CHAPTER 41

EVALUATION OF THE JAIC REPORT AND COMPARISON WITH THE REPORT OF THE GERMAN 'GROUP OF EXPERTS'

The two reports differ substantially. Subchapter 41.1 will describe the difference in structure and in findings, which are the basis for the conclusions drawn. Subchapter 41.2 will deal with the differences in methodologies applied by the two investigating bodies.

41.1
Differences in Structure and Findings

The following comparison shows the difference in the structure of both reports:

 

THE REPORT OF THE JOINT ACCCIDENT INVESTIGATION COMMISSION	THE REPORT OF THE GERMAN 'GROUP OF EXPERTS'
PART A FACTUAL INFORMATION	PART A FACTUAL INFORMATION
Chapter 1 The Accident	Chapter 1 The Casualty
	SECTION I UNDER FINNISH FLAG
Chapter 2 Ownership and Operating History	Chapter 2 The Vessel "VIKING SALLY"
Chapter 3 The Vessel including Surveys, Maintenance, Damage & Repairs	Chapter 3 Ownership and Operating History, including Surveys, Maintenance, Damage & Repairs

	SECTION IINORDSTRÖM & THULIN AND THE STOCKHOLM-TALLINN SERVICE
Chapter 5 The Circumstances of the Voyage	Chapter 5 The Historical Development
	SECTION III UNDER ESTONIAN FLAG
Chapter 6 Summary of Testimo-nies by Survivors	Chapter 6 The New Owners/Managers and the Take Over
Chapter 7 The Rescue Operation	Chapter 7 Operations on Board
Chapter 8 Observations after the Accident	Chapter 8 Emergency and Lifesaving Arrangements and Equipment
	Chapter 9 Classification - Statutory and Port State Control Inspections
	Chapter 10 Operational and Characteristics of the Vessel
	Chapter 11 Cargo Handling Systems
	Chapter 12 Operating History including Mainte-nance, Damage and Repairs
	SECTION IV THE LAST VOYAGE
	Chapter 13 The Crew and the Advisers
	Chapter 14 The Day in Tallinn
	Chapter 15 The Sjöfartsverket Inspectors and Their Trainees
	Chapter 16 The Condition of the "Estonia" and the Status of Her Main Class and Safety Certificates before Com-mencement of the Last Voyage
	Chapter 17 The Loading and Securing of the Cargo
	Chapter 18 Weather Forecasts/Storm Warnings
	Chapter 19 The Departure
	Chapter 20 The Route - Wind and Sea Conditions Actually Encountered - The Speed
	Chapter 21 Summary of Testimonies by Survivors
	Chapter 22 The Rescue Operation
	SECTION V INVESTIGATIONS AFTER THE SINKING
	Chapter 23 Search for Drifting Objects
	Chapter 24 Locating the Wreck and the Visor
	Chapter 25 The ROV Inspections of the Wreck Area

	Chapter 26 Recovering the Visor
	Chapter 27 The Diving Investigation 1-4.12.94
	Chapter 28 The ROV Inspections in 1996
	Chapter 29 The Wreck
	Chapter 30 The Condition of the Visor
	Chapter 31 The Casualty Scenario
	Chapter 32 Unexplained Damage/ Unexplained Evidence
PART 2 ASSOCIATED FACTS	PART B ASSOCIATED FACTS AND SEPARATE INVESTIGATIONS
Chapter 9 International Conventions, Legislation, Regulations and Cooperation	Chapter 33 Bow Door Failures and Other Incidents of Ro-Ro Vessels
	Chapter 34 Separate Investigaions Chapter 34.1 "Forgery of Documents to hide the initial Unseaworthiness"
Chapter 10 History of Ro-Ro Ferry Traffic in the Baltic Sea	Chapter 34.2 "Structural Analysis of Bow Visor and Locking Devices by means of the Finite Elements Analysis"
Chapter 11 Bow Door Failures and Incidents	Chapter 34.3 "Systematical Fracture tests with Atlantic Lock Mock-Ups"
	Chapter 34.4 "Determination of the Steel Quality of the Atlantic Lock Mock-Ups"
PART 3 ANALYSIS AND EVALUATION
Chapter 12 Overview of Separate Investigations	Chapter 34.5 "Bow Impact of Ro-Ro Vessels"Chapter
Chapter 13 Development of the Accident	34.6 "Investigation Report of Video Tapes Featuring the Car/Passen-ger Ferry Estonia"
Chapter 14 Ownership and Operating Arrangements	Chapter 34.7 "Investigation Report on Possible Explosion Damage"
Chapter 15 Strength Evaluation of the Visor and the Ramp Attachments	Chapter 34.7.1 "Supplementary Investigation Report" Chapter 34.8 "Defect and Failure Analysis of the Bow Visor Structure"
Chapter 16 Analysis of the Evacuation	Chapter 34.9 "Evaluation of the Video Film made on 17.09.94"
Chapter 17 The Rescue Operation	Chapter 34.10 "Structure Analysis of the Bow Ramp Hinges"
Chapter 18 Compliance with Collision Bulkhead Requirements	Chapter 34.11 "Calculations of the Floatability of the Bow Visor" Chapter 34.12 "Breakload Calculations of the Deckbeam at Frame 159"
Chapter 19 Development of Regu-lations after the Accident	Chapter 34.13 "Comments on JAIC Report"
	PART C THE JOINT ACCIDENT INVESTIGATION COMMISSION (JAIC) AN INDEPENDENT BODY ?
	Chapter 35 The Foundation of the JAIC
	Chapter 36 Other Activities

	Chapter 37 Activities of the JAIC and Surrounding Circumstances after the Casualty to the End of 1994
	Chapter 38 The Year 1995
	Chapter 39 The Year 1996
	Chapter 40 The Year 1997
	Chapter 41 Evaluation of the JAIC Report and Comparison to the Report of the German 'Group of Experts'
PART 4 CONCLUSIONS	PART D FINDINGS AND CONCLUSIONS
Chapter 20 Findings	Chapter 42 Findings
Chapter 21 Conclusions	Chapter 43 Conclusions
Chapter 22 Recommendations

 

Hereafter the JAIC Report is commented, wherever this 'Group of Experts' is of the opinion, that the factual assumptions of JAIC are wrong or stand correction:

1. JAIC Chapter 2.1 :

"The JAIC does not mention the statement of ex boatswain Juhani Luttunen that the lugs of the Atlantic lock on the forepeak were renewed already in 1982/83, which could be confirmed by the fact the basic primer of the starboard lugs as found on the wreck was grey while the original basic primer was yellow as found on the visor lug." (See Chapters 3.3 / 2.9 sub 8).

2. JAIC Chapter 2.2 :The following is noteworthy in this chapter:

"Operation of the ESTONIA was under the supervision of the Navigational Department of ESCO. The crew was provided by the Personnel Department of ESCO. Two full crews were employed, manning the ship in two-week shifts each. The qualifications and training of the crew are described in Chapter 4.
The master taking over a shift was required to visit the ESCO Navigational, Technical and Personnel departments for briefing. The master being relieved likewise had to report personally to the navigational department of ESCO on the situation on board.
A captain's meeting was held at the ESCO office once a week attended by all masters in Tallinn on that day, including those on vacation. Regular meetings were also held on board the ESTONIA, attended by the masters, chief officers and chief engineers of both shifts and by representatives from ESCO and from Nordström & Thulin AB." That means that the Navigational Department of ESCO was responsible for the "operation of the ESTONIA" and that the master of the ESTONIA, before taking over the command of a new shift, was briefed by this department. Head of the Navigational Department was Captain Enn Neidre, who participated in all meetings at first as member and subsequently as Expert to the Estonian JAIC. Enn Neidre thus participated in the investigation of his own department's activities in the operation of ESTONIA. See also Subchapter 39.6.

3. JAIC Chapters 2.2, 2.3

- especially if compared with Chapter 12 of this Report - reveal a remarkable reluctance of the JAIC to concern themselves with the actual operating history of the vessel and the surrounding conditions, whilst it was traded under Estonian flag.

4. JAIC Chapter 3.1.1 reveals

- if compared with Subchapter 2.4 of this Report - that the JAIC did not find it necessary to describe the design and construction procedures of the vessel. This is indeed remarkable as the information contained in the above-mentioned Subchapter was given to the JAIC and confirmed to them during their visits to the building yard.

5. JAIC Chapter 3.2.6 :

The JAIC states here that the doors from the car deck into the centre casing were locked at sea. This is in controversy with the statements of many previous passengers who had been on the car deck at sea at their leisure (see Subchapters 12.4.4 and 12.4.5).

6. JAIC Chapter 3.2.7 :

Here the following remark is found:
"Because of the retracted position of the navigation bridge, the bow of the vessel was not visible from the conning station, as Figure 3.4 indicates."
This statement is too superficial given the importance of the issue. The correct description can be found in Subchapter 2.5.7 above and is reiterated here for the convenience of the reader:
"Because of the retracted position of the navigation bridge, only the flag pole on the bow of the vessel was visible from the conning station - see drawing below - whilst the most forward part of the visor could be seen through the two windows on deck level at both sides of the extended central part of the bridge, as can be seen on the drawing below." See drawing on page 110.

7. JAIC Chapter 3.2.10 :

Here the JAIC describes in detail which inspections were carried out by Port State Control and the surveyor of the Classification Society "in line with common practice and requirements". The JAIC has always known positively that neither the visor nor the forward ramp of the vessel were weather- respectively watertight. (See Subchapter 38.2.) The JAIC was at all times furthermore aware, that the vessel - on the route Tallinn-Stockholm - did not comply with stringent SOLAS requirements with regard to the position of the upper extension of the collision bulkhead above main deck. (See Subchapter 6.5.2.) Such deficiencies render any such vessel unseaworthy without any further debate. If the inspectors appointed by the Swedish government to execute Port State Control or the surveyor of the Classification Society overlook such deficiencies then such behaviour is not considered to be "in line with common practice and requirements" amongst reputable members of the shipping community. It is furthermore noteworthy that the JAIC in this Chapter describes the delivery drydocking in Turku "in 1993" without any mention of the Repair List issued by the former owners and known to the representatives of the new Owners. (See Subchapters 6.5. and 12.5. and Supplement 231 to the JAIC Report). This list - as described in detail in Subchapter 12.5 - contains the root of all the deficiencies, the further worsening of which later led to the catastrophe. Given this fact, hardly any interested reader will consider the following casual remark, which can be found in Chapter 3.3.6., to be a satisfactory description of the problem:
"Just before transfer to Estonian flag by the end of 1992 attention had been given to the strength of the ramp and visor locking devices and a quotation for reinforcing them had been requested by Wasa Line. However, nothing was made to the locking devices."

8. JAIC Chapter 3.3.5 :

The JAIC states here (page 42, middle column):
"It has been stated that the lower locking bolt on the port side of the ramp sometimes failed to go to fully extended position. The standard procedure was then to retract the bolt and again command it to locked position, whereby it would normally go to fully extended position and the green indicator lamp would come on."
Evidently the lower port locking bolt of the bow ramp could not engage the mating pocket at the ramp side and consequently also not contact the sensor because the port side of the ramp was misaligned by ca. 21/2 inches = 10 cm (diver's statement 2.12.94 - see Subchapters 27 and 29.2) which had the consequence that neither the upper port bolt nor the port ramp (pull-in) hook of the bow ramp were able to engage their respective mating pocket/mating lug. The cause for this severe misalignment was the collapse of the port outer ramp hinge - see Subchapters 12.4.3, 12.5 - by which the lugs connecting the ramp with the vessel slid off the pin respectively broke. This had been known to the technical managers and the crew since several weeks before the casualty and the crew had - according to Börje Stenström - Enclosure 12.5.166 - frequently asked for repairs by putting this item on the repair list. Although these circumstances - as stated above - rendered the ESTONIA unseaworthy they are not mentioned in the Final Report.

9. JAIC Chapter 3.3.6:

Here we read:
"After transfer to Estonian flag no more service work was carried out by the MacGregor service base in Turku as the regular maintenance was carried out by the ship's crew and, according to the new owners, no need for external service had developed. New rubber seals had, how ever been ordered. It was known that the play in the ramp hinges was approaching the point where corrective action would be needed."
In this respect reference is made to Subchapters 12.4 and 12.5 where the observations of the many previous passengers are reported. Contrary to the statement of the new Owners, upon which the JAIC apparently relied, many repairs were carried out both to visor and bow ramp parts, partly with heavy burning and welding. There were frequent problems with opening of the locking devices of the visor and/or the bow ramp after arrival in Tallinn which sometimes made it necessary to tow the ferry away from the berth, turn her around and berth her again stern first. This subsequently created very substantial difficulties for the trucks to turn around and leave the car deck.
As stated by witnesses the lugs of the side locks were frequently burnt off and subsequently rewelded. In this text reference is also made to the divers' report - see Chapters 29.2 and 30 - who stated when inspecting the lugs of the side locks still in the wreck that only a very small piece of (white) visor bulkhead was attached to the lug, otherwise there were only very thick welding seams. Nevertheless there were rectangular holes of the size of the lugs in the visor plating which means that the lugs were since some time before the casualty not welded anymore to the visor plating but only stuck through the existing rectangular holes and then spot-welded from outside and/or inside which explains the extraordinary thick welding seams on the lugs. Thereby it was possible for the crew to adjust the lugs to the changing distance between visor-platings and vessel-platings which increased due to the growing misalignment of the visor. These very obvious deficiencies have apparently not been investigated by the JAIC at all and consequently also not taken into consideration when calculating the remaining load carrying capacity of these lugs. Instead the JAIC based their calculations on newbuilding standard. The JAIC continues further on page 43:
"Minor routine welding repairs had been carried out on the mating boxes for the ramp locking bolts whilst the ship was in service in the Gulf of Bothnia."
Actually when the vessel was in service between Stockholm and Tallinn the top plates of these mating boxes were frequently burnt off by crew members when they were unable to disengage the bolt after arrival at Tallinn. Subsequently the plates were rewelded. Reportedly this was also done after the last arrival on the morning of 27 September 1994 when the starboard upper mating box had been burnt open but the plate had obviously not been rewelded because the box is still open with no sign of the top plate. See Chapter 29.2.
"Local welding of a crack in a stiffener underneath the mounting platform for the port side visor actuator has been noted."
Actually the two lugs by the port visor actuator were found to have been in the following condition:
- The outer stiffener had been very poorly repair-welded some considerable time before the casualty.
- The inner stiffener was no more the original one since it did not show any protective coating and it was only spot welded to the deck - if at all. All stiffeners however were fully welded to the deck by the shipyard during newbuilding, as it can still be seen on the starboard actuator foundation.
For details see Chapter 30 - pages 990-1002. The JAIC continues further on the same page:
"One of the visor hinge pins had, according to verbal information, a tendency to move out of position, breaking away the locking plate. This was repaired once at the Finnboda yard by pushing the hinge pin back in place and drilling for new locking bolts.
No other repair was, according to available information and extensive search, carried out during the lifetime of the vessel on or in the areas of the various operating and locking devices for the ramp and the visor."
This is wrong for the following reasons:
- According to the statement of the long-term chief officer Stig Lindström (( January 1996) one of the visor locking devices had to be strengthened some time before the sale - see Enclosure 3.4.101 and in the Swedish JAIC register D11.
- The JAIC was made aware of several statements of truck drivers that the lugs of the side locks were frequently burnt off and that the ESTONIA berthed sometimes stern first in Tallinn in July, August, September 1994 because visor and/or bow ramp could not be opened upon arrival, but subsequently, after certain repairs could be operated again.
- Truck drivers have also directly reported to the JAIC that the port side of the bow ramp was severely misaligned, was actually hanging down and could not be properly closed since some time before the casualty.
- Truck drivers have also reported to the JAIC that securing bolts could not be opened and therefore the top plates of the mating boxes at the ramp were burnt off.
- Passengers/truck drivers have furthermore directly reported that the ferry after having berthed bow first in Tallinn, was subsequently towed back and turned by tugs and subsequently berthed stern first whereafter the trucks could leave the car deck only with difficulties which reports have made available to the JAIC.
- The JAIC has in its possession a video film made by a passenger upon departure from Tallinn on 17.09.94 which clearly shows that the starboard visor hinge had been repaired very badly with disastrous effect on the load carrying capacity.
- The as-found condition of the bushings and hinge plate parts of the starboard visor hinge arrangement confirms the above.
The JAIC also neglected the old damages in the visor, apparently caused when the ESTONIA was used as an "ice breaker" and was forcing ice barriers several meters high at full speed according to passenger information, which are known to the JAIC. See Chapters 12.4.2 and 30.
Also the very fresh footprints on the 3rd and 2nd stringers of the visor were not explained in the JAIC Report although the last JAIC chairman, Uno Laur, has stated that they were created by crew members when they went down to hammer open or close the bolt of the Atlantic lock before arrival and after departure from Tallinn. The reason was the impossibility to open/close the bolt hydraulically because the visor was that much misaligned and the lugs of the Atlantic lock were that much deformed. See Enclosure 12.5.175.

10. JAIC Chapter 3.6.2 and 3.6.3 :

The Interim Passenger Ship Safety Certificate (PSSC) was false. It confirms that the vessel fulfils the SOLAS requirements, which however it did not in respect of the location of the upper extension of the collision bulkhead. On the ESTONIA this was the bow ramp, which was positioned too much forward. Since the Tallinn-Stockholm route - contrary to the Turku-Mariehamn-Stockholm route - leads more than 20 nm away from the nearest land, no exemption was permissible. The "partial collision door" initially offered by Meyer Werft but rejected by AB Sally against a credit of DM 45.000,00 should have been installed prior to taking up the Stockholm-Tallinn service. This was not done and thus the ferry did not comply with the SOLAS requirements and consequently the PSSC confirming this was false. The JAIC finds it appropriate to explain the failure of Bureau Veritas in the issuance of the false PSSC with words, that stem from Bureau Veritas, namely:
"When Bureau Veritas surveyed the vessel for change of flag this was done in accordance with the requirements to the extent of a periodic survey, which did not include examination of construction drawings. The location of the extension of the collision bulkhead was thus not considered during this survey."
It is doubtful, whether a periodic survey did suffice (see Subchapter 6.5.2.) and it may also be debated whether inspection of the structure of a passenger ship does not also include a check of the design drawings. The essential point in this case is that Bureau Veritas had accompanied this vessel since its birth and hence perfectly well knew her design. Their own form for the Survey Report as a prerequisite for the issuance of a PSSC demanded the inspector to check the structure of the vessel! (See Subchapter 6.5.2). The same is true for the Load Line Certificate, allegedly issued on 9 September 1994, which confirmed that the vessel complied with the requirements of the International Load Line Convention. This the vessel did not for the simple reason, that its hull was not closed watertight against the seas at its bow. Both parts of the double security to ensure this state, namely the visor and the ramp, were not watertight. See Chapters 12.4.3 and 12.5.

11. JAIC Chapter 3.7.3 :

Here the following comments seem to be appropriate: At the time of the casualty a new Trim and Stability Booklet was not yet available, but was still in progress, therefore the PSSC and Load Line Certificates were issued only interim and B.V. had to carry out Load Line Surveys every 3 months. In relation to the Trim and Stability Booklet valid at the time of flag change which had been approved by the F.B.N. on 20.01.91 the JAIC states among other things:
"The Commission has noted that at the inclination test, the ship's centre of gravity was positioned to starboard to such an extent that the port side heeling tank was filled with about 115 t more water than the starboard tank in upright condition. The load cases in the trim and stability manual, however, include the heeling tanks as being either both empty or both full."
Such a condition did not exist during the initial inclination test performed in the presence of Gunnar Edelman of the F.B.N. on 21.06.80 in Papenburg and it was unknown what had caused such unfavourable weight distribution 101/2 years after delivery.
Had the JAIC investigated this matter and not left it as mystery, they would probably have found the same answer as this "Group of Experts", namely a hole in the underwater hull which opened a tank or void space to the outside and thereby permitted the creation of unknown weights in the vessel. (See Subchapter 17.1)

12. JAIC Chapter 5.2 :

Here the JAIC states:
"On departure from Tallinn on 27 September the ESTONIA was seaworthy and properly manned. There were no outstanding items either from the authorities or from the classification society's surveys. The maintenance standard of the vessel was good as witnessed by various instances."
It has been stated before, that this statement is not only untrue, but that it has also been made with full knowledge of it not containing the truth. This Group of Experts is not the only one to say so.
Last - but not least - the chairman of the Swedish Masters' and Ship Officers' Association, Captain Christer Lindvall, has frequently condemned the findings of the JAIC. With good reason.
The JAIC further comments on the "Port State Control" carried out until shortly before the last departure:
"During the last day in Tallinn the vessel was used in a training programme for Estonian Maritime Administration surveyors in the conducting of a Port State Control in compliance with the Paris Memorandum of Understanding on Port State Control (see about Paris MOU in 9.1). The trainees made a thorough Port State Control inspection of the ESTONIA and were supervised and instructed by two senior inspectors from the Swedish Maritime Administration. The exercise was documen-ted in protocol, set up in a form according to the Paris MOU. A copy of this protocol is included in the Supplement."
With regard to the inspection and the protocol reference is made to SUBCHAPTERS 34.1 and 36.1. Evidently several different versions of this protocol do exist with the knowledge of Sjöfartsverket and the JAIC.
"The Swedish inspectors leading the exercise have been interrogated by the Commission and have stated that the vessel was in good condition and very well maintained. They found no deficiencies that would have caused detention or other serious remark, if the inspection had been a regular Port State Control." Contrary to the statement the Swedes have actually tried to prevent the departure of the ferry after having detected the many serious deficiencies which are noted in the protocol registered in the files of the Swedish JAIC under A 46 b - see Enclosures 15.200 - see Chapters 15 and 36.1.
The JAIC continues:
"However, some deficiencies were noted, such as that the rubber seals for the bow visor were worn, had tear marks in some places, and were in need of replacement, and watertight hatch covers on the car deck were open and in a condition indicating that at least one was not normally closed. It was also stated during the interrogation that the Swedish inspectors had experienced "lack of respect for issues related to load line matters" in their contact with officers met during the exercise."
Whichever protocol is the correct one, they all contained deficiencies rated 17, which means that they should have been mandatorily remedied before departure. The protocol contained in the Supplement to the JAIC Report (Enclosure 15.200) contains no less than 7 of such deficiencies, none of which was remedied before departure.
In a telephone conversation after the hearing of Åke Sjöblom and Gunnar Zahlée by the Swedish JAIC between Bengt Schager and Åke Sjöblom, the latter did state, that the ESTONIA and her crew were the worst that he had ever experienced.

13. JAIC Chapter 5.3 :

The JAIC does not mention the filled void spaces at starboard side due to corroded bottom plates which are most likely the cause for the starboard list. This is hardly a condition that would be described by experts as a "loading condition that was normal for the route". The contrary is true. A passenger ship with unknown weights of abt. 200 mts leading to an undefined list of abt 10 degrees, which cannot be compensated by filling of the opposite heeling tank is - on this count only - unseaworthy and should under no circumstance be put to sea.
The JAIC also does not mention that according to eye witnesses from the "SILJA FESTIVAL" the ESTONIA passed the breakwater with half open visor towards the open sea. The respective statement was found in the files of the Finnish JAIC. See Enclosure 19.236 - Chapter 19.

14. JAIC Chapter 6.1 :

The JAIC create the impression that they have actively participated in the interrogation of survivors, which was not the case. JAIC members and experts have only questioned one passenger - Pierre Thiger - and some of the crew members, whom they considered to be key witnesses. However, the questioning of a witness simultaneously by six or seven persons can hardly be called an "interrogation". The psychological expert to the Swedish JAIC, who wanted to interrogate all the important witnesses separately, including the passengers, was precluded from doing so by Olof Forssberg, with the exception of the purser Andres Vihmar, whom he questioned alone. The statement is not available. This means that the JAIC questioned the following crew members only:

3rd engineer Margus Treu
Motorman Hannes Kadak
Watch A.B. Silver Linde
System engineer Henrik Sillaste
Trainee officer Einar Kukk
Purser Andres Vihmar (only by Bengt Schager)

and decided already at a very early stage to rely almost exclusively on the statements of 3rd engineer Margus Treu and A.B. Silver Linde as far as the casualty scenario is concerned. As demonstrated in Subchapter 21.2. the numerous statements of these gentlemen are better evaluated with utmost care and when doing so another consideration should be taken into account. It is a fact well known in the shipping community, that crew members generally tend to be very loyal to their owners and, as a matter of fact, it has been confirmed by Börje Stenström to a member of this 'Group of Experts' that the Swedish and Finnish JAIC members and experts were very much aware, that the Estonian crew members were lying when it came to the most crucial parts of their evidence. Nevertheless the frequently changing statements of Margus Treu and Silver Linde became the essential evidence for the casualty scenario developed by Börje Stenström one week after the casualty.
The JAIC goes on to state:
"Police interrogations in languages other than Swedish have been translated into Swedish and this Summary is based on the Swedish text."
It has been described in Subchapter 36.5 that the statements of Estonian survivors taken in Tallinn in the Estonian or Russian languages had for example not been completely translated into Swedish and that therefore important details were missing. Therefore the summaries of the survivors' statements contained in the JAIC Report are to a certain part based on incomplete translations. It also has to be mentioned that most of the Swedish and Finnish survivors were questioned by policemen not trained to interrogate witnesses of marine casualties. Therefore most important details did not come up in the course of the questionings, because the relevant questions were never asked and thus did not become part of the JAIC investigation and cause consideration at all. Chapter 21 and the numerous statements by survivors as attached to this Report demonstrate the scarcity of the database of the JAIC Report.
There are indications that the Estonian Commission members as well as the Estonian security police and other government bodies had frequently spoken to the crew members, in particular to Margus Treu and Silver Linde. It is unknown whether these questionings were recorded, but at least, recordings are not available.

15. JAIC Chapter 6.2.2 :

As demonstrated in detail in Subchapter 21.2.2 the statements of this crew member are constantly changing to the extent, that this witness must be regarded as excluded from any further consideration of this accident. It can be said with certainty, that
- Silver Linde had not been on the car deck on his last round;
- Silver Linde had never seen whether all the control lights for visor/bow ramp were still green, because the control panel was locked and the boatswain had the key;
- Silver Linde had not been back to the bridge at around 01.00 hours, because he was then already in the crew accommodation;
- Silver Linde had never been at the Reception to ask for the car deck doors to be opened, because these doors were not locked;
- Silver Linde had never been on his way down to deck 1 after the starboard heel, because he was then in the crew accommodation area (probably to fetch his relevant personal belongings such as passport, money and the like). All this is revealed from either his own testimony or the testimony of passenger survivors, who were not properly questioned by the police respectively not interrogated by the JAIC at all.

16. JAIC Chapter 6.2.3 :

Treu is the main witness for the JAIC scenario, although his evidence is as conflicting as that of Silver Linde and, in addition, is in conflict with Silver Linde's testimonies when it comes to Treu observing Linde on the car deck. It is obvious that Treu's timing is about 15 minutes late when he states that the heel was about 45° at 01.30 hours, whilst the vessel was actually already on the side according to a number of other witnesses. Nevertheless the JAIC scenario is based almost entirely on Treu's wrong evidence.

17. JAIC Chapter 6.2.4 :

Much more information can be found in Subchapter 21.2.4 since a member of this 'Group of Experts' was able to question Sillaste at an early stage and he was subsequently interviewed twice by journalists who gave the protocols of the interviews to this 'Group of Experts'. Two aspects remain open however, viz.:

(a) Sillaste has testified that the pumps were running to drain the water, without stating from where. Actually it can only be from compart-ments of the 1st deck and 0-deck.

(b) Sillaste has indicated on the drawing he made on 13 January 1996 for the Estonian Police, as he did on the drawing he made for a member of this 'Group of Experts' already in March 1995, that there was a roll at the upper part of the bow ramp. In March 1995 he said it was a tarpaulin rolled together. It definitely did not belong there and on the available videos and photos showing the closed bow ramp from the inside such a roll is not visible and also not on the videos/photos showing the car deck opening from the outside with open bow ramp. Since the bow ramp was also known to be partly open at the upper side while in closed condition - see the statement of Carl Övberg - Enclosure 12.4.2.151 - it has to be assumed that this tarpaulin roll was also some sort of sealing material, same as the mattresses, bedding, blankets, etc. at the lower side of the ramp.

18. JAIC Chapter 6.2.5 :

Kadak saw at 00.46 hours a jet of water coming into the car deck at the upper starboard side of the bow ramp, but was persuaded finally by his Estonian principals (Neidre) that he had not even said so when being interrogated for the first time. Kadak stated that the heel was about 50 degrees when he and Sillaste left the engine control room and that the light went out and came back when they were at the Emergency Exit between decks 5/6 (Sillaste said the same) and further, that the heel was 90 degrees when they reached deck 8. Actually the heel was about 40 degrees when the auxiliary diesels/generators stopped and power disappeared for a short while until the emergency generator started to generate power to a limited number of consumers including all the emergency lights. Furthermore, Kadak was seen by 2nd engineer Peeter Tüür in front of his cabin window when he was climbing out of it shortly after the "Mr. Skylight No. 1 and 2" message. Actually both Sillaste and Kadak but also Treu left the engine control room much earlier as they had initially stated and that was admitted by them (Treu, Sillaste) in their last statements, which, however, are not included in the summary of the JAIC.

19. JAIC Chapter 6.3.1 :

The JAIC just quotes the statements of the two sailors having been engaged with lashing and securing of the trucks and trailers and disregards the many statements of passenger/truck drivers, e.g. Per-Arne Persson, who had seen that their trucks and trailers were not secured at all.
The JAIC even adds that both sailors have testified that the bow visor was properly closed before sailing, although according to the evidence in the Finnish JAIC's files the visor was just provisionally closed and half opened again after the ferry had pulled back from her berth and the vessel finally proceeded through the breakwater with half open visor. Not a word can be found in the whole of the JAIC Report about this incident contained in their own files.

20. JAIC Chapter 6.3.2 :

According to the JAIC only 22 persons survived from Deck 1, of which three were crew members, viz. Treu, Sillaste and Kadak from the engine control room, however, actually the following passengers survived (forward to aft cabins):

1. Jaan Stern - cabin 1120
- left cabin after the big heel
- water penetrated the door above the sill of his cabin

2. Neemi Künno Kalk - cabin 1122
- left cabin after big heel
- saw water on car deck level (must have run through water on 1st deck, because he had to pass the cabin of Jaan Stern)

3. Ulla Marianne Tenman - cabin 1098
- left cabin before the big heel (no detailed statement available)

4. Carl-Erik Reintamn - cabin 1094
- left cabin after the big heel and noted a lot of water in the alleyway which came from somewhere under great pressure

5. Carl Övberg - cabin 1049
- left cabin before heel
- saw water escaping under pressure from two gooseneck-type pipes into the alley-way and also penetrating the door of another room

6. Holger Wachtmeister - cabin 1047
- left cabin at the big heel and noted water in the alleyway and on car deck level

7. Antti Arak - cabin 1056
- both left cabin after the big heel and noted water in the alleyway

8. Ain-Alar Juhanson -

9. Taavi Raba - cabin 1070
- left cabin after heel and had to jump through a water curtain, saw also water on car deck level

10. Martin Nilsson - cabin 1028
- left cabin after heel, saw water on the car deck level

11. Daniel Svensson - cabin 1027
- left cabin after heel and saw water on car deck level (must have seen water on 1st deck alleyway because he was in the same cabin as Jasmina Waidinger)

12. Jasmina Waidinger - cabin 1027
- left cabin after the heel and saw water penetrating the floor in front of her cabin

13. Bengt Nilsson - cabin 1026
- left cabin after heel
- saw water penetrating car deck doors

14. Ants Nadar - cabin 1025
- left cabin left cabin before the heel and does not mention water at all

15. Andrus Maidre - cabin 1022
- left cabin left cabin after heel, saw a lot of water on the car deck through a partly open door

16. Tambet Herbert Lausma - cabin 1023
- left cabin after heel, saw water on car deck level

17. Ints Klavins - cabin 1024
- left cabin not properly questioned or incomplete statement available

18. Gennadi M. Pärson - cabin 1013
- left cabin after the heel
- no water mentioned

19. Dainis Sleiners - cabin 1015
- left cabin left cabin after heel and noted water on car deck level

20. Nikolajs Andrejev - cabin 1016
- left cabin after heel, noted water on car deck level

21. Mats Finnanger - cabin 1002
- left cabin after heel
- did not mention water

This means that 21 plus 3 = 24 crew members and passengers survived from the 1st deck and not 22 as stated in the JAIC Report. From the 21 passengers, of which 9 have reported water in cabin and/or alleyways of the 1st deck, 8 were in forward cabins. The JAIC mentions that one passenger saw a "thin trickle of water" in the corridor. This was meant to be Carl-Erik Reintamm, who actually saw a lot of water under pressure rushing through the corridor. As the JAIC spoke to none of the 1st deck passenger survivors they cannot know better. No doubt, they should have gone deeper into the matter, because water on the 1st deck penetrating from the 0-deck below under pressure indicates one or more flooded compartments of the 0-deck.

21. JAIC Chapter 6.3.4 :

The JAIC mentioned only statements from passengers putting the time for the heel at well after 01.00 hours, although there are in total only 13 (01.10-01.30 hours) out of 45 survivors having made time statements. On the other hand, the JAIC has quoted from some of the statements correctly that there had been impacts to the vessel before or after the big heel which made the survivors believe that there had been a collision. This refers in particular to Pierre Thiger in the Pub Admiral, the only survivor interrogated by Olof Forssberg because he, Pierre Thiger, had insisted on being questioned. However, none of this very detailed and valuable evidence - see Enclosure 21.3.3.319.1 - is contained in the JAIC Report.

22. JAIC Chapter 6.3.5 :

Again only such statements are quoted which put the time for the heel well after 01.00 hours.

23. JAIC Chapter 6.3.6 :

The statements quoted in the Summary include those of deck passenger Valters Kikuts, who stayed together with his friend in the port stairway behind the windows facing the forecastle deck visor. Reportedly he had told the JAIC that he had seen the visor moving up and down, which he later denied, and that the visor was moving forward/aft and that a transverse gap opened/closed between visor and forecastle deck - a clear indication that the hinges were broken. He further testified that water was gushing out of the gap when the vessel was diving into a wave and that water was surging into the gap when the bow was rising, which makes sense as a moving up and down of the visor is not possible as long as the actuators are connected to B-deck, because the actuators follow the opening movement, however, resist the closing.

24. JAIC Chapter 7 - The Rescue Operation

- has been investigated by the JAIC in great detail, but has not been part of the investigation of this 'Group of Experts' except for the "Distress Communication" which is explained in detail in Subchapter 22.1. The JAIC does not mention the possibility that there had been an earlier "Mayday". As no one on board will ever admit to have heard an earlier "Mayday" without having reacted, it is very well possible that there had been an earlier "Mayday". This was at least reported by the watch A.B. of a big Swedish ferry in the area - see Chapter 22.1. The notes taken during the telephone conversation with an anonymous caller are attached as Enclosure 42.485. The JAIC also does not mention the Estonian car/passenger ferry "BALANGA QUEEN" (bareboat chartered), which was on way from Trave-münde to Tallinn in the vicinity of Cape Ristna when the casualty occurred, however, was instructed by the Estonian Coast Guard to proceed on to Tallinn. The vessel is only mentioned in the JAIC Report to have participated in the search during the afternoon of 28 September, when she was already on her way back to Travemünde. It is also strange that the distress communication picked up by the "BALANGA QUEEN" and her offer to help is nowhere mentioned.

25. JAIC Chapter 8.1 :

It has to be mentioned that the survey vessel "SUUNTA" stayed in Hangö during the 28th when the weather was relatively bad and the wind speed was 16/18 m/s. On the 29th and the 30th the wind speed was just 12 m/s, however, "SUUNTA" departed only on 30th at 08.40 hours from her berth to the casualty position, which was, of course, known by the Utö and the "MARIELLA" radar observations. She commenced the search at 16.27 hours and found the wreck at 17.32 hours on 59°22,92'N; 21°41,06'E, which is the actual wreck position. She dropped a buoy and returned at 18.45 hours to Hangö.
Consequently the real position of the wreck was known to the Finnish authorities from the very beginning, and with certainty also to Kari Lethola. Nevertheless, he reported 59°23,0'N; 41°43'E by fax to Olof Forssberg on the same evening and, furthermore, Sjöfartsverket took up in their tender specification for the diving investigation sent out to various contractors in Northern Europe a wreck position which is 2100 m to the NNE of the actual one.
As for the further mysteries surrounding the fairly simple task of finding a wreck the size of ESTONIA at just 80 m of depth, the reader is referred to Chapter 24.

26. JAIC Chapter 8.2 :

It is noteworthy that the videos produced on 5/6 October and in 1996 are not mentioned by the JAIC - see Chapters 25.1-25.3 and 28. The JAIC here seems to create the impression that the vessels used, viz. the "HALLI" at first and "TURSAS" subsequently, were engaged exclusively by the JAIC which according to the logbook entries of both vessels however is doubtful. These entries indicate that the vessels, manned with navy personnel and operating under the command of the Western Fleet (of Finland), primarily performed military activities.

27. JAIC Chapter 8.4 :

The Report does not state that the diving survey described here was not the first ordered by the Swedish Government. The JAIC furthermore just spends a few lines on this major operation carried out by very professional contractors on behalf of Sjöfartsverket. The evaluation of the video tapes presented to this Group of Experts show that this operation was conducted simultaneously with another diving investigation by other divers. Since it has to be excluded that this second operation could be carried out without the divers and the operators and supervisors on board of the diving support vessel "SEMI I" noting it, it has to be concluded that this other diving operation was also performed with the approval of or by Swedish governmental authorities. It is noteworthy, that no tapes or written documentation of this second operation have ever been released by the Swedish authorities to the public. They are however available. It has further to be mentioned that the Finns obviously tried to hide the presence of Tuomo Karppinen onboard - see Chapter 27 - the reason probably being the attempt to leave the responsibility for the many obvious mistakes made with Börje Stenström being the only "official" participant on behalf of the JAIC.
These mistakes were:
- the failure to instruct the divers to search the bridge properly for bodies and identify the bodies by means of their uniforms (or not wearing uniforms at all);
- the failure to have the front bulkheads, the longitudinal bulkheads and the recesses on both sides of the bow ramp, the locking devices of the bow ramp and the ramp hooks examined properly by the divers;
- the failure to have recovered at least the port visor hinge bolt with bushing, the lugs of the visor side locks and the whole bow ramp with hinges, just to mention the most important items;
- the failure to have examined by the divers why the starboard stern ramp was open;
- the failure to have the starboard side of the wreck above the mudline including the starboard stabiliser video filmed and properly recorded;
In summary it has to be concluded that the wreck examination by the JAIC was carried out very poorly and insufficiently which is also reflected in the description of the damage to the wreck in the following chapters.

28. JAIC Chapter 8.5.1

- General Condition of the Wreck - where it is stated:
"No external damage other than that in the visor and forward ramp area was observed on the wreck."
This is wrong because other substantial damage exists such as:
- Bridge: The steel plates of the underside of the port bridge from the superstructure to the outside were completely torn off, with the support stanchion smashed forward and broken off;
- Aft accommodation: The port aft accommodation area of decks 7 and 8 was distorted and pressed in.
- Foreship:

• the starboard front bulkhead was cracked off the forepeak deck, hull plates and the inner bulkhead;
• the port longitudinal bulkhead was cracked open from forward into the car deck, including the area below the control panel over several meters.

  
  - Aft ship: The starboard stern ramp is evidently open.
  - Bottom and bilge strake area: The starboard side above the mudline was noted to be holed several times. These are just the most obvious damages noted on the publicly available videos, however, it has to be assumed with certainty that there is much more damage at the starboard side above the mudline, which was cut away from the publicly available videos - see Chapter 34.6.

29. JAIC Chapter 8.5.2 :

The damage in the bow area is allegedly summarised in the drawing 8.1 on page 120. This is misleading.
The drawing does not show
- the damages mentioned above, i.e. the cracked off starboard front bulkhead and the large holes in the longitudinal bulkheads;
- the missing and damaged rubber packing of visor and bow ramp;
- the cracked off outer starboard girder of the bow ramp, just to mention a few examples, instead
- pounding damage is indicated where is no such damage;
- the port outer and inner hinges of the bow ramp are indicated to have failed, which they did but some time before the casualty;
- "deep indentations" are just indicated at the lower part of the bow ramp, i.e. in way of the contact area with the forepeak deck, in case the ramp should have been fully open, although all transverse girders up to the flaps are very heavily distorted in way of the centre line.
In summary the JAIC again indicates existing or non-existing damage the way it fits their casualty scenario. Missing rubber packings, cracked open bulkheads and distorted, cracked off girders, which obviously cannot have been caused during the hypothetical casualty scenario of the JAIC are either not mentioned or misinterpreted.
Some details:
- The JAIC states that the visor parking devices (harbour securing) were undamaged, but do not state that they were open (this means that there had to be "one red light" on the control panel when it was allegedly checked be Silver Linde - see Chapter 21.2.2.).
- The JAIC states that "the opening in the front bulkhead on the port side had rather clean cut contours", which is true, however the JAIC does not state that the starboard front bulkhead was completely ripped open from the inside to the outside, that a green painted deck piece is sticking in the opening and that the starboard side corresponding to the photo at Fig. 8.2 is just a big black hole of the size that the diver could crawl into it.
- The mounting bracket for the locking-bolt position sensors, in short the sensor plate of the Atlantic lock, was found to be empty with corroded screw holes indicating that the sensors had been dis-connected some time before the casualty;
- The sensor cables were clearly cut - not torn - all of which is not mentioned in the JAIC Report. Moreover the sensor plate as well as the cables had been cut off by the divers in December 1994 and thrown away to the sea bottom, thus disappeared forever, under the eyes of Stenström. There was indeed substantial damage to the rubber seals and flatbar housings in the "corner of the mouth", however not or rather limited to the forepeak deck.
- Pounding damage was noted in way of the stempost area, but only to a very limited extent to the edges of the forepeak deck.
- The bulbous bow does not only show scratch marks, but 3 partly deep indentations indicating very heavy contact because the bulbous bow is a very strong structure.

30. JAIC Chapter 8.5.3 - Visor Damage :

At first the JAIC describes the big indentation in the starboard shell plating of the visor in a misleading way creating the impression that it was only one indentation, although there are actually two, i.e. the upper part is of older and different characteristics and the lower larger part is extending into the older upper part as can be seen in Figure 8.5. The JAIC uses repeatedly the term "pounding" when describing the damage to the visor bottom and alleged damage to the edges of the forepeak deck, although the visor bottom is severely distorted and pressed in which occurred obviously when the visor had moved that wide forward that the stempost area was extending the forepeak deck and thus had lost its carrying function. As a result the forepeak deck was pressed into the visor bottom with the visible result. The only "pounding" which actually occurred was within the play of the locking devices. This had created the low banging noises heard by many passengers before the casualty on this voyage and also already on previous voyages.
On pages 122/123 of the JAIC Report the visor and parts of it are shown on 7 photos (Figure 8.4 - 8.10) in a very particular way.
Fig. 8.4 shows the visor looking from aft to forward and starboard to port. The picture shows the damage to the port inner longitudinal bulkhead and the deep indenta-tion on the port side of the upper cross beam. Both damages can be seen in more detail on Figure 8.7. What is not shown is the opposite port side: There is absolutely no damage, i.e. the starboard inner longitudinal bulkhead does not even show scratches in the paint and the port side of the upper crossbeam just shows paint scratches. The explanation for this damage being restricted to the port inside of the visor is the apparent fact that the vessel was considerably heeled to starboard when the lugs underneath the visor arms (visor lugs) broke through the front bulkheads of the vessel and did not support the visor any longer against moving to starboard. The visor fell for about 100 mm to starboard until the port inner bulkhead of the visor was resting on the bow ramp then lying inside the visor already on the vertical and crossbeams. This impact caused the up to 360 mm deep indentation on the port inner bulkhead of the visor. There is corresponding damage in way of the port upper side of the bow ramp - see Chapters 29, 30, 31 (Casualty Scenario).
Figure 8.7 also shows the port inside of the ramp house with the last two of nine frames of the aft part of the ramp house bent. That is to say that actually only the last frame (P4) at port side was pressed together while the next one (P3) is only slightly indented, the next one (P2) even less and P1 just shows a slight contact mark and the remaining frames towards the starboard side are unaffected. See pages 955 ff. in Chapter 30.
Figure 8.9 does not show the starboard side (outside) of the port, but of the starboard actuator attachment lug (visor lug) with deep scorings and green (deck) paint marks indicating frequent forward/aft movements of the visor when the visor was tilted down by different angles. The JAIC does not show pictures of the inside (port side) of this starboard lug and also not from inside and outside of the port visor lug, thereby depriving the reader of the possibility to draw conclusions from the conditions of these lug plates as to movements and tilting angles of the visor. The respective pictures are shown in Chapter 30 on pages 973 and 996. It reveals that both the outsides and insides are deeply scored at starboard side, though differently, i.e. much more and deeper at the outside and at the inside only one main scoring line almost parallel to the forecastle deck.
At port the outside of the visor lug plates is totally unaffected, i.e. not even paint scorings, while the inside is very deeply scored, almost engraved indicating forward/aft movement of the visor at varying tilting angles.
The obvious fact that the starboard outside and the port inside of the lug plates were most severely scored leads to the conclusion that the vessel was already heavily heeled to starboard when the hinges broke, first at starboard and subsequently at port, because the obvious fact that the port outer lug plate is not scored at all indicates that the vessel must have been heeled to starboard already quite considerably when the port hinges broke because there was no contact between the lug plate and the deck/deck beam.
Figure 8.8 shows damage below the recess for the port locating horn which was obviously caused by the port locating horn at a time when the port hinges were broken already, because the visor was in raised condition as otherwise the locating horn would be resting deeper and higher in the recess as confirmed by the contact marks at both sides of the recess.
Figure 8.10 shows the big visor lug being part of the Atlantic lock installation. It shows the bore to be elongated, but it cannot be seen that the hole lug is bent to starboard, it almost cracked off the visor bottom, obviously when the visor moved the above explained ca. 100 mm to starboard, a very strong indication that the Atlantic lock was at that time still intact. The JAIC picture also does not show the flame cut-off part of the lug with two deeply penetrating cracks having started in one of the burning marks. For details see page 1028.
Figure 8.11 shows a rather foggy picture of the port outer bow ramp hinge (the JAIC has crystal clear pictures in particular from this area) which is again described in a misleading way. The lines allegedly point to "rags" are actually pointing at a thick blue mattress at the upper side and the bed-cloth at the right which were put there by the crew as "sealing" material because there was a gap of some centimetres between bow ramp and bulkhead in this area since the hinge had failed several months before the casualty. The bolt is visible in a declined condition much too far to starboard. The brown lug visible at the upside slipped off the bolt several months before the casualty where after the other one broke. The JAIC is wrong when stating that the aft deck plating of the visor had heavy pounding marks. Just in the recesses at the port and starboard side there are some contact marks, otherwise there are no indications of pounding in way of the deck plating.

31. JAIC Chapter 8.5.4 - Ramp Damage corresponds to Chapter 29.2, item 6.
The JAIC writes:
"The condition of the ramp was inspected primarily from its lower side due to the limited access to the upper side."
This is wrong. The ramp was accessible at the upper side as well as the lower side, from the inside and from the outside. The divers went everywhere - even inside, i.e. the car deck side - and everything is on video.
The JAIC writes: "The 2 port side hinges at the bottom the ramp were torn apart", thereby creating the impression that this occurred during the casualty. This is wrong. The heavy port hinge should have been renewed already in January 1993 according to the specification of the last Finnish crew of the vessel. See Subchapters 3.4/6.5.1. This was ignored by the new technical managers N&T and nothing was done. As time went by the bolt of the port outer hinge worked itself more and more to starboard, broke the securing plate and, finally, the outer lug connecting the ramp to the vessel via this hinge bolt, slipped off the bolt which caused the failure of the inner lug as well. The ramp was no more connected to the vessel at the port outside, a gap of some 20-30 mm occurred which increased. See memo about the discussion with Stenström in October 1995 - Enclosure 12.5.166. The car deck was open to the at sea always water-filled visor. According to Stenström the damage was frequently put on the repair list, however, repairs were rejected by N&T. It is unknown when the port inner hinge of the bow ramp broke, however according to the damage picture it might well have been sometime before the casualty. The two starboard hinges of the bow ramp are just elongated.
The JAIC writes: "Both hydraulic actuators for the ramp had failed in their piston rod end eyes, i.e. at the ramp attachments points." That is correct, however, the starboard piston rod broke twice, once in the eye and another time between eye and piston.
The JAIC continues: "The actuators were in partly extended position as when the ramp is partly open." This is wrong. The starboard actuator is not visible at all. Its opening in way of the recess of the starboard front bulkhead is almost covered by the bow ramp resting on the recess and what is visible is torn and deformed. The JAIC fails to mention that the starboard landing of the bow ramp to which the attachment points were fitted was completely torn open (inside to outside) and severely distorted. The port actuator is visible inside its housing in slightly open condition. On one video it is completely inside the housing, on another one it is slightly extending to the outside - see pages 836, 837. Apparently the divers did change the condition of this actuator. Also inside this housing an angle iron is visible which obviously had been pressed into the bulkhead plating in way of the lower side of the opening. See Chapter 29.2 - item 6 - pages 832, ff.
The JAIC writes that the "wires preventing the ramp from falling down to the forepeak deck had detached from the lugs on both sides of the ramp". That is true, both ramp lugs are intact and without wires, which are however both still connected to the attachment points at the upper car deck opening. The starboard wire is full length visible to the intact lug with shackle and bolt attached. The bolt is apparently intact and screwed into the shackle which raises the question who did unshackle the wire from the ramp lug and screwed the bolt again into the shackle? Needless to say that all this is, of course, not mentioned in the JAIC Report.
The JAIC: "The ramp port side beam was damaged in several places, mostly towards the top end". Meant is probably the port outer vertical girder, which is only slightly damaged at its bottom part between the lower and the next upper transverse girders. It is also possible that the JAIC means the damage at the port upside, outside of the ramp which was caused when the visor was resting on this part of the ramp.
The JAIC: "The lugs for the pull-in hooks were twisted." Actually both lugs are intact, i.e. not broken, but heavily bent away from the location of the pull-in hook and on the ROV video from 09.10.94 there are two wooden pallets visible which jammed in between the bulkhead recess and the bow ramp in way of the landing of the lug for the pull-in hook. On the diver videos from December 1994 these pallets were no more at this location, which means that the bow ramp must have been opened and closed.
The JAIC continues: "The hooks themselves could not be inspected closely." This is wrong. The port hook arrangement including actuator is fully visible on the available videos and was also checked by the diver Dave Mawston: "There is a latching mechanism." The port hook is in its initial position and intact which means that it cannot have been engaged before the casualty respectively if it was engaged upon departure Tallinn it must have been opened at sea before or during the casualty. The starboard hook is not in its initial position, where it should be is a big black hole.
The JAIC continues: "The boxes on the ramp side bars, mating the bolts of the ramp side cleats were twisted to open position except for the lower port side one." This is wrong: None of these mating boxes were twisted to open position, i.e. the port upper one was completely intact but just slightly bent upwards, the port lower one was completely intact with a rope wound around it, the starboard upper one was intact with the upside missing (had been burnt off upon arrival in the morning of 27 September 1994 by flame cutting when the crew was again unable to disengage this securing bolt). Obviously there had been no time to re-weld the cut off part to the box before the last departure. See also chapter 12.5. Finally the starboard lower box was completely smashed together in a way that the bolt was unable to enter the box. This damage was apparently caused earlier when the ramp had been closed when the bolt was already extended.
In addition attention has to be drawn to the reports of diver Dave Mawston when checking the ramp. He found that the extended bolts at the port side of the ramp were about 21/2 inches = ca. 100 mm below the respective mating boxes, i.e. none of the port side bolts could anyway have engaged their mating boxes and this is apparently also the reason why the port pull-in hook had not engaged its mating lug. All this was obviously due to the very severe misalignment of the whole ramp and its disastrous consequence - nothing of it is mentioned by the JAIC.

32. JAIC Chapter 8.6 - Damage to Visor and Ramp Attachment Devices :

8.6.1 The Visor Bottom Lock (The Atlantic Lock) : JAIC: "The remains of the attachment lugs and the locking bolt were removed from the wreck during the diving operation for close investigation." The locking bolt was brought up by the divers but thrown back into the sea by Stenström, thus it could never be "closely investigated". Nevertheless the JAIC writes: "Only a slight variation in diameter was measured at the contact area between the bolt and the visor lug. No other damage to the bolt was noted."
This is wrong. Although the bolt is not available for close examination the following can be concluded from the quite good video footage:
- there were two contact areas indicating that the bolt was sometimes fully closed, sometimes only partly;
- the vertical steel bracket fitted to the bolt was bent to port and showed heavy hammering marks at its edges;
- the two lugs, between which the piston rod was connected to the bolt by pin, were bent outwards, i.e. away from each other, and also showed heavy hammering marks.
The reason for these damages were the problems the crew had with closing and opening the bolt which did not function any more hydraulically since some months before the casualty because the lugs were severely deformed. See Chapter 12.4.3 and 12.5.
The mating lug of the visor was already discussed further above.

33. JAIC Chapter 8.6.2 - The Visor Side Locks :

The JAIC writes: "The port side lug had rotated as far as it could in the recess in a direction indicating an upward movement." Taylor made for the JAIC scenario, but it is wrong. On the ROV videos from 02.10.94 and 09.10.94 the port lug was not extending the bulkhead , the lug condition visible on the picture, Figure 8.17, has been created by the diver. The starboard lug, however, was indeed pointing out of the bulkhead.
The hole above the side lock in the front bulkhead stated to be punched in by the manual hooks was actually not punched in but torn out, i.e. the plating was bent inside to outside - see Chapter 32. The condition of the lugs and its welding seams in relation to the visor plating shall be discussed in Chapter 12 - Overview of Separate Investigations.

34. JAIC Chapter 8.6.3 - The Visor Hinge Arrangements :

It is already visible from the pictures - Figure 8.21-8.24 - that the starboard hinges were in a much worse condition than the port one with deep burning marks and deeply penetrated cracking, however, the comments shall be made under Chapter 12 - Overview of Separate Investigations - in order to avoid repetitions. It was another unforgivable mistake from Stenström not to arrange for the two hinge bolts - one with the bushing still attached - to be recovered.

35. JAIC Chapter 8.6.4 - The Visor Actuating Arrangements :

The explanations of the JAIC concerning the failure of the port actuator foundation, called bottom mounting platform, is confusing and partly wrong. The initial construction and the damage picture of the foundation is explained in detail and illustrated by several photos on pages 990 ff. of this Report. The summary reads as follows:
"(1) The outer stiffener of the port actuator foundation shows an old temporary repair with very poor welding seams in its forward part. Due to the corrosion visible on the previous photos it has to be assumed that this improper repair was carried out already some considerable time before the casualty.
(1) The stiffeners show relatively straight cracks directly below the forward and the aft ends of the lug plates. Therefore it can be reasonable assumed that the stiffeners were affected by fatigue cracks and thus pre-damaged. The cracks had developed during some considerable time before the casualty due to load changes during the opening and closing of the visor.
(2) The B-deck was also affected by fatigue as already explained for the stiffeners. This fact is indicated by the condition of the ripped off deck remains.
(3) The port inner stiffener was no more the original one since firstly it did not show any protecting coating and secondly was only spot welded to the deck -if at all. All stiffeners were however fully welded to the deck by the shipyard during new-building, as it can still be seen on the starboard actuator foundation.
(4) The load carrying capacity of the port visor actuator was considerably reduced."
The JAIC explanations about the failure of the starboard actuator is accepted, however except for the following remarks by the JAIC:
"The lugs for connecting the actuators to the visor deck beams showed indentations and scoring on the forward and starboard side faces (Figure 8.9). The sealing arrangement around the deck openings for the actuators, consisting of rubber seals supported by steel flat bars, was compressed over most of the surface and some paint marks showed that the hinge arms had been in limited contact with the deck plating."
The "lugs for connecting the actuators to the visor deck beams" were called "actuator attachment lugs" in the previous Chapter 8.5.3 and were actually the pair of lugs underneath the port and starboard visor arms (called visor deck beams by the JAIC) by means of which the actuators were connected to the visor. The condition of the lug plates, i.e. starboard outside: deeply scored, starboard inside: slightly scored: port outside: no contact marks at all: port inside: very deep scorings; has been explained and commented under Chapter 8.5.3 above and needs not be repeated.
The JAIC is also wrong when stating that "the rubber seals supported by steel flat bars (around the deck openings for the actuators) were compressed over most of the surface" because this is the case only at port side where the rubber seals were indeed distorted apparently by rubbing. See pages 996 ff. The starboard side rubber seals are, however, unaffected. See pages 973 ff. The forward parts of the port and starboard lug plates show contact marks without paint at their upper parts, which were apparently caused when the lug plates were cutting through the forecastle deck plating. Below these areas there is more or less unaffected or just slightly affected white/red paint at starboard side all the way down, but at port side there are further contact areas without paint.
Bearing in mind the strong deck beam at frame 159 which the lugs at both sides reached after only 120 mm of 8 mm forecastle deck plating were easily cut through and which was evidently cut through at both sides, it is difficult to believe that this was performed by the above explained foreparts of the two starboard and two port lugs. Calculations revealed - see Chapter 34.12 - that weight and forward momentum of the water-filled visor were theoretically able to cut the deck beam, however the damage picture of the cutting tools - the lug plates, and in particular, the starboard ones, do not confirm this.
This problem has been closely examined by The Independent Fact Group, Stockholm, who more or less proved that the lugs could not have cut the deck beam, however, do not offer a reasonable solution but leave that to a new investigation.
As to the starboard side the possible explanation is outlined in Chapter 32 - Unexplained Evidence - because there are several indications that a powerful explosion occurred also inside the void space above B-deck, which blew open the front bulkhead and possibly also destroyed the deck beam in question before the hinges broke.
At the port side, however, there are no such indications. Here the answer might be that the deck beam was cut by the piston rod of the partly extended actuator. The piston rod is made of high tensile steel. See Figure 8.25 in the JAIC Report.
Finally the remark of the JAIC that "some paint marks showed that the hinge arms (now the "visor deck beams" are called "hinge arms" to confuse the reader even more) had been in limited contact with the deck plating" has to be totally rejected because not even the primer is affected.
Note: This "contact" between the undersides of the visor arms and the forepeak deck in front of the deck openings for the actuators has been one of the strongest arguments in favour of the JAIC casualty scenario presented in the Part-Report published already early April 1995. The argumentation of Stenström then was that "as soon as the visor bottom was compressed deeply enough due to repeated up/down pounding of the visor the underside of the visor arms did rest on the forepeak deck and due to the leverage created the hinges broke". This was proven to be wrong and the above is the rest of this line of argumentation and even that is wrong.