CHAPTER 4 OPERATIONS ON BOARD

The work schedule for the crew of the ESTONIA was in general two weeks' service on board, followed by two weeks ashore. Consequently two full crews were employed alternately and all positions on board were held by two persons.
In the deck department there were, besides the master, five deck officers, one radio officer and eight ratings. Organisationally the ship's doctor was also a member of the deck crew. The engine department consisted of eight engineers and eight ratings. In the catering department there were eight positions with officer's status and 113 other staff.

Prior to departure on 27 September 1994 a crew list of 186 people was presented to the Tallinn harbour master. Of these 149 comprised the actual crew, which was into the 13th day of its current 14-day duty period. In addition the list contained 6 trainees, 18 entertainers, 9 advisors and 4 crew members of the alternate crew. One of them was the master of the alternate crew, aboard for examination for his pilot exemption certificate.
All members of the actual crew were employed by the Estonian Shipping Company (ESCO). When senior officers were to be employed, Nordström & Thulin was consulted in compliance with the contract on technical management.
Nine advisors (one master mariner with pilot exemption certificate for the two fairways used in the Stockholm archipelago, one advisor with knowledge of the ship's computer systems and seven with long experience of catering in Baltic ferry traffic) were all employed by the Swedish manning company Rederi AB Hornet. Before employment, catering personnel were recommended by Estline and the pilot and the computer specialist by Nordström & Thulin.
All the deck officers and most of the crew were Estonian citizens. The working language on board was Estonian, and that language was understood by all crew members.
All crew members held certificates required for their positions on board.

4.2.2 Qualifications of the deck officers and the deck crew

The deck officers on board Estonian vessels - as well as on Swedish and Finnish - are called chief officer, second officer, third officer and fourth officer. The ESTONIA had two second officers, here designated second officer A and second officer B.

The master

The master was born in 1954. He graduated at the Maritime School of Tallinn in 1973 and started his career at sea in 1974 (The Maritime School of Tallinn together with the Tallinn Fisheries Maritime School merged to form the Estonian Centre of Maritime Education which was established on 1 January 1992 and is the highest maritime academy in Estonia). He served as fourth and third officer until 1977. He studied at the Admiral Makarov Highest Engineering Maritime Academy in Leningrad from 1977 to 1982 (Leningrad changed name to St. Petersburg in November 1991). He subsequently served as second and then chief officer until 1986, when he got his master mariner's licence, and his first command as master on general cargo ships in transocean traffic.
In 1992 he became master of the passenger ship GEORG OTS on the rou-te between Tallinn and Helsinki. When the ESTONIA was bought, he was appointed first captain. He was from the start involved in the transfer of the ship and development of the organisation on board. After Estonia's re-independence and the creation of the new Estonian Maritime Administration, he received in 1994 the first master mariner's certificate issued in Estonia.
He held radiotelephone operator's general certificate, Automatic Radar Plotting Aid (ARPA) certificate and a pilot exemption certificate for the fairway via Sandhamn through the Stockholm Archipelago. He had just before the accident passed his examination for the fairway via Söderarm.
In addition to his formal licence, he had taken relevant courses in, among other areas “Passage planning in narrow waters”.
Apart from his native Estonian, he was able to communicate in Swedish, English, Finnish and Russian.

The chief officer

The chief officer was born in 1964. He graduated at the Admiral Makarov Highest Engineering Maritime Academy in Leningrad in 1988. He held a chief officer's unlimited licence. He had served as third officer on general cargo ships 1988-1990 and was third and then second officer on the GEORG OTS 1990-1992. In January 1993 he was appointed second officer on the ESTONIA, and in August 1994 was promoted to chief officer.
He also held radiotelephone operator's general certificate and ARPA certificate. He had taken additional courses in, among other subjects, “Passage planning” and “Bridge Resource Management”.

The second officer A

Second officer A was born in 1963. He graduated at the Maritime School of Tallinn in 1988. He held an officer-of-the-watch licence, issued in Leningrad in 1988. He served as third officer on ro-ro vessels between 1988-1992. In 1992 he became second officer on the GEORG OTS. From 1993 he was appointed second officer on the ESTONIA.
He held radiotelephone operator's general certificate and ARPA certificate. He had also taken additional courses in “Passage planning” and other subjects.

The second officer B

Second officer B was born in 1964. He held a chief officer's unlimited licence, issued in Tallinn in 1994. He graduated at the Admiral Makarov Highest Engineering Maritime Academy in Leningrad in 1991. In 1992 he was second officer on the GEORG OTS and from 1993 held the same position on the ESTONIA.
He held radiotelephone operator's general certificate and ARPA certificate. He had also taken additional courses in “Passage planning” and other subjects.

The third officer

The third officer was born in 1966. He graduated at the Maritime School of Tallinn in 1988 and at the Kotka Maritime College, Finland, in 1992. He held an officer-of-the-watch licence, issued in Helsinki in 1992. He was appointed fourth officer on the ESTONIA in 1993 and in 1994 promoted to third officer.
He held a radiotelephone operator's general certificate, issued in Helsinki in 1992. He also held an ARPA certificate, and had taken additional courses in among other things “Passage planning”.

The fourth officer

The fourth officer was born in 1973. He graduated at the Estonian Centre of Maritime Education in Tallinn in 1992. He held an officer-of-the-watch licence, issued in Tallinn in 1994. In 1993 he was appointed quartermaster on the ESTONIA, and in 1994 he was promoted to fourth officer.

The radio officer

The radio officer was born in 1941. He graduated as ship's radio operator and radio navigator at Tallinn Technical School No. 1. in 1962 and at the Tallinn Fisheries Maritime School in 1986. He held a first-class radio operator certificate, issued in Leningrad in 1974. He had served as radio officer in cargo ships 1962-1993. In March 1993 he was appointed radio officer on the ESTONIA.

The deck ratings

The boatswains and all the able seamen had attended the general ship safety course on the training vessels ARZAMASS or KORALL.
The AB seaman of the watch during the critical hours of the accident was born in 1970. He was employed by ESCO in January 1993. Before serving on the ESTONIA, he had worked on board the ro-ro ferry TRANSESTONIA and on the GEORG OTS.

4.2.3 Qualifications of the engineers and the engine crew

The engine officers on board Estonian vessels - as well as on Swedish and Finnish - are called chief engineer, first engineer, second engineer and third engineer.

The chief engineer

The chief engineer was born in 1950. He graduated at the Maritime School of Tallinn in 1972 and at the Admiral Makarov Highest Engineering Academy in Leningrad in 1989. He held a chief engineer's unlimited licence, issued in Tallinn in 1994. From 1972 until 1990 he worked as third, second and chief engineer in different vessels. He served as chief engineer on the ro-ro ferry TRANSESTONIA and on the motor vessel SAINT PATRICK II 1990-1993. From February 1993 he was chief engineer on the ESTONIA.

The first engineer

The first engineer was born in 1952. He graduated at the Admiral Makarov Highest Engineering Academy in Leningrad in 1976. He held a first engineer's certificate, issued in Leningrad in 1976. He also held a certificate from the Advanced Training Course in Leningrad in 1990.
He worked as fourth, third and second engineer in various vessels 1976-1992. In January 1993 he was appointed second engineer on the ESTONIA and in June 1993 promoted to first engineer.

The second engineer

The second engineer was born in 1947. He graduated at the Maritime School of Tallinn in 1968 and at the Admiral Makarov Highest Engineering Academy in Leningrad in 1981. He held a second engineer's certificate, issued in Leningrad in 1972.
He served as third and second engineer on various vessels 1968-1981, and between 1982 and 1992 he was third engineer on a ro-ro vessel. In January 1993 he was appointed second engineer on the ESTONIA.

The third engineer

The third engineer was born in 1964. He graduated at the Admiral Makarov Highest Engineering Academy in Leningrad in 1990. He held a third engineer's certificate, issued in Leningrad in 1990.
He served as fourth and third engineer on different vessels 1990-1993. In July 1993 he was appointed fourth engineer on the ESTONIA and in September 1994 he was promoted to third engineer

The fourth engineer

The fourth engineer was born in 1966. He graduated at the Maritime School of Tallinn in 1986. He held a third engineer's certificate issued in Leningrad in 1986.
He served as motorman and fourth engineer in cargo ships 1989-1993. In 1994 he was appointed motorman on the ESTONIA and from September he was promoted to fourth engineer.

The electrical engineer

The electrical engineer was born in 1951. He graduated at the Admiral Makarov Highest Engineering Academy in Leningrad in 1974. He held a first-class electrical engineer's licence, issued in 1984.
Since 1977 he had worked on board different types of ship as electrical engineer. In January 1993 he was appointed electrical engineer on the ESTONIA.

The refrigeration engineer

The refrigeration engineer was born in 1959. He graduated at the Tallinn Fisheries Maritime School in 1978. He held a refrigeration engineer's certificate, issued in Tallinn in 1992.
He worked as refrigeration engineer in a fishing company 1978-1992. In January 1993 he was appointed refrigeration engineer on the ESTONIA.

The systems engineer

The systems engineer was born in 1969. He graduated at the Maritime School of Tallinn in 1991. He held a third engineer's certificate issued in Leningrad 1991. He held positions as fourth engineer 1991-1992. In January 1993 he was appointed systems engineer on the ESTONIA.

The engine ratings

There were eight ratings in the engine department: four senior motormen, two electricians, one welder and one turner. All had passed the general ship safety course on the training vessels ARZAMASS or KORALL.

4.2.4 The catering crew

The highest-ranking officer of the catering crew was the chief purser (sometimes called hotel purser). He was born in 1965. He had been employed by the ESCO since 1985. He had passed the general ship safety course.
The professional qualifications of the catering crew have no relevance for the accident. The only aspect for the investigation is their role in the ship's safety organisation.

The master was responsible for all activities on board the vessel. He reported to the ESCO on all matters regarding navigation, day-to-day operation, personnel and related issues. In technical matters, he reported to Nordström & Thulin.
The master in command on the accident night was the Number 1 master of the ESTONIA, and it was he who, together with his superiors at the office, laid down rules and routines for work on board. According to standing orders laid down by him the various responsibilities and duties, in addition to normal watch duties, were divided between the deck officers as described below.
The chief officer had the responsibility for cargo operations and the planning of these. He was also responsible for the daily work of the deck crew.
The second officer A was responsible for the navigation equipment, and also assisted the chief officer with cargo operations. He led the port lifeboat group and was responsible for associated life-saving equipment.
The second officer B was responsible for stability calculations prior to departure, and assisted the chief officer with the cargo operations. He also led the starboard lifeboat group and was responsible for associated life-saving equipment.
The third officer was in charge of nautical charts and literature, and was also responsible for the calibration of all clocks on board.
The fourth officer was responsible for keeping the log of the working hours of the deck crew, and for keeping lists of certificates of competence and passports for the deck crew. He was also responsible for cargo declarations to the harbour authorities, and for the documentation of cargo operations.
The radio officer was responsible for the radio, including the emergency beacons (EPIRBs), and communication equipment, and in co-operation with the second officer A for the maintenance of the electronic navigation equipment. He was also responsible for making and updating crew lists. The ESTONIA was certified for pre-GMDSS operation (7.3.1), and consequently the radio officer had to keep watch on 500 kHz and 2182 kHz. The watch hours at sea were from 1900 hrs to 0100 hrs.
When the vessel was at sea, there were always two officers and one AB seaman on duty.
On westbound voyages, the second officer B was on duty between 2000 hrs and 0100 hrs assisted by the third officer, and the second officer A was on duty between 0100 hrs and 0600 hrs, assisted by the fourth officer. For the periods between departure and 2000 hrs and between 0600 hrs and arrival, the bridge watch was taken by the master and the chief officer.
During the sea voyage, the AB seamen changed watches at 2200, 0200 and 0600 hrs. Their duties at sea were to be additional lookouts and to make watch rounds on a defined route throughout the vessel (Supplement). These rounds were made once every hour, starting at 2030 hrs, and lasted for about 25 minutes.
Watch rounds were also made by the security guards. They had no other duties than to ascertain the safety and security of the vessel and the passengers, and they patrolled continuously.

4.3.2 Engine department

The chief engineer was responsible for the organisation and all work in the engine department, for the purchase and storage of spare parts and consumables, and for the technical maintenance of the entire vessel. He reported to the technical superintendent of Nordström & Thulin, and certain parts of these reports were copied to ESCO.
The first engineer was responsible for the maintenance and running of the main engines and the propulsion system.
The second engineer was in charge of the separators, the steering gear and all other hydraulic and pneumatic systems, including the systems for manoeuvring and locking the visor, the ramps and the hull doors.
The third engineer was in charge of the compressors, the bunkering of the vessel, and of the electrical generator sets, including the emergency generator.
The fourth engineer was in charge of boilers, deck machinery and lifeboat engines.
The systems engineer was in charge of the fresh water distribution systems, the sewage system and the galley equipment.
The refrigeration engineer was in charge of the air conditioning plant and the refrigerating plant for store-rooms.
The electrical engineer was in charge of all electrical systems and installations.
The work schedule in the engine department was a traditional three-watch system. On each watch there were one engineer and one motorman.
The 1200-1600 hrs and 2400-0400 hrs watches were held by the third engineer, the 0400-0800 hrs and 1600-2000 hrs by the second engineer and the 0800-1200 hrs and 2000-2400 hrs by the fourth engineer.

4.3.3 Catering department

The total number of persons employed in the catering department was 121.
Many of them spoke two or more languages. In addition to Estonian, English was compulsory for all persons in positions involving work contact with passengers.
The catering department was managed by the chief purser, who was responsible for the organisation and conduct of the work. He was also responsible for the commercial result of the department. Regarding personnel, maintenance and other operational matters, he reported to ESCO, via the master. His economic reporting was to Estline in Stockholm.
The catering department consisted of five sub-departments with their own managers. The sub-departments were the hotel department including the information desk, the galley, the restaurant department including the conference department, the tax-free shops and the automatic data processing (ADP) administration. The security guards were administrated by the hotel department, but they reported direct to the master.
The chef, the restaurant manager, the shop manager, the ADP administrator and the conference purser were employed on behalf of Nordström & Thulin in accordance with the agreement on ship management between the parties involved. They were formally employed as advisors and were consequently not part of the crew. However, they acted in all aspects as responsible work leaders for their departments. Since they were not crew members, they were not included in the safety organisation of the vessel.
The catering department working hours were adapted to the opening hours of the various restaurants, bars and shops. The information desk was manned 24 hours a day and, during the busy periods 0900-1100 hrs and 1700-2200 hrs, by two pursers.

When the operation of the ESTONIA was taken over by ESCO in 1992, a new safety organisation was established. The new organisation was based partly on the previous owner's organisation plan, and partly on the experience of Nordström & Thulin from their previous vessel on the same route.
All documents, plans and manuals included in the safety system were in both Estonian and English, and the safety organisation was implemented at all crew levels prior to commencement of traffic. The safety organisation was tested during the port state control in February 1993 (see 3.2.10).
The safety organisation and the training and implementation thereof were described in the emergency plan, the safety manual and the training manual.

4.4.2 Alarm signals

Various types of alarm were used on board the ESTONIA. The lifeboat alarm and fire alarm were general alarms, addressed to passengers and crew. Besides these there was a coded alarm “Mr Skylight” addressed only to the crew and intended to alert relevant parts of the safety organisation.
The alarms were described in the emergency plan and in the safety manual, available at various locations in the crew accommodation such as mess rooms, day rooms and all major workplaces.

Lifeboat alarm

The lifeboat alarm - seven short sound signals, followed by one long one - was given repetitively with the alarm bells and/or the vessel's horn. When the alarm was given, the command group, the port and starboard boat groups, the engine control group and the eleven evacuation groups were alerted.

Fire alarm

The fire alarm - continuous repetitive short sound signals - was also given with the alarm bells and/or the vessel's horn. When the alarm was given, the command group, the two fire groups, the engine control group, the control group, the port and starboard boat groups and the first aid group were activated.

“Mr Skylight”

Without alarming the passengers, the crew could be alerted over the public address system with the coded message “Mr Skylight”. This message could also be used with a suffix. Depending on which suffix was used, selected parts of the safety organisation were activated. The boat groups were activated by all Skylight messages.

4.4.3 Alarm groups

The safety organisation was led by a command group mustering on the bridge. The command group consisted of the master, the chief engineer, the chief officer, the chief purser and the third officer.
The master was the overall commander of the operations. The chief engineer was the fire chief, commanding the two fire groups and the engine control group. The chief officer was responsible for stability calculations and was also the deputy fire chief. He commanded the port and starboard lifeboat groups, the first aid group and the helicopter groups. The chief purser was responsible for evacuation, the evacuation groups reporting to him through forward and aft zone leaders. The third officer's main responsibility was to record times of events and to take notes.
According to the emergency plan and the safety manual, the chief officer - not the radio officer - was responsible for external radio traffic. The reason for this is believed to be that the safety organisation for the ESTONIA was partly copied from organisation plans made for vessels not carrying a radio officer. The Commission has not been able to elucidate whether this order was applied in practice
Various checklists were included in the equipment of the command group. Among these were checklists for collision, grounding, leakage and evacuation.
Fire groups no. 1 and no. 2 were led by the second engineer and the third engineer respectively. They were alerted by the coded alarm signal “Mr Skylight” and by the general fire alarm given by the alarm bells. A number given after “Mr Skylight” indicated the fire station where the group should meet. The call “Mr Skylight” followed by the Estonian words for “damage control” indicated that the damage control group should bring equipment for damage control and without further instructions start their work. Fire group 1 was trained and equipped mainly for fighting fires in the accommodation, and fire group 2 was focused on fires on the car deck and in the engine room. Fire group 2 was also trained in the use of chemical protection equipment.
The engine control group was led by the first engineer, and the only other member was the motorman on duty. The group was alerted by the “Mr Skylight” alarms, and by lifeboat and fire alarms. The muster station for the engine control group was the engine control room, and the prime task was to relieve the engineer on duty and take over responsibility for the running of the engine plant.
The lifeboat groups were alerted by the call “Mr Skylight” and by the general alarms. The muster stations were for the port lifeboat group number 2 lifeboat and for the starboard lifeboat group number 1 lifeboat. The main responsibility for the lifeboat groups was to ready lifeboats and liferafts for launching, and to prepare the ladders for use. Organising passengers on boat deck and distributing lifejackets were also duties included in the directions for these groups. Each group was under the command of a second officer and consisted of four other members. Four of these, two in each group, belonged to the deck crew and the other two were from the catering crew. The members of the lifeboat groups were all assigned positions in the lifeboat or liferaft crews.
The first aid group was led by the ship's doctor, and consisted of 11 members. The group was alerted by the call “Mr Skylight 727”, and the meeting place was the ship's hospital. The meeting place could be somewhere else, and in this case a suffix was added to the alarm call, indicating the meeting place. The main duties of the first aid group were to take care of injured and/or deceased persons, give first aid and prepare them for transport ashore or to other vessels. In an emergency situation which included “abandon ship”, the first aid group was also responsible for moving the injured to lifeboats.
The helicopter group was not intended to work in “abandon ship” or other situations when the entire safety organisation was mobilised. The group was therefore made up of persons with suitable skills from other groups in the emergency organisation such as the lifeboat groups and the fire groups. The ten-member helicopter group was led by the second officer and its duties were to prepare the vessel for helicopter landing.
For restricted evacuation and for closing off specific areas, there was a control group. The seven-member group was led by the security assistant. This group was alerted by a “Mr Skylight” alarm, and assembled at the cashier's office on deck 5. The duties of the group included restricted evacuations, searching of restricted areas, blocking off of areas where other groups were working, and assisting the first aid group. The control group was disbanded by the lifeboat alarm, the members then taking other duties in the evacuating groups.
Total evacuation of the vessel was the responsibility of 11 evacuation groups, led by the forward and aft zone leaders. The forward zone leader was in charge of groups 1, 2 and 3 and responsible for evacuation through the forward staircase. The aft zone leader was in charge of the other eight groups, and responsible for evacuation through the aft staircase. The evacuation groups were mustered by the lifeboat alarm or by “Mr Skylight”. Each group had a specified area to evacuate, from the muster station within, or in the vicinity of, that area. The evacuation groups were as far as possible composed of persons normally working in the area they were to evacuate, to ensure local knowledge thereof.
Each lifeboat had seven crew members with defined duties during launching and on board.
All liferaft stations had one station leader, and there was one raft leader for each liferaft.
Every crew member was assigned his/her own unique alarm number upon commencing service on board. This alarm number indicated his/her duties and position in the safety organisation.

4.4.4 Training and drills

The various groups in the safety organisation drilled according to the vessel's exercise schedule. The drills were led by the group leader, who also made a report of the content of the drill and of any group members absence. This report was submitted to the responsible officer in the command group.
The fire groups, the engine control group and the boat groups were scheduled for training every two weeks, and the first aid group and the evacuation groups were to exercise once every month.
Lifeboats on the port side were launched into the water every three months, and those on the starboard side once a year. Under normal operation the vessel always had her starboard side alongside the dock. The starboard lifeboats were, however, lowered every three months.
Of the current crew, 142 had undergone a one-week IMO-approved safety training course on a training vessel, and were certified as proficient with survival craft.
When the ESTONIA commenced her traffic between Tallinn and Stockholm, an operative control was carried out on board by the Swedish Maritime Administration. The control included implementation of the entire safety organisation and a check on the skills of the crew in conducting their duties according to the plan.
In January 1994 the ESTONIA also participated in a major fire exercise. The purpose of this exercise was to train co-operation between helicopter-landed, shore-based, fire-fighters and the vessel's safety organisation.