PREFACE
The Joint Accident Investigation Commission has concluded its investigation of the foundering of the MV ESTONIA, a disaster that has taken the greatest toll of human life in the Baltic Sea in times of peace.
The Commission has thoroughly considered all available information directly related to the accident and the rescue operation. The information includes documents and statements regarding the ship and its operation, witness statements, analysis of the prevailing weather and sea conditions, results from diving investigations and analysis of the recovered bow visor. In addition, to reach a full understanding of the sequence of events, the Commission has initiated theoretical and experimental studies to analyse in more detail the vessel's wave-induced motion and loads, structural strength, manoeuvring characteristics and stability when flooded. The Commission has furthermore found it necessary to investigate the design procedures and operating history of the vessel as well as to collect information on other bow visor failure incidents and to consider legal and administrative issues.
This final report covers all factors and circumstances considered to have contributed to the development and outcome of the accident. In the report the Commission presents the facts found, the analysis and evaluation, conclusions drawn on the basis of the work and the recommendations made to help prevent the occurrence of similar accidents in the future. The fundamental purpose of investigating the accident was to determine its circumstances and causes, with the aim of improving the safety of life at sea and avoiding further accidents. It is not the Commission's task to apportion liability nor, except so far as is necessary to achieve the fundamental purpose, to apportion blame.