6.3
The Swedish Maritime Administration Sjöfartsverket

The present Sjöfartsverket was established in 1956 through the merger of the Pilot Administration and the Sea Chart Administration. In addition, further responsibilities as regards waterways were transferred to the new administration. The name Sjöfartsverket was invented in 1969 and in 1988 it received a new structure. In 1975 the head office was moved from Stockholm to Norrköping where about 400 of the approximately 1400 employees are working headed by the general director, who at the time in question, viz. January 1993 to October 1994, was Kaj Janérus. The administration is part of the national defence organisation and is divided into six divisions, i.e.

Sea Traffic
Sea Charts
Icebreakers Shipping Inspection (Sjöfartsinspektionen)
Technical Department
Financial Department - see Enclosure 6.3.115.

The country is divided into thirteen sea traffic areas including the pilot stations, other installations and three shipping inspection districts, to one of which the Rotterdam office is attached. It is within the scope of Sjövfartsverket to supervise the performance of the rules and regulations relating to safety at sea, in particular in accordance with the Sea Safety Law, the subsequently issued Ship's Safety Regulation, further the Law Concerning the Investigation of Sea Accidents and other internal administrative regulations. Due to the international character of shipping Sjövfartsverket participates in the relevant international organisations.

 

6.3.1
The Shipping Inspection Sjöfartsinspektionen

The Shipping Inspection (Shipinspec) is one of the six divisions of Sjövfartsverket and is headed by the ship's safety director. Although directly responsible to the general director of Sjövfartsverket, this director has rather far-going own decision powers due to a number of laws and regulations. Therefore Shipinspec has a comparatively independent position compared to the other divisions, in particular in matters of sea safety.

The sea safety director (safety chief) is appointed by the government upon recommendation of the general director of Sjövfartsverket. The head office of Shipinspec is also in Norrköping where 60 of the about 120 employees work while the other 60 are distributed among the three regional offices in Stockholm, Gothenburg and Malmö and the Rotterdam branch office. The heads of the district offices carry the title "Oberinspektor" = chief inspector and are directly responsible to the safety chief - safety director - who during the relevant time frame from January 1993 to October 1994 was Bengt-Erik Stenmark while the chief inspector positions were occupied by

Ulf Beijner - Stockholm
Åke Sjöblom - Malmö (also responsible for the Rotterdam office)
Ralph Grundell - Gothenburg.

All three were naval architects by profession and well trained safety inspectors. The head office is divided into the following departments:

a) planning : budget, personnel, organisation, legal, EDP, ships' movements.
b) technical : safety relevant construction/design of vessels, equip-ment, stability, freeboard, maintenance, fire protection, crew accommodation, navigation equipment, dangerous goods, etc.
c) operative : crew matters, certificates, sailor register, working environment.
d) investigation : investigation of ship accidents, personal injury and death cases on board, accident statistics, violation of safety and environment protection regulations.

The safety chief is directly responsible for ensuring that the Swedish vessels and the foreign passenger vessels regularly calling at Swedish ports comply with the legally required safety standards. The same refers to the investigation of sea accidents reported to Shipinspec. According to the internal Sjövfartsverket Working Regulation, Shipinspec has among other things to provide

1) that respective regulations maintain compliance with the sea safety law;
2) that supervision and inspection of Swedish and foreign vessels regularly calling at Swedish ports ensure that they comply with the legally required safety standard;
3) the investigation of sea accidents and the evaluation/analysis of the results;
4) the keeping of accident statistics and the drawing of conclusions with the aim to prevent similar accidents in the future.

as to 1) :
This obligation of Shipinspec is based on the respective requirements of the Sea Safety Law of 1988 (in force at the relevant time) which refers to Swedish and foreign flag vessels regularly calling at Swedish ports according to which, among other things:

- The master is responsible for the vessel being in seaworthy condition upon commencement of the voyage.
- The owner is obliged to prevent the vessel from departing in case of a known unseaworthiness.
- The master is obliged to report all sea accidents to Shipinspec, and Shipinspec has to make sure by respective regulations that masters/ owners do comply.

as to 2) :
This item is separated into parts, viz.

(a) newbuilding inspections for Swedish owners;
(b) regular inspections of Swedish vessels;
(c) inspection of foreign passenger vessels regularly calling at Swedish ports;
(d) inspection of foreign vessels in Swedish ports on the basis of the international Port State Control agreements (PSC).


(a) Newbuilding inspections for Swedish owners

Shipinspec experts do the checking of all drawings relating to the design/ construction of safety relevant installations, do the approval and subsequently issue the respective certificates, however not in respect of hull & machinery matters. According to the respective conditions of the Sea Safety Law this obligation of Shipinspec was delegated to a number of approved Classification Societies, among them B.V., on the basis of particular agreements. These societies have at their disposal considerable technical resources and a worldwide net of inspectors which otherwise Shipinspec would have to create as well. Before this background of technical competence and well established control net the national maritime administrations, such as Sjöfartsverket and F.B.N., have since many years ago acknowledged the requirements and performance of these classification societies. In order to remain up-to-date with rule and/or other changes within the societies, the safety chief is for example a member of the supervisory boards of B.V., DnV and ABS. On the basis of respective agreements B.V. carries out on behalf of Sjövfartsverket, MARPOL, SOLAS and the Load Line inspections on board of Swedish vessels which are classed by B.V. In the light of these agreements and understandings both DIANA II and VIKING SALLY were built with B.V. being the Classification Society and as such also responsible for the approval of structural parts on behalf of Sjöfartsverket and F.B.N. This includes the location of "the upper extension of the collision bulkhead above bulkhead deck" as well as the locking devices and hinges of visor and bow ramp.

(c) Inspection of foreign passenger vessels regularly calling at Swedish ports
Based on the Sea Safety Law it is also required that passenger vessels, i.e. also car/passenger ferries, who are regularly calling at Swedish ports, have to be inspected as if they are Swedish vessels - see also Subchapter 6.4. In other words they have to pass the so-called "1/92 inspection" before taking up service and thereafter the vessel has to undergo continuous inspections in intervals determined by Shipinspec. This was the situation of the ESTONIA from January 1993 to 28 Septem-ber 1994.

as to 3)
The investigation of sea accidents on the basis of the requirements of the "Law Concerning the Investigation of Accidents" from 1990.
It is mandatory for a sea accident to be investigated if :

In addition, nearby accidents also have to be investigated in the case that they were caused by substantial failures of the vessel and/or safety relevant installations.

The law clearly defines that - apart from establishing cause and development - the gained information is to be evaluated and proper measures have to be decided in order to prevent a repetition of the occurrence on this or similarly constructed vessels.

According to §2 of the "Law Concerning the Investigation of Sea Accidents" of 1990 the government has decided that all accidents and nearby accidents have to be investigated by the "Statens Havarie Kommission" (SHK) - the "Government's Casualty Commission". During the investigation carried out by SHK a representative of Shipinspec, generally the head of the Investigation Department, has to be present. Based on the same law SHK has the authority to delegate the investigation of smaller accidents, which have to be carried out under safety aspects only, to Shipinspec who report the result among others also to IMO.

as to 4) :
The keeping of accident statistics and the drawing of respective conclusions apparently failed completely within Shipinspec because the internal investigator Magnus Sjöberg concludes in his Report from March 1995 that there was a lack of procurement and transfer of the ship safety relevant information as well as the evaluation and analysis of the available material or the material which should be made available and, furthermore, of a follow-up of induced measures.

Note:

Magnus Sjöberg was instructed on the basis of a government decree of 3rd October 1994 which reads as follows:
»On the 28th September 1994 on voyage from Tallinn to Stockholm the passenger ferry "Estonia" sank southwest of the Finnish island Utö. The vessel sailed under Estonian flag.
On 29th September 1994 the Swedish government instructed SHK to participate in the casualty investigation. Thereupon a Joint Accident Investigation Commission was formed from representatives of the Estonian, Finnish and Swedish authorities. The main objective of the commission was to establish the cause of the casualty.
Survivors of the shipping catastrophe had reported that the visor had been torn open, which could be one cause of the casualty.
Subsequently obtained information revealed, that already earlier there had been accidents and problems with bow doors of ferries of the same type as the "Estonia". Proper safety at sea requires that conclusions are continuously drawn from casualty and incidents. In addition to the investigation by the Joint Accident Investigation Commission (JAIC) therefore, also the reporting routines and other procedures adopted by Shipinspec should be closely examined.«

In compliance with the above-mentioned instructions Magnus Sjöberg has listed a number of incidents on board Swedish Ro-Ro vessels whereby problems with bow doors, their hinges and/or locking devices were involved. These were:

Although the respective causes for the above-mentioned incidents, viz. too weak design, were realised by Shipinspec and counter-measures were required from the respective class of the vessel - which were promised in all cases - there was no follow-up from Shipinspec to control whether the promises were actually fulfilled by the classification societies and whether the relevant construction was changed respectively strengthened.
Since the damage statistics kept by Shipinspec were also made up according to the names rather than according to types of vessel, it was also not easily recognisable whether particular types of vessels, e.g. Ro-Ro's, had repeated damage to particular components such as the safety-relevant locking devices and hinges of bow doors/visors.
This was the situation within Sjöfartsinspektionen at the end of 1994 and many years before. The English translation of the complete report of Magnus Sjöberg is attached as Enclosure 6.3.116, the Swedish original as Enclosure 6.3.116.1.