A perspective on organisational culture in relation to the sinking of the Estonia

In May 2007, Hannu Hänninen, Doctor of Economics, defended his dissertation on the sinking of the Estonia. According to his dissertation, this was a so-called systemic failure, meaning that it was due to the operating culture of the maritime transport industry at that time. No individual fault or person can be blamed for the accident.

The passenger ferry Estonia sank early in the morning of 28 September 1994, when its bow visor came off and the seawater entered the car deck freely, sinking the ship in half an hour. Of the 989 people on board, only 137 were rescued.

Hänninen bases his research on the report by the official commission of inquiry. The report states that at least 14 similar instances of damage to the bow visor had occurred in shipping in the Baltic Sea between 1973 and 1993 – one of which was the Estonia’s sister ship Diana II, whose bow visor had been broken a year and a half earlier.

According to Hänninen, information on bow visor accidents remained in the hands of individual ship owners. Not even Diana II’s visor problems were communicated to its sister ship, the Estonia; they only became public after accident involving the Estonia. The authorities responsible for maritime safety did not receive sufficient information on visor problems, and the rules on visors were not tightened.

It is noteworthy that a year before the sinking, the owner of the Estonia, then Wasa King, had planned to strengthen the locks on the bow visor. However, the plans were not implemented before the sale of the vessel and were not communicated to the new owners of the Estonia. So the problems were known, but the accident was not prevented!

Hänninen explained the weak safety culture in the history of shipping, in which the strongest players were shipping companies that defended centuries-old traditions of free trade and profit maximisation. In return, ship owners had supervisory and guiding authorities who set guidelines and regulations but did not get to know enough about the problems on board.

Hänninen also identifies a third group, namely, seafarers. Due to the dangerous nature of their workplaces and a ship’s hierarchical operating culture, Hänninen considered them passive in relation to the development of their own safety and that of their ship. In addition, there was a lack of NGOs in the maritime sector, which would have highlighted significant shortcomings in the sector and called for action.

Hänninen defended his dissertation at the Helsinki School of Economics in 2007. After the event, I spoke with Professor Michal Tamuz, who acted as the opponent. I asked that if, according to Hänninen’s theory, shipping companies are only trying to maximise profits, sailors are fatalists, and the authorities are powerless, what could make shipping companies share information with each other and learn about near-miss situations.

Tamuz said that in American air traffic, close monitoring and information sharing have been demanded especially by aircraft crews. At their request, the airlines themselves, not just the supervisory authorities, are actively developing their safety.

Much has happened in shipping since 1994. Today, there are stricter regulations for ships’ bow visors and control, and training and rescue equipment have been reformed. Perhaps the most important reform is the ISM Code, a mandatory safety management system for the maritime sector, which obliges ship owners to continuously assess and further develop their safety activities.

Tämän kuvan alt-attribuutti on tyhjä; Tiedoston nimi on total_losses.png
The number of total losses in maritime transport has been steadily declining. Allianz Safety and Shipping Review 2020.

The shipping industry has thus become part of a modern management system, in which responsibility for strategy and operations lies by no means only with the captain on board, but with the entire shipping company and its management. The effects of the changes are reflected positively in accident statistics.

Photo: Stan Shebs, MS Estonia model at the maritime museum, Tallinn, taken August 2003. Source: https://commons.wikimedia.org/wiki/File:MS_Estonia_model.jpg

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