraulic leakages on some piston. No defect, however, has been brought to Hobro's knowledge. In case of any extensive defect to the bow visor, this would have been reported to Bureau Veritas.«

The statement was taken by the Stockholm police on 22.11.94 and is attached as Enclosure 12.5.171.

In addition, this 'Group of Experts' had the opportunity to ask Ulf Hobro questions in the presence of JAIC on 17.02.95 in Stockholm, which revealed the following:

- With the exception of the unscheduled drydockings due to the leaking stern tube seals in March and April 1993, the vessel under the management of N&T was only once at the Yard and in drydock, i.e. in January 1994 in Turku, when the stabilisers were installed and the ice paint was touched up the last time.
- At that time the B.V. surveyor Anders Wirstam carried out a Load Line Survey, which normally should have included the rubber packings of the visor.

Note: At that time Ulf Hobro knew very well from the specification of the previous crew that they had asked for a renewal of 15 m of rubber packing in way of the visor, which was never carried out.

- This was said to be the last time that Ulf Hobro had been inside the closed visor near the Atlantic lock. There were smaller leakages of the hydraulic cylinders of the Atlantic lock and the side locks as well as the bow ramp, which were said to be normal according to him. Larger hydraulic oil leakages inside the visor were said to be unknown to the Inspection Department of N&T.

Note: The picture on the next page was taken in October 1993 and shows the lower part of the closed bow ramp severely stained by oil, most probably hydraulic oil, which cannot just be explained by normal leakages.

 

 

- During the time between the take-over in January 1993 and the sinking on 28.09.94 no rubber packings had been renewed in way of the visor. "Why should they?" asked Ulf Hobro. "It was known to everybody that the visor was anyway full of water at sea and this was also the explanation for the white paint washed off in the area below the 3rd stringer."
- Upon being confronted with the photos showing the severely oil-stained 3rd stringer with rather fresh footprints Ulf Hobro stated that to be normal due to the crew carrying out maintenance work, but he did not state what was maintained.
- According to his knowledge there had never been problems, neither with the Atlantic lock nor with the side locks.
- Upon being confronted with the empty sensor plate of the Atlantic lock he reacted with surprise and then drew attention to the changed system on board of MARE BALTICUM (where the sensors had been mounted higher up above the normal water level). He promised to clarify this with the electrician having survived, who was now serving on board of MARE BALTICUM.

Note: The sensor plate of the Atlantic lock - see explanations in Chapter 2.6.2 - page 117 ff. - was noted to be empty, i.e. without sensors, on all the underwater videos, moreover the cables leading to the sensors were evidently cut. These facts were presented to Ulf Hobro, who apparently subsequently spoke to ESCO and the result was the 'Explanatory Note' with sketch dated 23.02.95 which was submitted shortly afterwards to JAIC. The note states "that contrary to the von Tell drawing 49111-373 showing mechanical sensors, there were installed 'magnetic sensitive elements' when the vessel was taken over, which were not replaced, but just the distance was regulated and the indication checked. It is assumed that these 'sensitive elements' had already been installed during newbuilding as the same type can also be found on various other installations, such as lifeboats, lifts, car deck platforms, etc."

The note does not state that the 'sensitive elements' were still in position on the last voyage nor does it give any explanation for the empty sensor plate.
Underneath the text the following names are listed without any signature:

 

the chief engineer of the other crew H. Moosaar
the electric engineer of the other crew M. Doronjuk
the electrician of the other crew D. Salomon
the electrician, who survived A. Rohumaa
the boatswain of the other crew H. Leik

The 'Explanatory Note' is attached as Enclosure 12.5.172.

- The proof for the empty sensor plate was also submitted to B.V. and a retrospective class withdrawal was suggested by this 'Group of Experts'. This resulted in respective questions by B.V. to N&T which forced N&T to examine the matter quite closely. The result is summarised in the letter of N&T to Börje Stenström dated 15.11.95 with enclosures - all of which are attached - with office translations - as Enclosure 12.5.173.
- Part of the enclosures to the above-mentioned letter is a "Memorandum concerning a meeting on board MARE BALTICUM on 6 November 1995 in Tallinn". At this meeting the three electricians and the boatswain of the Piht crew - Heino Leik - were questioned in respect of the following subjects.

It is revealed in this memorandum that the crew experienced problems with the magnetic switches between the spring of 1994 and September 1994 to the effect that the green light did not go on if the bolt was closed. The problem was said to be solved by a simple adjustment of the magnetic switch. These problems were mentioned already by Henrik Sillaste and Tanel Moosaar during the interview on 10.03.95 in Stockholm see Enclosure 12.5.174.
According to information received by one of the Finnish engineers from one of the Estonian engineers shortly after the casualty the magnetic switches had actually been destroyed by ice hacking already in February/March 1994 and were not replaced, because crew members had to go down anyway to hammer close and open the bolt of the Atlantic lock - see statement Arvi Myyryläinen Enclosure 12.5.175 - and therefore it was decided not to renew the switches for the time being.
- Stabilisers were installed into pockets already arranged at newbuilding with respective electrical connections. The installation - according to Hobro - became necessary after less than one year in service to be able to compete also in this respect with the Helsinki ferries from Silja and Viking.

Note:

-As a matter of fact, Hobro had asked the Turku Repair Yard already in April 1993 to quote for the installation of stabilisers, i.e. after less than 3 months in service the management had to realise that the vessel was now trading in a completely different sea area with a much rougher sea state. The quotation is attached as Enclosure 12.3.143.
- Hobro did not say a word about the fire in way of the starboard stabiliser pocket at the time of installation of the stabilisers in the drydock of Naantali which - according to Henrik Sillaste - had caused damage and had cut the short time planned for installation of the stabilisers at the shipyard even shorter. Reportedly the required careful welding work to install the starboard stabiliser therefore could not be carried out as it otherwise would and should have been the case.
- The damaged parts of the "Inerta" ice paint in way of the bootop strake including the lower part of the visor with stempost were touched up.

 

as to (4):
Tomas Rasmusson: (Telephone Interview)

- He had been on board WASA KING already to become acquainted with the vessel.
- His boss was Ulf Hobro
- he was between Hobro and the crew.
- He took part in the work in connection with changing flag to Estonia, lots of translations and the like.
- Everything functioned well between N&T/crew.
- His job was more social. He had no direct responsibilities.
- He carried out his own inspections and controls.
- He was also the contact between the crew and the spare parts handler Lennart Klevberg.
- At the beginning he was on board in 14-day periods, he and Anders Andersson relieved each other.
- Later he was more shore based and made one trip per week.
- He worked mainly with engine matters, Hobro and Kleberg.
- Everything was perfect. The crew never drank alcohol. The crew was ambitious and good. No incidents or problems whatsoever.
- ESTONIA was in very good condition. Deficiencies were rectified at once. Everything was listed by the data system AMOS-D. Each month a list was printed which showed what had been done and what had to be done. In case the chief engineer had done nothing, he was instructed by Hobro or himself what to do.
- He did not know if and how the visor was controlled. He never heard anything.

The above are notes made when sighting the files in the office of the prosecutor in Stockholm. A photocopy of the transcript is attached as Enclosure 12.5.176.

 

as to (5):
Lennart Klevberg: (Statement)

- He was frequently on board the ESTONIA.
- He ordered the hydraulic parts and valves for the visor and bow ramp.
- He had ordered rubber packings for the visor which were to be delivered together with the packings for MARE BALTICUM.
- Capt. Andresson and Tomas Rasmusson had told him to wait with the delivery of the new rubber packings until MARE BALTICUM would be taken over and then have it done for both ships at the same time.

Note:

Hobro stated that no rubber packings were ordered, nor was it their intention ever to order them.
Rasmusson stated not to have direct responsibility, however, he was the contact between the spare-parts man Lennart Klevberg and the crew, on the other hand he testified that he did not know if and how the visor was controlled and that he never heard anything in this respect.
Kleberg, however, testified that he had been told by Capt. Andresson and T. Rasmusson that he should wait with the delivery of the rubber packings for the visor of ESTONIA until MARE BALTICUM had been over.

 

as to (6): (Statements of some of the surviving crew members and the member of a working team)

a.) The member of the working team and then student at the Nautical Academy Tallinn, Rain Oolmets, has testified respectively had been interviewed three times about his observation on board and the respective statements/transcripts are attached as follows:

Rain Oolmets worked on board ESTONIA from 11 July to 11 September 1994.
The relevant parts of the testimonies shall be quoted as follows:

Q: When were observations made of cracks in the visor of "Estonia"?
A: I observed them while painting on the bow deck of the "Estonia" in early August 1994. Painting was done in the port of Tallinn.
Q: In what position was the visor when you were working?
A: The visor was open, otherwise we could not have seen the cracks.
Q: What colours did you paint?
A: Both green and white (i.e. both the deck surface and areas rising from the deck).
Q: Can you show on the visor where the cracks were?
A: Those parts have been removed, this is why I cannot show the crack locations. (Upon instructions of Börje Stenström the hinge remains had been removed for metallographic investigations and mechanical testing already in January, that is why the crack locations could not be demonstrated.)
Q: Could you indicate on these sketches where the cracks were?
A: You have to look from forward to aft at the hinges to be able to see the cracks in the welding seams between the bushings and the hinge plates of the visor hinges (hinges at the visor). The cracks were opposite to the deck when the visor was closed. At the starboard hinge there were cracks in both welds. At port side there was only one crack in the weld. The drawing below shows the location and approximate length of the cracks.

 

 

The cracks were less then 10 cm long. (Reference is made to the statement taken by the Estonian police on 03.10.1994).

Q: Could you tell us a bit more in detail about the paint work and the damage to the visor?
A: Actually the damage could only be seen when the visor was open. There were very many. On a drawing one could see that more in detail. Actually at one side there were these cracks. Possibly as a result of mechanical action.
Q: You said on one side the crack was 10 cm long and on the other side about 6 cm long? This is written in your statement.
A: This might have been so.
Q: Quite sometime has passed but I assume that you are not going to withdraw your written statement?
A: No.
A: I did not inform the boatswain about my observations. It was the time when the cars were rolling on board. And the boatswain ... you had to work with him. He did observe exactly. He disliked it if somebody did not work during his working time. Then I did not get a chance to tell him. I was actually of the opinion that it was known anyway. Therefore I forgot to report it.
Q: What was the condition of the visor when you started to work?
A: I did not have specific instructions to do something at a particular location. During my work I was climbing everywhere, cleaned and painted. This location was difficult to reach. Presumably the last time this area had been painted was when the vessel was painted white for the first time. I thought that certainly somebody from the administration knew about the cracks because the vessel was checked quite often. Also the boatswain checked our work. Therefore I believe that certainly somebody knew of the cracks.
Q: Thus you were convinced that due to the frequent checks that somebody knew about the condition of the visor and also of the cracks?
A: Yes, I was sure that they knew it.
Q: Did the crack appear only after you had removed the paint?
A: No, the crack was visible already before.
Q: It was consequently enough to climb there to see the crack?
A: Yes.

The complete interview is attached as Enclosure 12.5.179.

In summary of these three statements it has to be concluded that the welding seams between the bushings and hinge plates of the visor hinges were visibly cracked up to 10 cm at the beginning of August 1994, less than 8 weeks before the casualty.
The photo below shows a part cut out of the bushing recovered by divers from the wreck. It is most probably the starboard inner bushing as will be explained in Chapter 30.

 

photo of stb. inner bushing recovered by divers

 

For a better understanding, the relevant parts have been numbered as follows:

1 = steel bushing
2 = hinge plate
3 = area between hinge plate/bushing
4 = welding material
5 = arrow pointing to the large gap between bushing and hinge plate
6 = welding seams between bushing/hinge plate

Without going too much into detail, already now attention has to be drawn to some very obvious irregularities, viz.

- The bushing had been too small for the bore of the hinge plate (2), therefore a gap (5) remained between bushing and inner surface of the hinge plate.
- The welding seams (6) are rather weak compared to the dimension of hinge plate and bushing.
- There had obviously been a crack at the left side in the welding seam (4) which had been tried to be closed by welding. This led to the accumulation of welding material inside the gap between bushing / hinge plate.
- The surface area between hinge plate/bushing (3) is severely corroded which would not have been possible if the inside had been airtight by intact welding seams. In other words, the apparent fact that the space between bushing/hinge plate could be attacked by corrosion as found is proof that the welding seams had been cracked over the full thickness for a longer time already.

b.) That there was something seriously wrong at least with the starboard hinge arrangement of the visor well before the casualty becomes very obvious when having a close look at the video film made by a passenger upon departure from Tallinn on 17 September 1994, i.e. 10 days before ESTONIA's last sailing. He stood on the open forepart of the 8th deck and with his video camera filmed the closing of the visor. Thereby he zoomed in on the starboard hinge arrangement. The subsequent evaluation of the video proved that the starboard visor hinges were totally misaligned with the lower part of the outer bushing as well as the securing plate missing. The video was analysed and evaluated in detail by the Reconnaissance Expert Bryan Roberts of Churchgate/UK and his report is attached as Enclosure 12.5.180.

The print is shown below and the enlargement is attached as Enclosure 12.5.181.

 

 

Although the distortion and misalignment of the starboard hinge is clearly visible to everybody, the Swedish part of JAIC gave a copy of the film to the Military Intelligence Service, who produced the picture attached as Enclosure 12.5.181.1, which evidently shows the same. Nevertheless, the Intelligence people declared the whole film to be unreliable since 5 out of about 800 sequences had been slightly "jumping", which was accepted by the JAIC as well as N&T and the film from then on was ignored by the JAIC and consequently is also not mentioned in their Report. What the film really shows becomes clear on the enlargement below, viz. some major deficiencies:

 

 

- the gap between the starboard vessel hinge plate and the outer bushing is much too large (Arrow 1).
- the outer bushing is sticking much too far out of the outer visor hinge plate (Arrow 2) (which explains the large gap mentioned above).
- the lower part of outer bushing is missing.
- the securing plate is missing and the outer end of the bolt is not visible.
- the outer bushing appears to be twisted anti-clockwise.
- the inner bushing appears to be twisted anti-clockwise.

Bearing in mind that the nautical student Rain Oolmets reported the cracks observed at the beginning of August 1994 immediately after he had learned of the casualty to his uncle, who was then sailing as chief officer for ESCO, and the uncle went to the police who subsequently interrogated the student on 03.10.94, it is difficult to believe that Rain Oolmets had remained silent on the real damage to the starboard hinge, had it been there already.

On the other hand, he had told Klaus Rahka during the questioning at Hangö on 24.03.95 that he had painted the visor hinges green and white and - as clearly visible on the video image on the following page showing the starboard hinge bolt - there is quite a lot of green paint on the bolt which could not possibly have got there as long as the hinges were in their original, intact condition because then it was practically a closed system, i.e. paint could not reach the bolt. The intact system has no gap as can be seen from the drawing below showing the intact starboard hinge arrangement.

 

 

As it is, however, obvious from the video print below, showing the starboard bolt - without bushing - resting on the rail bar, there is a stripe of green paint at the bolt. Measurements reveal that the paint is in way of the gap between the outer bushing and the vessel hinge plate which is visible on the enlarged video print on the previous page (Arrow 1).

 

 

Therefore it has to be concluded that the gap must have been there already when the green paint was applied, however, this will be evaluated more in detail in Chapter 29/30.
Oolmets commenced his job mid July 1994 and left the vessel on the 11 September 1994. He had discovered up to 10 cm long cracks in the weldings between bushings and visor hinge plates both at port side and starboard side of the visor hinges when the visor was open. This was in early August, at a time after 16.30 hours when the loading of the trucks had already commenced. The boatswain then on board was Vello Ruben, thus it was the Andresson crew. Considering the fact that the Andresson and Piht crews relieved each other every 14 days, further that the Andresson crew would have been relieved on the 29.09.94, thus came on board on 15 September 1994, going back from that date in 14-day intervals, it becomes obvious that the early August time for the Andresson crew with Vello Ruben as boatswain ended on 4 August 1994 in Tallinn. As on that day the crews would change in the morning, the loading of the trucks after 16.30 hrs was already attended by the boatswain of the relief crew, Heino Leik. As on the day before, 3 August 1994, the vessel had been in Stockholm, it has to be concluded that Rain Oolmets found the cracks on 2 August 1994 as this is the only day in early August when Vello Ruben was on the car deck after 16.30 hours. The Andresson crew returned on 18 August 1994, but this date or later would hardly be considered early August by Rain Oolmets. On 11 September 1994 he left the vessel (see time schedule of crew change - Enclosure 12.5.182).
If he had finished painting the starboard hinges, which has to be assumed as he stayed on board for another 6 weeks after discovery of the cracks in early August, there must have been quite a gap between the inside of the outer visor hinge plate and the outside of the outer hinge plate at the vessel's side, as otherwise it would not have been possible for such green deck paint to reach the bolt.
This could indicate that the repairs to the starboard hinges of the visor had already been carried out when Rain Oolmets discovered the reported cracks on 2 August 1994. It would, of course, mean that he told the criminal police as well as JAIC only part of the truth, which would not be surprising.

 

c.) According to the statement of 2nd engineer Peeter Tüür he was also responsible for all watertight (weathertight) openings of the vessel, their maintenance and proper functioning. In his statement taken on 3 October 1994 by the Estonian security police in Tallinn - see Enclosure 12.5.183 - Peeter Tüür, who is the highest ranking officer to have survived, has testified:

»I am the 2nd Engineer. Each engineer has his tasks. Part of my tasks were the watertight openings and to keep the technical functioning in order. It was also my responsibility to see that the visor was in order, but I was specifically responsible for the hydraulic of the visor. The closing of the visor was carried out by the boatswain, however, I am unaware who was directly responsible for the closing, possibly the mate. Behind the visor is the ramp. This should also be hermetically tight, there are just a few places where the ramp does not close hermetically. The visor is closed hydraulically and securing wedges fix the visor in closed condition. There are 5 fixing points.«

This statement of Peeter Tüür is in many respects of great importance, because he has stated that

Further it shall be mentioned that N&T supplied the JAIC with the 47-paged "List of Maintenance and Repairs Works on M.V. 'Estonia', April 1993 - August 1994", which is drawn up in a rather peculiar way and is signed by the chief engineers Moosaar and Leiger. The list contains for example many repairs to dish washing and slicing machines in the galley as well as the cleaning of search lights, ventilation pipes, etc., however neither bow ramp nor visor are mentioned at all, although the crew and external repairmen did a lot of burning and welding and other maintenance work.
The only 10 items of interest on the 47 pages of the above-mentioned list have been summarised and are attached as Enclosure 12.5.184.
Finally, the transcript of the interview of Sten-Christer Forsberg (SCF) by Erik Ridderstolpe (ER) from Swedish Radio in December 1997 after publication of the Joint Accident Investigation Commission's Report shall be quoted. The transcript was also found in the files of the prosecutor and is attached as Enclosure 12.5.185.
After Forsberg had admitted that N&T was responsible for the condition of the ferry upon departure from Tallinn, he was confronted with the last repair list of the Finnish crew by Ridderstolpe and the following Q/A developed:

SCF: I have seen this repair list for the first time in the Final Report of the Commission.
ER: And you did not receive any information in this respect beforehand?
SCF: No, it was not available to us.

Note: This is wrong. The repair list - Enclosure 3.4.96 - and the yard quotation - Enclosure 3.4.97 - were handed over during the yard time in January 1993 from Wasa Line to N&T. N&T did subsequently order some of the items which were carried out by the yard. The subsequent yard invoice - Enclosure 3.4.103 - issued to N&T contains only the reference nos. of the repair list without any text. Thus N&T could interpret and understand these items only by means of the repair list.

ER: Silja had a maintenance contract with MacGregor concerning rubber packings, locking devices, etc. which you cancelled immediately.
SCF: We did have the time and capacities to do everything in port ourselves. The acting of the previous owners was more directed by short stays in port and lack of capacities.
ER: The vessel had a wrong PSSC.
SCF: The wrong construction of the vessel since newbuilding is mainly to be blamed for the casualty, not so much the wrongly issued certificate.
ER: The vessel was loaded totally wrong in Tallinn.
SCF: The wrong loading is regrettable. It would, however, also have been done by any other crew.
ER: The safety equipment did not comply with the regulations.
SCF: The bad and overaged safety equipment was accepted by Sjöfartsverket, otherwise we would have renewed everything.
ER: In my opinion N&T acted with gross negligence.
SCF: I cannot accept this, but insist to the contrary that we had a very well maintained and very well managed ship, which had been seaworthy in every respect. If anybody is of a different opinion and is able to prove it on basis of the now available report, then he is welcome do so.«

In the following chapters the condition of the "very well maintained" and "very well managed" vessel which was "in every respect seaworthy" upon her last departure from Tallinn shall be presented.