The sinking of MS Estonia: Case Reopened Part VII

[Vixen]

Well, they don't expressly have to use some particular word to mean "accident." The problem with the newspaper account, however translated, is that there is no "setup" for a manual-only activated EPIRB. There is literally the battery-test button, and then there is literally the switch whose only function is to start the beacon transmitting. That switch is under a guard, since you get fined for setting it off in a non-emergency situation. It's as literal an on-off switch as there can possibly be.

It is clear from the various reports that the set up point was at the stage of placing the things in their brackets and making sure they are switched on.


So the set-up stage was where the buoys were activated for automatic readiness.

 

[MarkCorrigan]

It is clear from the various reports that the set up point was at the stage of placing the things in their brackets and making sure they are switched on.


So the set-up stage was where the buoys were activated for automatic readiness.

Nope. Still lying then.

 

[Jack by the hedge]

It is clear from the various reports that the set up point was at the stage of placing the things in their brackets and making sure they are switched on.

So the set-up stage was where the buoys were activated for automatic readiness.

How clear is that, though? Clear enough that anyone could, for example, describe the procedure unabmiguously enough that a user could follow the instructions? I think not.

 

[Here_to_learn]

It 'has to be assumed' because no-one knows what happened on that bridge.

No, it does not have to "be assumed". You have to be very clear on the distinction between known facts, conclusions that you can draw on those facts and assumptions.

If you present an assumption as if it was a fact, and then use that to pretend to draw further conclusions the value of those are small to none.

There are situations where you just have to say "we do not know". Especially if there are many possible actions that may lead to the same result.

For example when it comes to the use of the VHF to broadcast a Mayday. You may have bad quality in the transmission for many different reasons:

• You are broadcasting on a 25w fixed set, but the antennas are not vertical.
• You are broadcasting on a 5w handheld set over a longer distance
• There are physical objects between your antenna and the recipient, blocking the traffic
• The person broadcasting is not used to the specific set, and therefor is not holding the microphone at the proper distance from the mouth
• Noice levels around the person broadcasting is high
• Wind noice is disturbing the broadcast
• Multiple people are broadcasting from different sets, thereby stepping on each others

Those are just some of the reasons that I could come up with right out of my head, since I have experienced all of them. If you assume just one of them without facts you go wrong.

There was a violent list of 40° at 01:02 after which the vessel momentarily righted itself for no more than ten minutes,

Not according to JAIC. If you want to make your own timeline you have provide a source for it. The Timeline in the JAIC reports puts the list after 01:15.

yet there is no record of a mayday until 01:21:59 or so.

And we do not know why. Maybe nobody tried to send it earlier than that. Maybe the sets where out of commission after main power was out but before emergency power was restored. We just do not know.

We have a record because M/V Silja Europa started recording.

We have multiple recordings, but since the Europa was the closest recording to the source, they had the best quality. As expected for Marine VHF traffic. I experience it regularly when the coastal stations pick the wrong base station to broadcast on. Even though they have a lot of power, I still receive it badly, and have to tell them to switch to a base station closer to my location.

It is asumed Ainsalu and Tammes were on walkie talkies because Capt. Thörnroos (sorry, not 'Thoresson) had to set his radio receiver to the maximum 1 on VHF Channel 16, and also disputes the JAIC claim that all was well with reception.

No, it does not dispute it. If you broadcast with a handheld 5W device with a small antenna, of course the transmission will not be good over distance.

Further, the Rockwater divers found a GPS logbook, so there was GPS coordinates in the GDMSS system of M/V Estonia.

So the bridge had a log. Good for them, but of course completely normal. A log tells you where you have been, not where you are.

What other assumption can you make that given Tammes' shout that there was a 'blackout' and lack of any record of an earlier Mayday, the guys were having to use their walkie talkies and it was a wonder that anyone got the mayday at all?

The conclusion (not assumption ) is that there is no communication blackout, since we know we can listen to the recorded traffic.

According to the JAIC report the main engines failed at around 01:24, and after that the emergency genset took over. This would lead to blackout where a lot of equipment and lights would stop working.

 

[Here_to_learn]

You brag about being a master engineer, well, it is my turn to boast about being a 'master business strategist' (as per the blurb on the website ) and I can tell you that the cost of putting up a couple of EPIRB brackets on a passenger ship to comply with the 1988 IMO edict is not material and if it was - say, it brought down the profit margin - then that margin would simply be passed on to the passenger in what they pay for their tickets. Given at today's cost of circa €600 per EPIRB, I can't see it would cause any great disruption at all, certainly not at the level of having to redesign an entire bow visor and recall all such vessels for refitting.

For being a "master business strategist" you show an enormous lack of understanding when it comes to the cost of changes.

When changing a piece of technology often the smallest parts of the costs are the purchasing price. Examples of other things you need to take into account are:

• Re-writing the procedures for testing and maintenance based on the new model
• Train all persons involved from all different crews on the new procedures
• Perform testing to ensure that the procedures work
• Ensure the correct records that all stakeholders have been trained and have passed the relevant exams/certification needed
• Coordinate with rescue authorities to ensure that IDs of the new EPIRBS are correctly assigned to the right ship
• Set up a new maintenance schedule for when the new EPIRBS will need to be replaced, based on expected battery life
• Agree on the correct disposal method for the old EPIRBs so that a false alarm is not sent out

I'm sure we could keep populating this list with more things...

All this needs to be planned, and when you do that you assign a priority compared to all other things going on. An important factor will be - when does it need to be in place to ensure the certification of the ship.

 

[Andy_Ross]

It is clear from the various reports that the set up point was at the stage of placing the things in their brackets and making sure they are switched on.


So the set-up stage was where the buoys were activated for automatic readiness.

No, there's nothing for the end users to do other than test the battery.
They don't have any mechanism that needs to be 'activated for automatic readiness'
They didn't then and they don't now.

The one we own was taken from the box and put on the boat, that's it.
When the boat is laid up between trips one of us takes it home along with the other expensive electronics.
It's just put in a box.

When it goes back aboard we test the battery, there's nothing to set up, tune or activate.

They were the same in the 90s. That's the point, they are foolproof and always ready.

On manual models it relies on someone turning them on in an emergency.
People in emergencies where the ship is flooding and turning over tend to overlook things that appear less immediate than saving their lives .

In a lot of distress situations crews delay sending a mayday as they underestimate the imminent danger.
Look at rescue and sinking records, delay or failure to send a distress message until too late is a common thing.

 

[W.D.Clinger]

It's commendable that you looked this up but you will note that section 15.13 refers back to the issues discussed in section 11. If you look up section 11, this is wholly to do with the bow visors and its constituent parts.

Those were the specific issues discussed in section 15.13, but the report goes beyond those specific issues to state the more general problem:

Retroactive upgrading of existing ships through rules and regulations with retroactive effect has generally been considered unacceptable within the shipping industry and this attitude has been accepted within IMO as well as amongst classification societies.​

Nowhere do you cite 'documentation of the facts' that the EPIRB's were 'manually-activated-only' EPIRBS.

As has been cited and quoted repeatedly:

As noted in 8.11 the ESTONIA's emergency beacons (EPIRBs) were not switched on when put in their housings. The only reason that they were found switched off is that they were not properly activated.

The EPIRB beacons along with some liferafts and lifejackets were found on 2 October 1994 by two Estonian fishing vessels in the vicinity of Dirhami on the north coast of Estonia. The beacons were switched off when found.

On 28 December 1994 the condition of the above EPIRBs was tested by the Finnish experts. The radio beacons proved to be in full working order when switched on.

The ESTONIA carried two emergency beacons (EPIRBs) of type Kannad 406F.

The last check of the radio beacons was reported to have been made about one week prior to the accident by the radio operator. The check confirmed that the EPIRBs were in full working order.

As has been documented using sources other than the JAIC report, the Kannad 406F is a manually activated model, not a model whose beacon is activated automatically upon immersion.

In other words, I have to thank you for confirming that the claim there is 'documentation of the facts' that the M/V Estonia EPIRB's were 'manually-activated-only' was mere waffle, designed to bulldoze through blatant misinformation.

In the spirit of Vixen's expression of gratitude, I have to thank her for confirming her continuing ignorance and denials of facts documented within the JAIC report.

 

[JayUtah]

Your attempt to persuade us that the EPIRBS is a major restructure of an inherent part of the vessels structure is pure legerdemain.

This is my industry. I'm not debating you, I'm telling you why you're wrong.

Yes, in some cases refitting emergency beacons from radio equipment rooms to external location is required. But I don't claim this is true for MS Estonia, nor did I claim as much in my hypothetical. I merely explained this previously as one reason for grandfathering in general, for the benefit of those who don't build and operate ships. Stop flaying straw men.

You brag about being a master engineer, well, it is my turn to boast about being a 'master business strategist'...

Which holds about as much water as every other bogus claim to expertise you've made. You didn't address my point. You just dismissed it and repeated your naive belief.

 

[JayUtah]

'Face saving' would have been an payout with a NDA gag.

How little you know. That would be interpreted in the industry as an admission of wrongdoing. An engineering company's reputation is sacrosanct. Yes, they are entitled—nay, expected—to contest findings against them. That doesn't mean they're doing so with the aim of finding the truth. Instead their goal is to erode faith in the strength of the findings by whatever means. This is why you see them making assumptions, cherry-picking the facts, and omitting key principles that take an expert reader to put back.

Again, this is my industry. I'm not debating you, I'm telling you why you're wrong.

 

[JayUtah]

It is clear from the various reports...

No, it isn't. To be sure, the engineering reports are clear: the beacons didn't transmit because they weren't switched on. The secondary sources you insist on using vary in their use of language and choice of authority, and suggest things that aren't physically possible. Your "various reports" are actually tertiary sources that are unreliable on their face.

This is why you can't tell me who is the authority for the one sentence in the one article you're insisting must be some smoking gun: you don't know.

 

[Steve]

The irony, it burns.

Vixen, you're a liar. It's been demonstrated so many times now it's just sad.

But well over 30,000 posts! And people are still interacting with her, so her goals are being accomplished.

 

[JayUtah]

For being a "master business strategist" you show an enormous lack of understanding when it comes to the cost of changes.

Indeed, I'm relieved that Vixen isn't running my business.

I'm sure we could keep populating this list with more things...

A major amendment I would make is the re-inspection and re-certification of covered items by outside authority. Some of the things we build have to be assembled in cleanrooms. One of my cleanrooms is down. The building that houses our cleanrooms was damaged in an earthquake in 2019 and will be torn down later this year. I'm building out new clean rooms in a new building, but they're not finished. The lingering circumstances of our present space meant I needed to make architectural and engineering changes to one cleanroom, and these changes now must be inspected and certified by outside authority before I can use the room. That depends on the availability of the inspectors. My production capacity for those items is cut in half for the moment, meaning I'm losing revenue.

Would I have chosen to upgrade my cleanrooms at this time? No. It had to happen because of the deterioration of our building and a consequential safety concern. The actual repairs took only one day and cost less than $10,000. Just one of the products I build in it retails for $65,000 per unit, and I can typically make four of them per day per cleanroom. I would have preferred to schedule the repairs and recertification for a lull in demand, but here we are.

 

[Here_to_learn]

A major amendment I would make is the re-inspection and re-certification of covered items by outside authority.

Good point - that is an area where I only have limited experience.

On GMDSS certified rescue boats I've been involved with this was handled via self-certification. Although still quite some work to do, it's simpler compared to having to coordinate and work with external auditors.

 

[Vixen]

No, it does not have to "be assumed". You have to be very clear on the distinction between known facts, conclusions that you can draw on those facts and assumptions.

If you present an assumption as if it was a fact, and then use that to pretend to draw further conclusions the value of those are small to none.

There are situations where you just have to say "we do not know". Especially if there are many possible actions that may lead to the same result.

For example when it comes to the use of the VHF to broadcast a Mayday. You may have bad quality in the transmission for many different reasons:

• You are broadcasting on a 25w fixed set, but the antennas are not vertical.
• You are broadcasting on a 5w handheld set over a longer distance
• There are physical objects between your antenna and the recipient, blocking the traffic
• The person broadcasting is not used to the specific set, and therefor is not holding the microphone at the proper distance from the mouth
• Noice levels around the person broadcasting is high
• Wind noice is disturbing the broadcast
• Multiple people are broadcasting from different sets, thereby stepping on each others

Those are just some of the reasons that I could come up with right out of my head, since I have experienced all of them. If you assume just one of them without facts you go wrong.

Not according to JAIC. If you want to make your own timeline you have provide a source for it. The Timeline in the JAIC reports puts the list after 01:15.


And we do not know why. Maybe nobody tried to send it earlier than that. Maybe the sets where out of commission after main power was out but before emergency power was restored. We just do not know.

We have multiple recordings, but since the Europa was the closest recording to the source, they had the best quality. As expected for Marine VHF traffic. I experience it regularly when the coastal stations pick the wrong base station to broadcast on. Even though they have a lot of power, I still receive it badly, and have to tell them to switch to a base station closer to my location.

No, it does not dispute it. If you broadcast with a handheld 5W device with a small antenna, of course the transmission will not be good over distance.

So the bridge had a log. Good for them, but of course completely normal. A log tells you where you have been, not where you are.

The conclusion (not assumption ) is that there is no communication blackout, since we know we can listen to the recorded traffic.

According to the JAIC report the main engines failed at around 01:24, and after that the emergency genset took over. This would lead to blackout where a lot of equipment and lights would stop working.

Survivors report the list commenced at 01:00 and Mikael Oun's travel alarm clock is on display at a museum as having stopped at that time, when the list caused it to crash to the floor.

Capt Thornroos' account differs from the JAIC and the coast guards. He states:

Another matter is, I believe, worth mentioning and which should be remembered by you, who are investigating this here, it concerns the alerting. After they had called out the emergency messages it was only EUROPA and we who confirmed to them, and we really had big problems establishing contact with the coastal stations. It is not as they told the media that they picked up the emergency messages. They did not do that. They did not do that before we called them over mobile phone. EUROPA phoned Turku by mobile phone and we phoned Helsinki by mobile phone. After they had sent out the emergency messages it was just EUROPA and we who replied to them.

A: Does this mean that the Rescue Services ashore never confirmed the receipt?

T: They never confirmed anything.

A: Not the receipt of the messages?

T: No, they never did so before we stirred them up by mobile phone. At first we didn't even know whom to call.

We tried at once after he had received the information from ESTONIA about her position and so on, and after the contact was interrupted we both tried, we and EUROPA, to contact MRCC and Helsinki Radio, Mariehamn radio. At first over VHF Channel 16, the emergency channel. No reaction at all. Nobody was listening in and not even in Stockholm. So we changed over to 2182, which covers the whole Baltic Sea, and were calling and calling. No contact whatsoever. The only thing we heard was somebody else calling. He spoke to EUROPA thereafter. He heard that we were calling and we heard that he was calling, but there was no reaction from ashore.

A: That means in summary that ESTONIA was sending a Mayday which was immediately only received by MARIELLA and EUROPA. It was just you two confirming receipt?

T: Yes, that was, in any event, what we heard.

A: You then tried to contact the Rescue Services?

T: Yes.

A: Both in Finland and in Sweden.

T: Yes.

A: And you did not get any reply?

T: No.

EFD


He put his radio receiver on 1 to block out the interference.

 

[JayUtah]

On GMDSS certified rescue boats I've been involved with this was handled via self-certification. Although still quite some work to do, it's simpler compared to having to coordinate and work with external auditors.

Self-certification remains an option for some things, subject to review in a yearly audit. But this is less acceptable in the wake of the Boeing 737 MAX fiasco. And some things remain subject to outside review. EPIRBs on passenger vessels are not likely to be one of those things—it's not as if the ship won't be allowed to sail with passengers until an inspector verifies that EPIRBs and the attendant processes and training are up to scratch. The point remains something we agree on fully: Vixen's conspiracy theory is ignorant of the actual costs of change.

As you point out, we draw a bright line between the category of things we must do in order to remain in compliance and things we know we can put off if needed. The items above that line are categorically different than the others: if we don't do them, we're out of business. Those take absolute priority. Things below the line are subject to cost-benefit analysis.

Ignoring the lessons of hindsight, upgrading EPIRBs to meet regulations not yet in force for your safety certificate falls fairly low on the cost-benefit analysis. You already have EPIRBs. They work. Your crew knows how to operate them. There would be a marginal increase in safety by having them be activated automatically. But the EPIRB is already considered a secondary, redundant signaling mechanism, so it makes business sense not to upgrade them.

However, as is frequently the case in post-accident analysis, the assumptions that held in the prior cost-benefit analysis did not hold for the accident scenario. The primary distress signalling was hampered, and it was shown that the secondary methods relied too heavily on operator action.

 

[JayUtah]

Capt Thornroos' account differs from the JAIC and the coast guards. He states:

EFD

Which is why his minority opinion is being emphasized by the team tasked with casting doubt on the JAIC report.

 

[Vixen]

For being a "master business strategist" you show an enormous lack of understanding when it comes to the cost of changes.

When changing a piece of technology often the smallest parts of the costs are the purchasing price. Examples of other things you need to take into account are:

• Re-writing the procedures for testing and maintenance based on the new model
• Train all persons involved from all different crews on the new procedures
• Perform testing to ensure that the procedures work
• Ensure the correct records that all stakeholders have been trained and have passed the relevant exams/certification needed
• Coordinate with rescue authorities to ensure that IDs of the new EPIRBS are correctly assigned to the right ship
• Set up a new maintenance schedule for when the new EPIRBS will need to be replaced, based on expected battery life
• Agree on the correct disposal method for the old EPIRBs so that a false alarm is not sent out

I'm sure we could keep populating this list with more things...

All this needs to be planned, and when you do that you assign a priority compared to all other things going on. An important factor will be - when does it need to be in place to ensure the certification of the ship.

Planning and implementation takes time, of course. However, if you are running one of these cruise ferries, then your business model will be passenger safety - there are families with very small children travelling on these boats - and economy. If a short 45 minute airflight will get you to Stockholm or Helsinki, Tallinn or Turku, you will need to attract custom to overnight or daytime ferries by offering cheap tickets (often as little as €15) plenty of entertainment, duty free shops and a bed for the night. It is also traditional for 'broke' students or work groups who want a good place for a conference.

After the 1986 Herald of Free Enterprise disaster that led to the public inquiry 1987 and the IMO CHAPTER III amendment 1988 re free-floating automatic EPIRB's becoming compulsory for all passenger ships by August 1993, the latest (a whole SIX years to 1994) then it would a matter of gross criminal negligence to not to have complied with this relatively cheap installment.

That is why I am confident that M/V Estonia was compliant. I have travelled on these ferries several times. They are not perfect but they are receptive to the needs of passengers, especially in respect of safety.

 

[JayUtah]

On manual models it relies on someone turning them on in an emergency.

And this was considered reasonably acceptable for the vessel type at the time. EPIRBs are secondary distress signals for large vessels that are presumed to have a large, well-trained crew and will have at least several minutes' survivability in the case of accident. Further, such vessels are not considered as susceptible to foundering as smaller vessels, and so the scope of accident contemplated for both primary and secondary distress signalling does not involve immersion.

People in emergencies where the ship is flooding and turning over tend to overlook things that appear less immediate than saving their lives.

This is why training is emphasized by designers and regulators, but often skimped on by operators. We rely heavily on rote checklists and second-nature behavior that can be addressed only by rigorous testing that translates into operational overhead for an operator. But to the point, we have seen on a number of occasions that the crews of ships are susceptible to "survival mode" when faced with actual emergencies.

In a lot of distress situations crews delay sending a mayday as they underestimate the imminent danger.
Look at rescue and sinking records, delay or failure to send a distress message until too late is a common thing.

The phenomenon of de minimis reasoning in an emergency is something I covered in the classes I taught. Case studies include Three Mile Island and Apollo 13.

There is also the issue that you can't recall a mayday. This is why the initial distress call in many contexts is often pan-pan. You can always upgrade a pan-pan to a mayday, or you can also withdraw a pan-pan. But once you say mayday, rescue efforts are set in motion. Since operators can be fined for improper use of distress calls, there is some reticence among operators to signal one until it's painfully evident that it's needed.

There is another paradoxical phenomenon associated with redundancy: initially it tends to be less reliable than singular solutions. Absent training and specific, pedantic requirements, redundancy can offer a false sense of security. In this case, operators may believe they don't need to operate the EPIRBs because the distress call was made by the primary method. Or one operator may believe the other one turned on the EPIRBs. This is one of the things we look for in accident analysis.

Rescinding the exemption for vessels under the 1974 SOLAS certificate puts the redundancy where it should be, and where it's less susceptible to the redundancy paradox.

 

[Andy_Ross]

Planning and implementation takes time, of course. However, if you are running one of these cruise ferries, then your business model will be passenger safety - there are families with very small children travelling on these boats - and economy. If a short 45 minute airflight will get you to Stockholm or Helsinki, Tallinn or Turku, you will need to attract custom to overnight or daytime ferries by offering cheap tickets (often as little as €15) plenty of entertainment, duty free shops and a bed for the night. It is also traditional for 'broke' students or work groups who want a good place for a conference.

After the 1986 Herald of Free Enterprise disaster that led to the public inquiry 1987 and the IMO CHAPTER III amendment 1988 re free-floating automatic EPIRB's becoming compulsory for all passenger ships by August 1993, the latest (a whole SIX years to 1994) then it would a matter of gross criminal negligence to not to have complied with this relatively cheap installment.

That is why I am confident that M/V Estonia was compliant. I have travelled on these ferries several times. They are not perfect but they are receptive to the needs of passengers, especially in respect of safety.

The beacons were recovered. They were manual activation only.
They worked as they should when tested.

 

[JayUtah]

However, if you are running one of these cruise ferries, then your business model will be passenger safety...

And if you knew anything about this industry then your opinion would matter.

You positioned yourself as a "master business strategist," but you're just as patently ignorant of those principles as you are of every other field in which you've claimed expertise. You have a child's understanding of what it actually takes to run a regulated business.

Armchair detectives are worse than useless.

After the 1986 Herald of Free Enterprise disaster that led to the public inquiry 1987 and the IMO CHAPTER III amendment 1988 re free-floating automatic EPIRB's...

Asked and answered. For someone claiming to be a brilliant business analyst, you can't seem to read regulations very well.

That is why I am confident that M/V Estonia was compliant.

It was compliant. You just don't know what that means, and it seems you're alone in that ignorance.