CHAPTER 38

THE YEAR 1995

The JAIC continued their endeavours to confirm their hypothetical casualty scenario and to improve the argumentation and evidence in favour of it. It was planned to publish a detailed technical Part-Report as soon as possible. Regular press statements in line with the above strengthened the public opinion in the Nordic countries that the main blame for the catastrophe rested with the builders, Meyer Werft in Papenburg.
      This caused the Managing Director of the yard, Bernard Meyer, to instruct his lawyer, Dr. Peter Holtappels, to form an own team of experts to investigate the real causes for the sinking of the ESTONIA. See also PREFACE.

 

38.1
The German 'Group of Experts'

Dr. Peter Holtappels, senior lawyer with the law firm Ahlers & Vogel, Hamburg, became the chairman of the new team and engaged Prof. Dr. Eike Lehmann from the Technical University, Hamburg, to perform the investigation from the Naval Architect's point of view and Captain Werner Hummel, Marine Consultant and Managing Director of Marine Claims Partner (Germany) GmbH, Hamburg was engaged to investigate the visor condition, the ESTONIA berths in Tallinn and Stockholm and collect all information relevant to the casualty. In addition, Captain Håkan Karlsson from Mariehamn/Åland Islands was engaged in his capacity as one of two masters having been in charge of the ESTONIA for about 12 years. Simultaneously Meyer Werft nominated a member of its Design and Construction Department, Naval Architect Dipl. Ing. Tomas Wilkendorf as co-ordinator of the internal yard investigation and link to the 'Group of Experts'. Already the first of three inspections of the visor in Hangö revealed:
   - that the visor, although well painted from the outside, was in an extremely bad maintenance condition; - that the starboard visor    hinge had been in a very poor condition already before the casualty with deep burning marks and fatigue crack propagations in    way of the broken parts of the visor arm and elsewhere;
   - that numerous water marks inside the visor indicated that the visor had been water-filled at sea up to different levels obviously    depending on the outside water height, i.e. that the visor had not been weather tight;
   - that the (lowest) 3rd stringer was covered with oil on which fresh footprints were visible indicating substantial activity inside the    visor after the water had left the visor the last time before it was lifted ashore in Hangö, i.e. before the last arrival at respectively    after the last departure from Tallinn.
The areas in the aft bulkheads of the visor, where the lugs of the hydraulic side locks had been located, were already burnt out and taken to Stockholm. The starboard hooks of the manual side locks were crushed while the port ones were intact and just bent slightly together.
      The big lug fitted to the after part of the heavily damaged visor bottom was in place but almost cracked off the visor. This lug was part of the Atlantic lock. For further details see Chapter 30.
     In brief, it was very obvious that this was not a normal and properly maintained visor, but a misaligned, leaking structure with poorly treated and thus considerably weakened hinges and manual locks, which apparently had not been engaged. The numerous footprints on the 3rd and to some extent on the 2nd stringer indicated quite some activities inside the closed visor which is unusual because the only installation inside the visor, the Atlantic lock, was normally operated remote controlled from the car deck.
      Two days later at a fortuitous meeting with Uno Laur in his Tallinn office, he explained the following:
- the visor was leaking and at sea full to the outside water level;
- the hydraulic installation of the Atlantic lock was leaking as "did all hydraulic installations on older vessels", thus hydraulic oil was swimming on top of the water surface inside the visor when the vessel was at sea;
- the hydraulic oil caused the water marks inside the visor and, when the speed was lowered, the water left the visor through the gaps in the bottom and the oil settled down on the stringers, frames and on the bottom - see also Subchapters 12.4.4. and 12.5.;
- as the Atlantic lock had suffered badly during the last ice winter (January to March 1994) when the crew had to hack to pieces the ice inside the frozen visor, it could no more be opened and closed by the hydraulic cylinder, but this had to be done manually by hammering;
- therefore each time before arrival at Tallinn two crew members went down and hammered the bolt open and after Tallinn they hammered the bolt closed - see Subchapter 12.5.
Note: At that time it was unknown to this 'Group of Experts' that the sensors had been dismounted because they were also damaged by the ice hacking and as long as crew members were going down to hammer open or closed the bolt of the Atlantic lock it was not required to renew the sensors, which were anyway hindering the hammering. This was at least the opinion of N&T as technical managers of the ferry. Had it been known, Uno Laur would certainly have been asked as well and he would probably have told the real background. Now it took some months longer before a Finnish engineer with a friend among the 2nd crew of the ESTONIA relayed the information that the sensors had been dismantled because they were damaged and were causing short circuits in the electrical system of the car deck and as each time when the Atlantic lock had to be opened or closed the crew members went down to do the job, the sensors were not needed. Before this background it is of course understandable that Stenström threw the already recovered bolt of the Atlantic lock back into the sea, because it clearly showed the hammering marks and also two different contact marks indicating that the bolt had sometimes been fully closed and sometimes only partly closed which has nevertheless been clearly established from the available video footage. It is also understandable that Stenström ordered the divers to burn off the sensor plate and to clip off the cut ends of the sensor cables and subsequently throw both to the bottom of the sea consisting of soft clay where they disappeared forever (see Subchapters 12.5, 27.1 and 29.2).

In any event, it was now quite clear that the publications and statements by the JAIC were, if at all, only part of the truth and that the crew and possibly also owners/technical managers of the ferry had had difficulties with exactly these locking devices which - according to the JAIC - had triggered off the casualty sequence-of-events by their failure.
      The new information was evaluated and discussed and by fax of 20 January Dr. Holtappels suggested a meeting with the JAIC to which Börje Stenström replied on 20 January among other things:

"Appreciate the opportunity to get views from a group of experts from your side, the commission is certainly open for any constructive comments on the development of the accident. For your information the full commission will have a meeting in Helsinki on 26-27 January. We do not expect to have any press conference but questions from media are unavoidable. The official view of SHK was published in a news release via the Swedish press news agency a week ago, stating that the report of the commission was delayed because more time had been allowed to the yard to complete their investigations, metallurgical investigations were still going on in Stockholm and the commission had initiated a second look at the weather conditions and in particular any specific wave conditions at the site of the accident."

On 26 and 27 January 1994 the JAIC met in Helsinki and from the protocol the following items are quoted:

"4 Bow Visor
Börje Stenström presented a status report on the technical findings and technical evaluation of the probable sequence of events and cause of the accident. Several supporting investigations are still going on. Comments from the shipyard have not yet been received. The members and experts are working on the report concerning the bow visor. When the draft report is ready it will be sent to the commission members and experts. Tuomo Karppinen presented SSBA model experiments. Simulations will be continued.
5 The Estonian delegation presented material on the adequacy and qualifications of the crew of M/V "Estonia".
6 All the lifeboats and liferafts of M/V "Estonia" which have been found after the accident in Finland and Estonia have been photographed and examined by the technical group for the Finnish Central Criminal Police with the assistance of an expert from the Finnish Maritime Administration. A copy of the report (including a selection of pictures) of one liferaft examination was presented."

At a subsequent press conference the present status was presented to the international media.
      On 30 January the first meeting of the German 'Group of Experts' was held during which the forthcoming meeting with the JAIC scheduled for 16/17 February in Stockholm was prepared. A model of the foreship with moveable visor and bow ramp of VIKING SALLY built by the yard was presented.

 

February 1994

On 2 February Börje Stenström sent his revised "Assumed Sequence of Events" with illustrating drawings - see Enclosure 38.1.462 - which repeated his earlier expressed thoughts.
By fax of 7 February Stenström requested the following:

"1. The bottom lock. You indicated that the assembly consisting of the locking plunger housing and the lugs should have been a shop assembly, properly welded. As far as I recall one of the engineers attending our last meeting at Papenburg (presumably a shop engineer) confirmed the weld was a normal installation weld. We have no detailed drawing of the bottom lock assembly except as shown in drawing number 49111-373. In case there is a shipyard drawing showing such an pre-fabricated assembly, including welding details, we would much appreciate a copy.
2. The side locks. We have no dimensional drawing of the side lock lugs except that shown in drawings 49111-372. If there is a more detailed drawing we would like a copy. We would also like, if available, a copy of the design calculations for the attachment to the visor and the associated weld joint.
3. Damage to rubber seals. As far as we understand, the heavy stem post on front of the visor rests against the fixed continuation on the stem/bulbous vow. This determines the vertical position of the visor in closed position and any change of the steel work at the rubber seals would not change the vertical position of the visor. In checking with inspectors who had been onboard shortly before the accident there had been no signs of changes to the rubber seal installation."

By fax of 10 February this 'Group of Experts' submitted what should be discussed at the meeting:

In the course of a telephone conversation on 15 February Börje Stenström informed about the following:

1. The participants from their side will be:
from Estonia: Captain Uno Laur
                     Professor Metsaveer
                    1 further expert

from Finland: Tuomo Karppinen - VTT, Helsinki
                     Klaus Rahka - Metallurgist

from Sweden: Börje Stenström - Naval Architect
                     Mikael Huss - Naval Architect

2. They are expecting a solely technical discussion and from the German side the answers to the questions raised by them already in November.
3. Video material: At first the Finns had sent down a ROV to the wreck which took better pictures than the divers did. The video sent to the yard does not contain ROV pictures which will, however, be made available, if requested. The film sent to the yard had been made by an English diving team having examined the wreck for 80-90 hours from a Norwegian semi-submersible (belonging to the Norwegian Smit-Tak subsidiary) by order of the Swedish Maritime Administration. The aim was to obtain material for a feasibility study in respect of the lifting possibilities. Subsequently the divers were available to the JAIC for another ca. 10 hours for examination of the foreship. Thereby Stenström has personally directed the divers via a monitor and had a close eye on them all the time. He excludes that the divers have dismounted the sensors of the Atlantic lock (therefore it is established that this must have occurred before the casualty).
4. Recovered objects: The divers have dismounted respectively burnt off the well known parts including the bolt of the Atlantic lock. When they were preparing the helicopter flight back some parts had to be left behind due to weight restrictions. As the bolt did not show any changes except for some notchings, it was left behind on the diving support vessel. He assumes that the bolt has been thrown overboard in the meantime (weight ca. 25 kg). The other parts will be shown to us tomorrow. We will receive name and contact of the owners of the diving support vessel and shall find out where the bolt actually is.
5. Surviving crew members: in total about 30, of whom only 4 were on watch, i.e. 1 engineer, 2 motormen, 1 decksman (name: Silver Linde). He was sent twice from the bridge to the car deck to check whether the ramp was still tight. The last time was shortly before the catastrophe, the green lights were always on.
6. Atlantic lock: As it had been assumed already they had not spent much thought on it. The lugs are obviously broken an that is sufficient for them, they thought. They have not yet realised that:
- the sensors were obviously dismounted before the casualty;
- the actuator as well as the bolt were turned about 90° towards aft;
- the port hydraulic hose was torn off.
They have no explanation for the oil spill on the lowest stringer of the visor nor for the many footprints (also the technicians from N&T do not). On the other hand, it is not in doubt that the heavy weather securings were not engaged.
7. 2 Swedish inspectors have indeed inspected the vessel on the departure day together with 9 Estonian trainees, however, they cannot give relevant information.
Note: This means that Stenström began the "cooperation" with this 'Group of Experts' with two untrue statements, namely:
(a) he alleged to have left the bolt onboard, although actually he had personally thrown it overboard; and
(b) he stated that the two inspectors had no relevant information, although at that time he had known for more than 3 months that those inspectors had found such grave deficiencies on the ferry that they had tried to stop her from sailing - see Chapter 15 and Subchapter 36.1.

 

38.2
The February Meeting

The meeting took place in Stockholm on 16/17 February and was attended by the persons mentioned on the previous pages.
Stenström advised that it was not the aim of the JAIC to blame somebody for the casualty, but to establish the facts, i.e. the causes, and to issue recommendations for the future which should avoid a repetition. He emphasized that the Swedish part of the JAIC - Statens Havarie Kommission - is completely independent and comparable to the U.S. National Transportation Board, while the Finnish part, headed by its permanent chairman Kari Lethola, was attached to the Ministry of Justice and the Estonian part was formed exclusively for this investigation.
Stenström further informed that the next JAIC meeting was scheduled to take place in 4 weeks in Tallinn when the basis for the subsequent final report was to be decided in respect of

- causes
- sequence-of-events
- conclusions

which should be published at the end of March/beginning of April by means of a preliminary report. This report should be amended in the course of the year, however, not as regards the three above-mentioned items - causes, sequence-of-events, conclusions, which would remain unchanged and taken over in the final report to be published by the end of the year.

Note: This means not more and not less but that the JAIC had considered its investigation as to the causes, sequence-of-events and conclusions finalised, no matter what would come up in the course of the year. As a matter of fact, that is what the JAIC upheld until the Final Report was finally published in December 1997. This also means, however, that the JAIC had established its firm opinion on the causes, the sequence-of-events and the conclusions already before 17 October 1994, as on this day the causes, the sequence-of-events and the conclusions, though in slightly different wording, were submitted to the public for the first time. The reader is reminded that this was on the 19th day after the casualty and prior to the visor being lifted and brought ashore. The reader is left with his own conclusion on the merits of such investigation by Swedish authorities into an accident which has cost hundreds of fellow citizens their life.

The open questions concerning the locking devices of the visor were discussed in detail and in every thinkable direction, however, whenever maintenance matters were discussed uncertainty came up especially on the Estonian side.
     Upon a respective question the Finnish and Swedish JAIC members explained that interrogation of the Estonian crew members as well as all questions concerning the vessel, the shipping company, the organisation and operation were exclusively dealt with by the Estonian JAIC member, Uno Laur, because the other two members were the Transport Minister and the Head of the Navigation Department of ESCO who could not - or only restrictively - participate in the daily work.
     The results are obvious: Only that information was passed to the Swedish/Finnish JAIC which did not affect Estonian interests or which was already public. It was thus not surprising that the same Uno Laur who had explained to a member of this 'Group of Experts' only 4 weeks earlier - in the presence of one of his Finnish clients - why the footprints were in the oil on the stringer, now tried to convince the audience that the Atlantic lock had been operated hydraulically up to the end. It became obvious in the course of the two days that the JAIC had not even considered to investigate the condition of the vessel before her last departure and was content with their hypothetical cause consideration and casualty sequence-of-events which - "so sorry" - did put the blame almost entirely on the builders.
      During the meeting, the personal talks with the Finnish participants and, in particular, with Börje Stenström were very open in response to the many questions concerning the circumstances of the casualty, the route, weather, crew and all the many relevant details of which this 'Group of Experts' knew practically nothing, but which were of crucial importance for the investigation. The Estonian participants in the discussions tried to do everything to avoid the creation of a bad impression of vessel and crew. When for example the subject "ice damage to vessel and visor" was raised because the visor had obviously at least two quite heavy old damages, Uno Laur said: "It was a very, very mild winter. What should have happened. Moreover the vessel had ice class 1A." Actually the Gulf of Finland and the Middle and Northern Baltic were covered by thick ice from the end of January to the beginning of April 1994 - see Subchapter 12.4.2 - and the ferry had frequently been used as an "ice breaker".

The hypothetical scenario of the JAIC had, however, serious weaknesses and some of them became very apparent at the meeting. These were mainly:

(a) the condition of the locking devices as found;
(b) the uncertainty whether the locking devices were still original;
(c) the apparent fact that the maintenance and damage history of visor, bow ramp, its locking devices and hinges had not been examined at all before arriving at and going public with their scenario and the conclusions therefrom;
(d) the apparent fact that visor seals were missing/damaged and the visor had been full of water to the outside level at sea with (then) unknown consequences.

Being so sure about their scenario the Finns for example agreed to the visor condition as explained under (d) above, while Stenström and the Estonians smelled trouble and were reluctant. In any event, Karppinen and Rahka fully agreed that the visor had always been full of water at sea, however later with-drew from this admission completely, when they realised what consequences water in the visor had in combination with a damaged bow ramp: water on the car deck.
      At the JAIC meeting in March in Tallinn among other things also the protocol of the statement of the nautical student Rain Oolmets to the criminal police in Tallinn made already on 03.10.94, i.e. 6 months before, was handed over to the Swedes/Finns. The reason for the long delay in presenting this important statement to the JAIC is obvious: It dealt with up to 10-cm long cracks in the welding seams of the visor hinges observed by the student only some weeks before the casualty when he was the member of a working team. See Subchapter 12.5 and Enclosures 12.5.177 - .179. It was agreed that the man should identify the cracks at the hinge remains of the visor in Hangö and Enn Neidre took over the arrangements (apparently no one told him that the hinge remains had been cut off from the visor already in January and were now at the KTH in Stockholm). In any event the Swedish chairman, Olof Forssberg, wrote to the Estonian chairman, Andi Meister, on 20 March among other things:

"We agreed in Tallinn to question two witnesses about the observation of cracks ........ "

Andi Meister replied on the following day, 27 March, among other things:

"Referring to the Protocol of Interrogation which was discussed by the Commission on the last meeting ... Rudissaar, whom Oolmets claims he told about the matter, knows nothing about it or has only heard people talking about this matter. There is a Mr. Gunnar Kull, who should know more. Captain E. Neidre, member of the commission, shall arrange the trip to Helsinki for Oolmets and Kull. He will be in Helsinki with Oolmets and Kull in the morning of Friday 24th, and they will go to Hanko by car."

The gentlemen met at the visor in Hangö, however the hinges were no more there. See Subchapter 12.5 and Enclosure 12.5.178. Rain Oolmets was obviously attending, however, Gunnar Kull never showed up and has not been mentioned again anywhere thereafter.

 

38.3
Investigation and Communication

In the course of the following days tank conditions and cargo distribution - then known by the JAIC, but later proven to be incomplete - the Finnish videos made by ROVs in the early days, and some stability calculations and other documents were received.
      In a subsequent letter Börje Stenström wrote to Dr. Holtappels, the chairman of this 'Group of Experts' among other things:

"I had the opportunity to see part of your instructions to the team members and noted with appreciation that they are instructed to work unbiased. I also feel that we were able to do so during our meeting. I do disagree, however, with your little indication that the international commission should not be unbiased. I would like you to rest assured that the commission has only three goals, to establish what hap-pened, why it happened and how it can be prevented from happening again. I am speaking for the Swedish part of the commission in this matter since we have a firm policy in this regard established by law. I take it that our policy will also be valid for the entire commission as we do, in reality, have the lead."
Note: The "little indication" that the JAIC might not be entirely unbiased refers, of course, to the Estonian JAIC members Andi Meister and Enn Neidre. The apparent fact that the Swedes had the "lead", although the Estonians had been awarded the chairmanship, reflects the factual situation.

The communication and exchange of documentation and information with JAIC, in particular with Stenström, went on and by fax of 28 March among other things the so-called "Explanatory Note" was received - see Enclosure 12.5.172 - which was apparently meant to be the Estonian answer to the allegation of this 'Group of Experts' that the sensors of the Atlantic lock had been dismounted some time before the casualty. The note, however, merely states that the sensors on the ESTONIA were magnetic and not mechanical - as stated on the drawings - and that during the time under Estonian flag the sensors had not been changed, moreover that it was believed that these sensors had been installed at newbuilding already because there were numerous others of this type on other installations. In other words: the drawings of the yard were wrong. This was not the case as was subsequently established when previous Finnish electricians declared when and why they had changed the initial mechanical sensors against the magnetic ones. See Subchapter 3.3.6, pages 42/43 of the Final JAIC Report.
      By fax of 29 March Stenström sent among other things the Cargo Manifest by which he considered "the truck loads to be properly documented and the truck loads to look quite harmless". It is revealed from the fax prints on top of the pages that it had been sent on 27 September 1994 at 18.38 hours from Estline-Tallinn and that Stenström had received it on 29.11.94 from N&T. See also Enclosure 17.1.211 and Subchapter 17.1. The manifest contains 39 trucks of which the last one was added in handwriting although there were actually 40 onboard according to the Customs List - see Enclosure 17.1.213. This list had been in the hands of the Finnish police since 14.10.94 already, however it is unknown when it was sent to Sweden.
     In any event, Stenström must have had in the early days some other manifest or list or information because by fax of 30.11.94 he informed SSPA (Ship Model Testing Facility) that there had been 34 trucks/trailers onboard only - see Enclosure 38.3.462 and this went into the weight calculations for the first model tests in the tank to establish the wave load on the visor/and the locking devices.
     In this connection attention has also to be drawn to a further mistake made in this above-mentioned fax about weight distribution because Stenström wrote: "tanks 13 + 14 (starboard and port heeling tanks) 183 ts". He means though - according to his own statement during his first visit to Papenburg on 27 October 1994 - that the port heeling tank - no. 14 - had been completely filled with 183 ts., while the starboard tank had been left empty - see also Subchapters 17.1 and 29.5. In a stability and trim calculation received earlier, performed by Ship Consulting Oy, Turku on behalf of the Finnish JAIC and dated 01.12.94 - see Enclosure 38.3 - both heeling tanks are stated to have been filled completely with 185 ts each plus 34 trailers.
      By fax of 10 March Börje Stenström had already distributed his "Draft Technical Report", the forerunner to the Part-Report, among other things also to Dr. Holtappels. Already on the following day the conclusions - pointing, of course, to Papenburg - could be read in "DAGENS NYHETER" and the Berlin paper "TAZ". It revealed subsequently that the Sea Safety Director of Sjöfarts-verket, Bengt-Erik Stenmark, had given a copy to DAGENS NYHETER and the Estonian JAIC member Uno Laur had sold a copy to TAZ.
      On the same day Jutta Rabe from SPIEGEL TV interviewed Börje Stenström in his Stockholm office and after respective questions Stenström admitted to have personally thrown overboard the bolt of the Atlantic lock - see also the Subchapter 37.2.
     In the course of the further interview he was asked whether they had examined the visor and the wreck for ice damage and his reply was: "We had no indications for ice damage: it was a rather mild winter (he had been shown the ice charts only 3 weeks before) and there were no indications for such damage. At least, as far as we know", and further: "Anyway, I believe that possible ice damage has not been examined, however, I am not quite sure. A good question you are raising. We should possible check that."
     In this context it has to be mentioned that a member of this 'Group of Experts' attended the hearings of several crew survivors as technical consultant of a German TV team and this was the first time that direct questions could be asked to key witnesses. One of the results was the drawing made by the survivor Henrik Sillaste about his observations on the monitor in the engine control room after the big heel. The drawing - see Enclosure 21.2.4 - shows the bow ramp in slightly open condition with water pressing through the gaps at both sides under pressure, however, more at starboard side. The drawing, confirmed by the other two survivors from the engine control room, Margus Treu and Hannes Kadak - see Subchapters 21.2.3 and 21.2.5 - proved that the bow ramp had still been closed or almost closed after the big heel, while according to the casualty scenario of the JAIC, the big heel was caused by huge water quantities having entered the car deck after the bow ramp had been pulled completely open by the forward tumbling visor. This was evidently wrong because the bow ramp was still been in the almost closed position when Sillaste and Kadak left the engine control room at a list of 30°/40°. From the very beginning of their testimonies Treu, Sillaste and Kadak have testified this water penetration at both sides of the bow ramp after the big heel. This was also reported in SVENSKA DAGBLADET and DAGENS NYHETER during the early days, however, unfortunately was ignored by the JAIC.
     Back to the "Draft Technical Report" of the JAIC which was analysed in detail by this 'Group of Experts'. After considerable discussions it was agreed not to comment on this draft report since it was out anyway and, in particular, since the JAIC was under no circumstances prepared to change its substance in preparation of the Part Report due to be published in early April. Instead Dr. Holtappels gave an interview to Lloyd's List which was published in the 17 March issue and reads as:

"German Yard inquiry finds lock system was altered MEYER WERFT HITS BACK ON 'ESTONIA' An investigation into the loss of the Baltic ferry 'Estonia' by the German yard which built her is set to counter Swedish press claims that a weak lock was responsible for the disaster. Meyer Werft, which is due to publish its first findings early next week, will claim that safety indicators had been tampered with and that the 'Estonia' was operating on a route where she would not have been. Lawyer and former shipowner Peter Holtappels, who heads the commission, said the findings would shed "a very different light" on the tragic accident than the impression given by parts of the report of the international commission published by the Swedish media. The preliminary German report claims that the safety indicators on the bridge showing whether the bow visor was locked had been tampered with to display permanent "green". It also alleges that the sensors on the major device, the Atlantic lock, had been removed. Dr. Holtappels declined to comment further on the claims but insisted that "the ship set sail from Tallinn in an unseaworthy condition"

On 6 April the representatives of the relatives were informed in Stockholm by the Swedish JAIC about the contents and conclusions of the Part-Report, i.e. that the sequence-of-events which led to the capsizing and sinking of the ESTONIA had been initiated by the failure of the locking devices of the visor, in particular the Atlantic lock. Allegedly the locking system had been 50 per cent under-dimensioned.
      Any questions concerning speed, behaviour of the crew, organisation of owners/managers were not answered with reference to the Final Report to be published by the end of the year. On the following day the Part-Report was introduced simultaneously in press conferences by the JAIC parts in Tallinn, Helsinki and Stockholm and copies were distributed to the media. In the introduction letter to the Part-Report Stenström states among other things:

"The full report, covering also operational aspects and other outstanding matters is expected to be published in the autumn of this year. The Commission is fully aware of the disadvantages of publishing a part report that deals with only one segment of the circumstances contributing to the accident. It has, however, been assumed to be of value to make the present findings available at an early stage to all sectors of the maritime world, working with various aspects of the safety of passengers ships."

The conclusions of the "Part-Report Concerning Technical Issues on the Capsizing on 28 September 1994 in the Baltic Sea of the Ro-Ro Passenger Vessel M.V. Estonia" reads as follows:

The previous hypothesis had become "conclusion" now and the JAIC made it quite clear in the Preface to the "Part-Report" that it was not their intention ever to change these "conclusions" when they stated:

"The Commission has previously concluded that the accident was initiated by the locking devices for the bow visor being unable to withstand the loads imposed during the prevailing speed, heading and sea conditions. This conclusion is still valid. This part-report covers main technical findings and conclusions. The final report to be issued later will cover also all other factors and circumstances found to have contributed to the development of the accident. This will include inter alia operational practices, certification and inspections, stability information, weather conditions and train-ing. Rescue operations and resources will be covered as well."

In other words, whatever the investigation ahead, for example of "operational practices" and "inspections", might reveal "it is anticipated that all facts and conclusions reported herein (the visor locking devices were calculated with less strength than required according to calculations) remain unchanged in substance". "Operational practices" for example includes the forcing of ice barriers several meters high at sea with full speed and the respective affect on the locking devices, the hinges and the visor structure in general, just to mention one example. For more examples see Subchapters 12.4 and 12.5.
      And Stenström continued with considerable energy to distribute his "present findings" - the term in itself implies that the findings are not final - to the maritime world by giving papers, for example at the IMO meeting on 31.10.94 and at the Marine Safety Seminar of the Cologne Re in Rotterdam - in 1995 - when he submitted his "present" findings as firmly established facts. He said in Rotterdam under the heading:

"MS Estonia
1. Aspects of Human Shortcomings
Sorting out the various contributory factors, it is obvious that the structural strength of the bow visor, the sea conditions and the speed of the vessel all contributed, and any one of these factors could be seen as triggering the catastrophe or could have prevented it. In the prevailing sea conditions two basic factors remain: The design of the locking device of the bow visor was too weak, and the speed of the vessel was too high under the prevailing conditions. The systems' inadequacies may be divided into three groups: Technical inadequacies, regulatory inadequacies and operational inadequacies.
2. Technical inadequacies
On the technical side, the classification rules valid at the time, and in particular those according to which the ship was built, were not very detailed and did not contain sufficient guidance for the design of the visor attachment devices. The shipyard designer did the best he could with the advice available and the result of his work would have been reasonably acceptable, albeit at the lower end of the scale. The manufacturing side of the shipyard, however, acted on quite different and unqualified information and built locking arrangements for the visor which had less than half the strength of the outcome of the calculation work. The visor attachment arrangements therefore had a total strength to failure of about one third to one half of what it should have had based on the knowledge of the sea loads at the time. The locking devices then failed under conditions equivalent to the assumed design load conditions. Such loads existed as extreme values under the prevailing speed and sea conditions. If the shipyard had had a quality assurance system similar to the current requirements under ISO 9000 there would have been routine procedures ensuring that the manufacturing was carried out on the basis of correct information."

Regardless of all this the exchange of information, the communication between this 'Group of Experts' and the JAIC, especially Stenström, continued and was even deepened during the coming months after Prof. Dr. Hoffmeister had become a consultant to this 'Group of Experts' in metallurgical matters.
      The main reason for the engagement of Prof. Dr. Hoffmeister of the University of the Armed Forces in Hamburg was the obvious attitude of the JAIC to state that the fractures of the locking devices and hinges had been caused in the overload mode while even the layman could see fatigue cracks at different vital places. Another reason was that the visor had to be examined in detail by a qualified metallurgist. In the course of the following weeks Prof. Hoffmeister closely inspected the visor and the parts already cut off and recovered from the wreck. After some time a relatively close co-operation developed with Prof. Kjell Pettersson from KTH, Stockholm, who had performed the metallurgical examination on behalf of the JAIC. The results of the investigations by Prof. Hoffmeister were laid down in draft reports nos. 1 to 4. Draft report no. 4 is still valid, because Prof. Hoffmeister is still expecting parts from the wreck for examination which would enable him to make final conclusions.
Note: The owners have repeatedly refused to let Prof. Hoffmeister have the parts in their possession for his examination. Simultaneously the exchange of views and information with Börje Stenström continued more or less uninterrupted. On 21 April there was a further meeting between Stenström and a member of this 'Group of Experts' when a complete set of photos made of the visor and the foundations of both visor actuators were handed over to Stenström with interpretation. Stenström's attention was drawn to the accumulation of oil in the forepart of the 3rd stringer indicating that either the vessel must have had a forward trim more or less all the time and/or the visor had been misaligned in relation to the vessel possibly due to a pressed in stempost. Furthermore Stenström's attention was drawn to the fact that the port visor actuator was no more connected to the B-deck at the time of the casualty. He was only mildly interested, but told the story of the Landvetter meeting instead:

"All the main witnesses were questioned again - especially watch A.B. Silver Linde - however, in the presence of Enn Neidre, the superior of all ESCO sailors, which was regrettable but unavoidable because Neidre insisted and he was a JAIC member. The main aim of this meeting had been to find out what had happened on the bridge, why they had been so passive. According to Silver Linde the 2nd and 3rd officers had left the bridge after 01.00-01.05 hours, thus at that time they considered everything to be normal and routine. About 5 or 10 minutes later the vessel suddenly took a starboard list of about 20° and started a sharp port turn which increased the starboard heel. It seemed possible that the 2nd and 4th, mates, then on the bridge, were knocked off their feet and became unconscious. Then probably the (other) 2nd mate and the 3rd mate returned to the bridge, transmitted "Mayday" and "Mr. Skylight to No. 1 & 2" and asked the engine room whether it was possible to pump over water to the high side. Survivors have confirmed that the lee side was the high side. A port turn has also been confirmed by the position of lost objects found on the sea bottom. Silver Linde had stated that when he was ordered to check the ramp to take the boatswain with him. The passenger who heard the hydraulic sound was midships on 4th deck - they believe he heard the stabilisers. There are no indications that they used the hydraulic actuators to hold down the visor."

So much for the Landvetter meeting. See also Subchapters 21.2.2, 21.2.3, 21.2.5.
      Furthermore, the Part-Report was discussed and Stenström's attention was drawn to the many mistakes, e.g. the "disappeared stempost" and the impossibility that the control lights were all green if the port lower bolt of the bow ramp had not engaged the pocket, etc. Finally Stenström was asked, why did they state in the Part-Report that "in all probability the sequence of events and cause consideration will not be changed" because evidently they had not even covered 10% of the required investigation extent. After some thinking, Stenström said: "These are our instructions and please don't ask us any more questions in this respect. We had to draft our report to the effect that the blame is more or less entirely resting with Meyer Werft, however, in the Final Report we shall draft it so vaguely that there will be not enough evidence to commence legal action against the yard, in other words, after our Final Report has come out, nobody can be blamed and the case will be closed shortly afterwards".
      In the course of the following weeks and the ongoing exchange of views and information Stenström admitted that his Part-Report was wrong in some respects, however, when it came to water in the visor, which evidently had been there, he was not prepared to give in. After this 'Group of Experts' had written, on 16 June:

"As to water in the visor which was flowing out once the vessel had reduced speed and the bow-wave became smaller we do not mean the crewmen of the pilot boat, but some Stockholm pilots who have observed the above, and they are not talking about just 150 litres. On the other hand the fact that at sea the inside of the visor was filled up to outside level with water due to poor or missing rubberseals was admitted by Ulf Hobro at our discussion in your presence mid February."

Stenström replied already on 22 June:

"I think there is nobody claiming that the space inside the visor was dry. It is not even required to be watertight by their rules. In a seaway water will be pushed in through any leaking seals at a higher rate than it would flow out when the bow rises out of the water and some water may have been there in bad weather. Please consider, how-ever, that the ramp seals were probably not 100 per cent watertight either, in particular not at the lower edge due to some play in the hinges and the fact that one locking wedge had not found its way fully into its female part. Any steady level of water inside the visor should therefore undoubtedly leak past the ramp into the car deck area. The area was inspected regularly, even shortly before the accident, and there was no water in the ramp area. Have therefore difficulties in believing in the existence of any large amount of water in the visor that could have influenced the dynamics of the visor in a seaway."

Of course Stenström could under no circumstances accept large quantities of water inside the visor because at that time he knew already of the partly open bow ramp at the port lower corner which meant water on the car deck which evidently had been the case already in 1993 - see Chapter 12.4.4, especially the statement of pilot Bo Söderman - Enclosure 12.4.4.161.
      Also another principle matter was seen differently by Stenström and this 'Group of Experts', viz. the non-recorded respectively non-documented repairs.

"4. Visor Structure
You might have good control about the documented repairs ,but what abut the ones not documented? Who has and when carried out the highly insufficient repairs to lower lugs at B-Deck of the port actuator (hydraulic cylinder), just to mention one example? These repairs as well as changing of bushings of the visor hinges e.g. are subject to class inspection and repair approval, which, as you know, has not been the case."

Stenström replied:

"It is quite possible, and normal onboard any ship, that small defects are repaired onboard, e.g. the crack in the stiffener underneath the port side platform for the lifting actuator. Replacing a hinge bushing is a different things, that would be a considerable undertaking even at a shipyard and can certainly not be undertaken whilst in service. There are no indications in all the records we have examined of such a repair, superintendents and other people who have followed the ship also deny that any such work should have been carried out. Why should it have been done secretly if there had been a need??? In case there had been a need to remove the bushing, burning off the old weld would undoubtedly have resulted in burning marks in tangential direction on the plating around the weld. There are no such marks. The cutting marks in the holes are perfectly perpen-dicular to the plate and cannot be generated by burning on an existing completed installation. Had there been a need for repair due to play, the old bronze bushing would undoubtedly have been removed by local machining. This is shipyard standard practice for relining any worn shaft bushing from propeller shaft bearings down to small diameters. As all four visor arm side plates have identical appearance, would you suggest that all four bushings were replaced by the crew in secrecy? The hinge bushing was inspected by Professor Hoffmeister last week and we had a few more sections cut and examined according to his desire. I hope he got the information he was looking for and will appreciate a copy of his report. The extra work has been done on behalf of the SHK as it is in our interest as well to find maximum amount of facts."

Stenström made it quite clear that the JAIC was of the definite opinion that the deep burning marks were caused by the yard already at newbuilding and did not hesitate to tell that also to the media. He was, however, wrong in almost all respects, because:

- at the starboard hinges were indications of tangential burning marks although covered by the welding seams;
- the perpendicular burning marks can very well be generated by burning on an existing completed installation as it was proved by a respective test carried out by Meyer Werft in summer 1995 - see the photo below and see also Chapter 30 - S3/P3.

- all four arms do not have identical appearances as it is evident from the two photos below, the left one shows the port outer visor arm and the right one the starboard inner visor arm.

Evidently the starboard visor arm plate looks identical to the test burnt installation part - see the photo above - and the port one is smooth without burning marks at all. A detailed inspection even revealed indications of circumferential drilling marks as initially the holes were drilled at newbuilding - see Subchapter 2.4.6. Therefore this 'Group of Experts' has always taken and still does take the view that the port bushings were still original while the starboard ones were very unprofessionally replaced. How gross negligently this replacement was carried out became fully clear when a passenger video was made available to this 'Group of Experts' in 1996 - see Subchapter 39.2.

38.4
The August Meeting

The investigations went on and after some time it was felt that another meeting with the JAIC should be held, preferably in Hamburg, however due to the health problems of Börje Stenström it was agreed to have it in Stockholm when among other things also Prof. Hoffmeister would present his findings.
The date was set for the 3 August and the following persons attended:

for Sweden:                                        Börje Stenström - member
                                                          Mikael Huss - expert (KTH)
for Finland:                                         Kari Lethola - member
                                                          Klaus Rahka - expert (VTT)
                                                          Tuomo Karppinen - member (VTT)
for Estonia:                                        Enn Neidre - member (ESCO)
                                                         Prof. Jaan Metsaveer - expert
                                                         Dr. August Ingerma - expert
                                                         Heimo Jaakula - expert (E.N.M.B.)
for German 'Group of Experts':              Dr. P. Holtappels
                                                         Prof. R. Herber
                                                         Prof. Dr. Hoffmeister
                                                         Dipl. Ing. Tomas Wilkendorf Captain Werner Hummel

This 'Group of Experts' presented their findings and the sequence-of-events supported by the metallurgical evaluations of Prof. Hoffmeister, all of which was discussed at the end.

- The JAIC admitted that the visor was already substantially damaged when the vessel departed from Tallinn.
- The JAIC admitted that the visor hinges were considerably weakened by fatigue.
- The JAIC admitted that the existing poor condition of the hinges and locking devices does not necessarily result from bad performance of the new-building yard if no repair work was found to be documented or otherwise recorded.
- It was agreed that Prof. Hoffmeister should make further detailed examinations of the hinges and Atlantic lock parts in close cooperation with KTH Stockholm and VTT Helsinki.

Finally, Dr. Holtappels indicated that the JAIC had to be considered biased due to the presence of the head of the Navigation Department of ESCO in the Commission, because ESCO having been 50% owner and crew manager of the ESTONIA was one of the subjects of the ongoing investigation. This was received by the audience in silence.

In summary it could be concluded that the JAIC got the message that their scenario was not necessarily the only one and that other circumstances had played a dominant role in the sinking of the ESTONIA and, further, that this 'Group of Experts' was not prepared to accept that the "scenario and main findings" of the Part-Report would remain "unchanged in substance". In those days this 'Group of Experts' still believed that the JAIC - being a governmental institution - wanted to find out the truth, maybe apart from the Estonians, however, the first shadows of doubt arose in particular created by the behaviour of Börje Stenström.