CHAPTER 42

FINDINGS

This Chapter is purposely written in the same order as the corresponding Chapter 20 in the Report of the JAIC in order to facilitate an easy comparison for the reader. Where no corresponding remarks are found, this 'Group of Experts' either agrees or has not investigated the specific subject.

Accident

- The car/passenger ferry ESTONIA sank during the early hours of 28 September 1994 in the Northern Baltic on its voyage from Tallinn to Stockholm. According to the official figures only 137 passengers and crew members survived. The wreck lies in international waters.

 

Weather / Sea state

- At the time of the casualty the wind was blowing from SW-ly directions with a speed of 18-20 m/sec. The significant wave height was about 4 metres. Neither wind speed nor sea state were exceptional for the season.
- Before the sequence-of-events of the casualty commenced the ESTONIA was pitching extremely hard in bow seas from port forward due to a speed which must be considered excessive under the prevailing conditions.

 

Ship's Condition

- When the ferry left Tallinn she was unseaworthy for the following reasons: Her bow was open to the sea. The bow visor and the bow ramp, which should both be water(weather)tight, were leaking with the consequence that seawater had uncontrolled access to the car deck, a condition which must be avoided by all means, as it severely endangers the safety of the vessel and it's passengers.
A part of the underwater hull was corroded to the extent, that seawater had free access to certain tanks and void spaces. The consequence of this fact was, that about 200 mts of unknown weights were in the vessel creating a 10 degrees list which could only be partly rectified by the ballasting of the port heeling tank.
The vessel's Passengership Safety Certificate was false, the same is true for her Load Line Certificate.
Trucks and cars on the car deck were not properly secured although the upcoming heavy weather was known to the master.

 

Sequence-of-events

- Due to missing rubber seals and damage to it's bottom the visor became quickly filled at sea up to the outside water level with seawater, which penetrated through the partly open bow ramp into the car deck.
- The existing starboard list was increased by the wind pressure from port.
- The vessel therefore heeled 2 to 4 degrees to starboard and the water that had penetrated through the bow ramp accumulated on starboard aft of the car deck as the vessel was trimmed by the stern at the commencement of the voyage.
- There are indications that the crew opened the starboard stern ramp slightly in an attempt to drain the car deck thereby.
- The bilge pumps were running and pumping from compartments of the 1st and/or 0-decks. It has to be assumed that the watertight doors in the engine room area were closed, whilst the watertight doors in the passenger area of the 1st deck were still open after the big heel.
- At about 00.40 / 00.45 hours heavy metallic bangs were heard and felt from the foreship and the movements of the vessel changed to softer pitching and rolling. The metallic bangs continued. It has to be assumed that the starboard hinges and side locks of the visor failed at about this time. The visor was now moving forward/aft between the hinge parts on the forecastle deck and the deck beam at frame 159.
- The speed was reduced and the damaged bow turned to starboard away from the waves, however when the vessel started to roll excessively the bow was turned back to port and wind and sea were now taken from straight ahead. The vessel now made soft, deep pitch movements for a while.
- At some time later also the port hinges and the port side lock failed, whilst the Atlantic lock held somewhat longer.
- At about 01.00 hours the vessel was shaken heavily and noises and vibrations as if the vessel was proceeding through ice were heard and felt by those on the 1st deck, shortly followed by another, even more severe impact, followed by a very wide heel of the vessel to starboard at 01.02 hours The vessel, however, came back to almost upright condition, heeled again, came back to 10-15 degrees starboard heel and subsequently heeled in steps to about 30-35 degrees to starboard and stabilized in this condition for some time.
- While the visor moved forward/aft and the lugs underneath the visor arms were slowly cutting trough the deck beam of frame 159, both bow ramp actuators broke and the unsecured ramp fell into the visor.
- After some time the lugs underneath the visor arms had worked their way through the deck beam - most likely first at the port side - and the visor now also moved to starboard following the increasing starboard heel and fell onto the bow ramp which rested in the visor.
- In the meantime the forepeak deck had penetrated the bottom structure of the visor whilst the shell plating edges were overlapping the forepeak deck.
- The visor was now held by the bow ramp and by the port side plates overlapping the forepeak deck, whilst the vessel continued to heel to starboard and the stern sank deeper.

 

Capsize

- The main engines stopped at about 01.10 / 01.12 hours at a heel of 25-30 degrees. At this time the vessel had turned to a North-Easterly heading.
- The vessel stabilized at a heel of 30-40 degrees for some time and the diesel generators stopped at about 01.15 / 01.20 hours whereafter the emergency generators started and supplied power to a limited number of consumers.
- The vessel continued to heel and was on the side at 01.30 hours and some time later completely upside down whilst the stern continued to sink deeper and the bow to raise higher.
- It has to be assumed that the visor did glide off the bow ramp and forepeak deck when the heel had reached some 130-140 degrees and sank to the bottom of the sea as it was unable to float.
- The stern finally settled on the sea bottom with the bow still raised to about 40-45 degrees out of the water. The bow ramp was almost closed.
- The bow sank slowly deeper and -
at 01.53 hours the echo of the ESTONIA disappeared from the radar screen of the nearest vessel "MARIELLA".

 

Action by the Crew

- Nothing can be stated with some degree of probability from the bridge for the time after 00.35 hours.
- It has to be assumed that a first "Mayday" was transmitted at around 00.45 hours, which for unknown reasons was not picked up.
- It has further to be assumed that after the problems with the bow ramp and visor were realised, the speed was reduced and attempts were made to take the loads off the visor.
- It is likely that the crew worked on the car deck attempting to hold the visor and the bow ramp to the vessel by different means. This attempt, however, failed.
- There are also indications that the engine crew was working on the starboard stabiliser. All attempts of the crew were apparently abandoned at about 01.00 hours.
- A warning for the passengers "Alarm, Alarm" was shouted in Estonian language a few times over the loudspeakers. No other information was given to the passengers.

 

Technical Matters

- At the time when the ESTONIA was designed and built, there were no specific design requirements for visors in the rules of the Classification Society Bureau Veritas. The SOLAS Convention at that time was not yet part of the B.V. Rules.
- The Finnish Board of Navigation considered itself exempted from the inspection of structural matters in newbuildings - such as locking devices - by the Copenhagen Convention of 1924 and hence had to rely on authorised Classification Societies for plan approval and inspection of structural matters on newbuildings. B.V. was authorised.
- The visor design load and the assumed load distribution on the attachments was in accordance with L R. Rules and the then state-of-the-art and technique.
- The visor locking devices installed by Meyer Werft, were manufactured in accordance with the design and good shipbuilding practice. These devices were not identical to those found onboard after the casualty.
- The SOLAS requirements for the upper extension of the collision bulkhead above bulkhead deck were never complied with. Nevertheless Passenger Ship Safety Certificates were issued by The Finnish Board of Navigation and - after the vessel had changed it's flag - by B.V. on behalf of the Estonian National Maritime Board. It may be debated wether the issuance of these certificates during the time the vessel spent under Finnish flag was completely in line with the requirements of SOLAS but that debate is irrelevant, because any such failure cannot have contributed to the Catastrophe.
- The Load Line requirements for a tight vessel were not complied with on 9.9.1994 although BV confirmed the Load Line Certificate on this date, i.e. 19 days before the casualty, on behalf of the Estonian National Maritime Board.
- The general maintenance standard of visor and bow ramp was unacceptable which fact was the main cause for the casualty.