The MS Estonia was a cruise ferry built in 1980 at a Germanshipyard, with almost 15 years of successful ferrying service forfour different owners and operators. The ferry was sold toNordström & Thulin on the Estline’s Tallinn–Stockholm route in1993. The MS Estonia consisted of 11 decks. Passenger facilitieswere located on decks one, four, five and six, while the crewmembers occupied decks seven and eight. Decks two and three werededicated to the respective cargo. The MS Estonia was also a carferry with large external doors close to the waterline. Theseferries with open vehicle decks with few internal bulkheads have areputation for being a high-risk design. An improperly securedloading door can cause a ship to take on water and sink, whichhappened in 1987 with the MS Herald of Free Enterprise. Watersloshing on the vehicle deck can set up a free surface effect,making the ship unstable and causing it to capsize. On 28 September1994, in the Baltic Sea, the MS Estonia sank off Finland’s coastand was recorded as one of the worst maritime disasters of the 20thcentury, claiming 852 lives of the 989 passengers and crew onboard. Headline news worldwide reported the massive loss of life;only 137 people survived. Free surface water on the vehicle deckwas determined to contribute to the sinking of MS Estonia.According to the official report, the bow door had separated fromthe vessel, pulling the ramp used to upload and download vehiclesajar. In addition, the ship also started listing/tilting because ofpoor cargo distribution. The ship rapidly took on water and startedto tilt to one side due to the damaged/open bow door, causing theflooding of other decks and the cabins. Following the flooding, thepower failed altogether, inhibiting rescue efforts and caused thata full-scale emergency was only declared after 90 minutes. Thisalso initiated criticism regarding the passive attitude of thecrew, who failed to notice that water was entering the vehicledeck, which delayed the alarm and caused a shortcoming in providingguidance from the bridge during the Instructions: Consider the casestudy and answer ALL the questions related to the case study. 2emergency. It seems as if the responsible crew were not adequatelytrained to sound the alarm during emergencies. There was a generallack of standing operating procedures when a problem wasencountered with the bow door. In addition, the loading crew failedto identify the incorrect loading of vehicles which caused the shipto list/tilt over. However, there were also other factors involvedthat should have been considered and which contributed directly orindirectly to the disaster. The MS Estonia disaster occurred onWednesday, 28 September 1994, between 00:55 and 01:50 (UTC+2) asthe ship was sailing across the Baltic Sea from Tallinn toStockholm, Sweden. The ship departed behind schedule at 19:15 on 27September and was expected to doc in Stockholm on 28 September at09:00. The ship was fully loaded and was listing slightly tostarboard because of poor cargo distribution. The captain failed tonotice or question to determine possible consequences andcorrective actions. According to the final disaster report, theweather was rough, with a wind of 15 to 20 metres per second (29 to39 knots [kn]; 34 to 45 mph) and a force of 7 to 8 on the Beaufortscale. There was also a significant wave height of 4 to 6 metres(13 to 20 ft) compared with the highest measured significant waveheight in the Baltic Sea of 7.7 metres (25.3 ft). The norm is thatships will only set sail when the waves are between 3 to 4 metres.Five metres and above is risky. The Captain of Silja Europa,appointed on-scene commander for the subsequent rescue effort,described the weather as “normally bad” or a typical autumn stormin the Baltic Sea. According to modelled satellite data, gusts werein excess of between 85 kilometres per hour (53 mph) to 100kilometres per hour (62 mph) at 01:00 that night over the BalticSea. However, the ship had not yet reached the areas with theheaviest gusts before its sinking. There was some rain andtemperatures around 10 °C (50 °F). The monitoring and theforecasting (by the weather bureau – which was ignored by thecaptain) of the height of the swells/waves on the sea on 27/28September 1994 is indicated in table 1. 3 Table 1: Height ofswells/waves Time: 27/28 September 1994 15:00 16:00 17:00 18
00 20:00 21:00 22:00 23:00 00:00 01:00 02:00 03:00 04:00 05:00Height of the swells in metres 2 m 3 m 4 m 5 m 6 m 6 m 7 m 7 m 8 m8 m 8 m 7 m 6 m 6 m 6 m Source: Fictitious data A safe height ofthe swells for a passenger liner is 2 to 3 metres. If the swellsare 4 to 5 metres, it becomes risky and higher than 6 metresbecomes dangerous for passenger ships. However, despite the 6-metreswells, the captain decided to depart at 19:15. The first sign oftrouble aboard the MS Estonia was when a loud metallic sound washeard, presumably caused by a heavy wave hitting the bow doorsaround 01:00, when the ship was on the outskirts of the Turkuarchipelago. However, an inspection, which was limited to checkingthe ramp and bow door indicator lights, showed no problems. Itseems the responsible crew did not perform a physical inspection ofthe bow doors. Over the next 10 minutes, similar noises werereported by passengers and other crew members. At about 01:15, thebow doors are believed to have separated and torn open the loadingramp behind them. The ship immediately took on a heavy starboardlist (initially around 15 degrees, but by 01:30, the ship hadrolled 60 degrees, and by 01:50, the list was 90 degrees) as waterflooded into the vehicle deck. The captain subsequently ordered theship to turn to port, but it slowed down before her four enginesceased completely. At about 01:20, a quiet female voice called“häire, häire, laeval on häire”, Estonian for “alarm, alarm, thereis an alarm on the ship” over the public address system, which wasfollowed immediately by an internal alarm for the crew, then oneminute later by the general emergency signal. The vessel’s rapidlist and the flooding prevented many people in the cabins fromascending to the boat deck, as water flooded the vessel via the cardeck and through windows in cabins and the massive windows alongdeck six. The windows gave way to the powerful waves as the shiplisted/tilted and the sea reached the upper decks. Survivorsreported that water flowed down from ceiling panels, stairwells andalong corridors from decks that were not yet underwater. Thiscontributed to the rapid sinking. A mayday was communicated by theship’s crew at 4 01:22 but did not follow international formats.The MS Estonia directed a call to Silja Europa, and only aftermaking contact with her did the radio operator utter the word“mayday”. The radio operator on Silja Europa, chief mate TeijoSeppelin, replied in English: “Estonia, are you calling mayday?”After that, the voice of the third mate took over on the MSEstonia, and the conversation shifted to “Finnish”. At first, thereseemed to be a language problem, but the third mate was able toprovide some details about their situation. However, due to a lossof power, he could not give their position, which delayed rescueoperations. Some minutes later, power returned (or somebody on thebridge managed to lower himself to the starboard side of the bridgeto check the marine GPS, which will display the ship’s positioneven in blackout conditions), and the MS Estonia was able to radioits position to Silja Europa and Mariella. The ship disappearedfrom the radar screens of other ships at around 01:50 and sank at59°23′N 21°42′E in international waters, about 22 nautical miles(41 km; 25 mi) on bearing 157° from Utö island, Finland, to thedepth of 74 to 85 metres (243 to 279 ft) of water. According tosurvivor accounts, the ship sank stern first after taking alist/tilt of 90 degrees. Search and rescue followed arrangementsset up under the 1979 International Convention on Maritime Searchand Rescue (the SAR Convention). The nearest Maritime RescueCo-ordination Centre, MRCC Turku, coordinated the effort inaccordance with Finland’s plans. The Baltic is one of the world’sbusiest shipping areas, with 2,000 vessels at sea at any time, andthese plans assumed the ship’s own boats and nearby ferries wouldprovide immediate help and that helicopters could be airborne afteran hour. This scheme had worked for the relatively small number ofaccidents involving the sinking of vessels, particularly as mostships have few people on board. A full-scale emergency was onlydeclared at 02:30. Ships rescued 34 people and helicopters 104; theferries played a much smaller part than the planners had intendedbecause it was too dangerous to launch their man-overboard (MOB)boats or lifeboats. Most passengers died from drowning andhypothermia, as the water temperature was 10 to 11 °C/50 to 52 °F.About 650 people were still inside the ship when it sank. It wasestimated that up to 310 passengers reached the outer decks, 160 ofwhom boarded the life-rafts or lifeboats. 5 The official reportindicated that the locks on the bow door had failed from the strainof the waves, and the door had separated from the rest of thevessel, pulling the ramp behind it ajar. The bow visor and ramp hadbeen torn off at points that would not trigger an “open” or“unlatched” warning on the bridge, as is the case in normaloperation or failure of the latches. The bridge was also situatedtoo far back on the ferry for the visor to be seen from there.While there was video monitoring of the inner ramp, the monitor onthe bridge was not visible from the conning station. The bow visorwas under-designed, as the ship’s manufacturing and approvalprocesses did not consider the visor and its attachments ascritical items regarding ship safety. The first metallic sound wasbelieved to have been that of the visor’s lower locking mechanismfailing and that the subsequent noises would have been from thevisor “flapping” against the hull as the other locks failed beforetearing free and exposing the bow ramp. The subsequent failure ofthe bow ramp allowed water into the vehicle deck, which wasidentified as the leading cause of the capsizing and sinking of theship. An incident report was critical of the crew’s actions,particularly for failing to reduce speed before investigating thenoises emanating from the bow and being unaware that the list wasbeing caused by water entering the vehicle deck. There were alsogeneral criticisms of the delays in sounding the alarm, thepassivity of the crew, and the lack of guidance from the bridge.The sinking of the MS Estonia remains the worst European peacetimemaritime disaster and the second-worst maritime disaster involvinga European-made boat since the Titanic. Due to the costs andcomplex logistics involved with raising such a large vessel, the MSEstonia has been declared a memorial site. Further exploration ofthe wreck was prohibited (a treaty was declared in 1994). Thisresulted in a lot of rumours and conspiracy theories circulating.In 2020, a Swedish TV channel released a documentary indicating alarge hole in the hull due to a collision. The Estonia governmentannounced on 28 September 2020 that a new “technical investigation”will be undertaken to investigate the disaster. Survivors of thedisaster and the relatives of those who died have petitioned formore than 20 years to re-open and expand the investigation into thedisaster. 6 For training purposes, some fictitious information isincluded in the case study. Analyse the case study and answer therelated questions below.Question 2
Discuss in detail four reputational risks that resulted from thesinking of the MS Estonia.