2.1 The Builders - Meyer Werft, Papenburg

2.2 'The General Scandinavian Practice'

2.3 The Forerunner "DIANA II" - subsequently renamed MARE BALTICUM / MELODY

2.3.1 Newbuilding contract and approval procedure

2.4 Contracting and Construction

2.4.1 Building contract and specification

2.4.2 Subcontractor von Tell GmbH, Hamburg / von Tell Trading & Co. AB, Gothenburg

2.4.3 Classification and newbuilding supervision by Bureau Veritas - The Class Certificates

2.4.4 Approval procedure by the Finnish Board of Navigation - Sjöfartsstyrelsen - and newbuilding supervision - the Passenger Ship Safety Certificate

2.4.5 Newbuilding supervision by owners

2.4.6 The construction phase

2.5 General Description and Data

2.5.1 General arrangement

2.5.2 The hull and deck arrangement

2.5.3 Propulsion system and control

2.5.4 Electrical system

2.5.5 Ballast system

2.5.6 Car deck arrangement

2.5.7 Bridge layout

2.5.8 Navigation equipment and systems

2.5.9 Communication equipment

2.6 Visor and Ramp Installations

2.6.1 General

2.6.2 Technical description of the visor

2.6.3 Technical description of the bow ramp

2.6.4 Technical description of the stern ramps

2.6.5 Passenger and pilot doors

2.6.6 Actuating, monitoring and control system for the visor, the bow ramp and the stern ramps

3 OWNERSHIP AND OPERATING HISTORY

3.1 Owners

3.2 Operations

3.2.1 Trade and crew

3.2.2 Seakeeping behaviour

3.2.3 Proceeding through ice

3.2.4 Wave condition history

3.3 Boatswain Juhani Luttunen

3.4 Surveys, Maintenance, Damage and Repairs

4 A SHIP EMANATING FROM THE BALTIC PHENOMENON

II NORDSTRÖM & THULIN AND THE STOCKHOLM-TALLINN SERVICE

5 THE HISTORICAL DEVELOPMENT

5.1 Company Structure and Activities

5.2 The Relevant Staff and AB Hornet

5.3 The NORD ESTONIA - Captain Per Ringhagen

III UNDER ESTONIAN FLAG

6 THE NEW OWNERS / MANAGERS AND THE TAKE-OVER

6.1 Owning and Managing Companies

6.2 The Estonian National Maritime Board

6.3 The Swedish Maritime Administration - Sjöfartsverket

6.3.1 The Shipping Inspection - Sjöfartsinspektionen

6.4 The New Role of Bureau Veritas and the Co-operation with Sjöfartsinspektionen (Shipinspec)

6.5 Take-over and Change of Flag

6.5.1 In Turku

6.5.2 In Tallinn

7 OPERATIONS ON BOARD

7.1 The Crew and the Advisers

7.1.1 The selection

7.1.2 The first crew

7.1.3 The first - and last - master and his adviser

7.2 Working Routines and Organisation

7.2.1 Deck department

7.2.2 Engine department

7.2.3 Catering department

7.3 Safety Organisation

7.3.1 The development of the safety organisation

7.3.2 Alarm signals

7.3.3 Alarm

7.3.4 Training and drills

8 EMERGENCY AND LIFESAVING ARRANGEMENTS AND EQUIPMENT

8.1 General

8.2 Lifeboats and Rafts

8.3 Lifebuoys and Lifejackets

8.4 Emergency Beacons (EPIRB)

8.5 Emergency Alarm Systems

8.6 Escape Routes and Instructions

8.7 Passenger Information

9 CLASSIFICATION INSPECTIONS, STATUTORY INSPECTIONS AND PORT STATE CONTROL INSPECTIONS

9.1 Classification Society Inspections

9.2 Statutory Inspections

9.3 Port State Control Inspections

10 OPERATIONAL CHARACTERISTICS OF THE VESSEL

10.1 General Observations

10.2 Speed Resources

11 CARGO HANDLING SYSTEM

11.1 Cargo Lashing Equipment

11.2 Operating Practice and Instructions

12 OPERATING HISTORY

12.1 Route / Schedule

12.2 Weather and Wave History

12.3 Always on Time

12.4 Observations on Board

12.4.1 Heavy weather, excessive speed and banging noises

12.4.2 Proceeding through ice

12.4.3 Difficulties with visor and bow ramp

12.4.4 Water in the visor and on the car deck

12.4.5 Other observations

12.5 Maintenance, Damage and Repairs

12.6 Further Evidence

IV THE LAST VOYAGE

13 THE CREW AND THE ADVISERS

14 THE DAY IN TALLINN

15 THE SJÖFARTSVERKET INSPECTORS AND THEIR TRAINEES

16 THE CONDITION OF "ESTONIA" AND THE STATUS OF HER MAIN CLASS AND SAFETY CERTIFICATES BEFORE COMMENCEMENT OF HER LAST VOYAGE

16.1 The Certificates

16.2 Condition of the Bow Area

17 THE LOADING AND SECURING OF THE CARGO

17.1 The Loading

17.2 Testimonies concerning Cargo Lashings

17.3 Other Information

18 WEATHER FORECAST / STORM WARNINGS

19 THE DEPARTURE

20 THE ROUTE - WIND AND SEA CONDITIONS ACTUALLY ENCOUNTERED - THE SPEED

20.1 Further Evidence

21 SUMMARY OF TESTIMONIES BY SURVIVORS

21.1 Introduction

21.2 Summary of Testimonies by Surviving Crew Members on Duty

21.2.1 Summary of testimonies by trainee officer Einar Kukk

21.2.2 Summary of testimonies by watch A.B. Silver Linde

21.2.3 Summary of testimonies by 3rd engineer Margus Treu

21.2.4 Summary of testimonies by system engineer Henrik Sillaste

21.2.5 Summary of testimonies by motorman Hannes Kadak

21.2.6 Further Evidence

21.3 Testimonies by Passengers and Off-Duty Crew Members

21.3.1 Reports from deck 1 - passenger area

21.3.2 Reports from deck 4

21.3.3 Reports from deck 5

21.3.4 Reports from deck 6

21.3.5 Reports from deck 7

21.3.6 Reports from deck 8

21.3.7 Further Evidence

21.4 Summaries of All Available Statements of Passengers and Crew

21.4.1 Sumaries of All Available

statements of Passengers And Crew P2

21.5 Summary of Observations and Noises Heard Before the Abrupt Heel

21.6 Time Statements of the Big Heel

21.7 The Righting Up after the Big Heel

21.8 Other Observations

21.9 The Sinking

22 THE RESCUE OPERATION

22.1 The Distress Communication

22.2 The EPIRB Buoys

22.3 The Rescue Operation

22.4 Further Evidence

V INVESTIGATIONS AFTER THE SINKING

23 SEARCH FOR DRIFTING OBJECTS

23.1 Lifeboats and Other Lifesaving Equipment

23.2 The EPIRB Buoys

24 LOCATING THE WRECK AND THE VISOR

24.1 Further Evidence

25 THE ROV INSPECTIONS OF THE WRECK AREA

25.1 The ROV Inspection on 02.10.94

25.2. The ROV Inspection on 05.10.94

25.3 The ROV Inspection on 09./10.10.94

25.4 Further Evidence

26 RECOVERING THE VISOR

26.1 Further Evidence

27 THE DIVING INVESTIGATION 01.-04.12.94

27.1 Further Evidence

28 THE ROV INSPECTIONS IN 1996

28.1 Further Evidence

29 THE WRECK

29.1 The General Condition

29.2 The Bow Area

29.2 The Bow Area Part 2

29.3 The Car Deck

29.4 The Bulbous Bow

29.5 The Shell and Bottom Plating

29.6 The Stabilisers

29.7 The Stern Area

29.8 Further Evidence

30. THE CONDITION OF THE VISOR

31. THE CASUALTY SCENARIO

32. UNEXPLAINED DAMAGE / UNEXPLAINED EVIDENCE

32.1 Introduction

32.2 Findings

32.3 Further Evidence

PART B

ASSOCIATED FACTS AND SEPARATE INVESTIGATIONS

33. BOW DOOR FAILURES AND OTHER INCIDENTS OF RO-RO VESSELS

33.1 The "DIANA II" Incident in January 1993

33.2 The "HABIB" Visor Damage 04.10.78

34. SEPARATE INVESTIGATIONS

34.1 "Forgery of Documents to hide the initial Unseaworthiness of the Estonia" by The Independent Fact Group, Stockholm

34.2 Structural Analysis of Bow Visor and Locking Devices by means of the Finite Elements Analysis by the Technical University Hamburg-Harburg 1164

34.3 Systematical Fracture Tests with Atlantic Lock Mock-Ups of M.V. "Estonia" by the University of Hamburg

34.4 Determination of the Steel Quality of the Atlantic Lock Mock-Ups by the Institute for Failure Analysis and Failure Prevention, Hamburg

34.5 Bow Impact of Ro-Ro Vessels by Det norske Veritas

34.6 Investigation Report of Video Tapes Featuring the Car/Passenger Ferry "Estonia" by Disengage, Axminster/UK

34.7 Investigation Report on Possible Explosion Damage on the Ferry "Estonia" by Brian Braidwood, Weymouth/UK

34.7.1 Supplementary Investigation Report by Brain Braidwood

34.8 Defect and Failure Analysis of the Bow Visor Structure of the M.V. "Estonia" by the Laboratory for Materials Technology and Welding Techniques of the University of the Armed Forces, Hamburg

34.9 Evaluation of the Video Film made on 17.09.94 by Means of Military Reconnaissance Methods by Bryan E. W. Roberts, Churchgate/UK

34.10 Structure Analysis of the Bow Ramp Hinges by the Technical University Hamburg-Harburg

34.11 Floatability Calculations of the Visor by the Technical University, Hamburg-Harburg

34.12 Breakload Calculations of the Deckbeam at frame 159 by the Technical University, Hamburg-Harburg

34.13 Further Investigations

PART C

THE JOINT ACCIDENT INVESTIGATION COMMISSION (JAIC)

35 THE FOUNDATION OF THE JAIC

35.1 The Members

35.2 The Experts

35.3 The Observers

35.4 The Police Liaisons

35.5 The Administrators

35.6 The Working Groups

35.7 The Documentation

36 OTHER ACTIVITIES

36.1 Åke Sjöblom and Gunnar Zahlée

36.2 Early Indications for Something Unusual

36.3 The "Hole in the Starboard Side"

36.4 Other Information from Tallinn

36.5 The Hearing of the Survivors

37 ACTIVITIES OF THE JAIC AND SURROUNDING CIRCUMSTANCES AFTER THE CASUALTY TO THE END OF THE YEAR 1994

37.1 29 September 1994 - Day after the Casualty

37.2 Activities to the End of 1994

38 THE YEAR 1995

38.1 The 'German Group of Experts'

38.2 The February Meeting

38.3 Investigation and Communication

38.4 The August Meeting

38.5 Further Investigations and Meetings

39 THE YEAR 1996

39.1 Communication and Investigation up to March 1996

39.2 The Break Tests and the FE Analysis of the Visor

39.3 The Passenger Video

39.4 The Survivors' Statements

39.5 Communication and Investigation as from April 1996

39.6 Changes in the JAIC

40 THE YEAR 1997

40.1 The Development until May 1997

40.1.1 The Dismissal of Olof Forssberg

40.2 The First Exhibition in Stockholm in June 1997

40.2.1 Preparations

40.2.2 The Exhibition

40.3 The Development from July to December 1997

40.4 The Second Exhibition in Stockholm 1 to 14 December 1997

40.5 "Why did Estonia sink?" The engineer knows the answer. - Seminar organised by the Royal Technical University (KTH), Stockholm on 1.12.97

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

41.1 Differences in Structure and Findings

41.2 Differences in Methodology

41.3 Summary

PART D

2 THE VESSEL "VIKING SALLY"

THE JOINT ACCIDENT INVESTIGATION COMMISSION