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Changes made after delivery bypassed critical redundancies. according to HD Hyundai Heavy Industries
Thei shipbuilder HD Hyundai Heavy Industries, which built the 'Dali', said that changes made after delivery bypassed critical redundancies, triggering the second blackout that left the ship without propulsion or steering in the critical moments before the allision with Baltimore’s Francis Scott Key Bridge. The shipyard has issued a detailed defense of the 'Dali'’s original design following the National Transportation Safety Board’s investigation into the accident on March 26, 2024. The NTSB had determined that the probable cause of the allision was a loss of electrical power due to a loose signal wire connection stemming from improper wire-label banding installation, resulting in the vessel’s loss of propulsion and steering near the bridge. The agency also made a recommendation to the HD Hyundai Heavy Industries, to incorporate proper wire-label banding installation methods into its electrical department’s standard operating procedures. The shipbuilder in turn emphasized that the'Dali' was delivered with extensive redundant systems and automatic restart capabilities designed to prevent catastrophic failures, noting that such vessels have onboard power plants and are built with safeguards to deal with the inevitable unpredictability of running a complex system in a harsh environment. According to HD Hyundai, the vessel was originally equipped with four independent diesel generators, two independent transformers, and fuel supply pumps set to automatic mode that would restart without crew intervention after a power outage. These redundancies, the shipbuilder noted, are required by relevant classification societies. However, the company alleged that some time after taking possession of the 'Dali', the shipowner and operator circumvented the ship’s safeguards by compromising its critical redundancies, and claimed that the operators replaced automatic fuel supply pumps with an electrical flushing pump, a single-point system designed for cleaning, not fuel supply, that can only be restarted manually and lacks critical protections. Using the flushing pump as a fuel supply pump sacrificed both redundancy and automation of the fuel supply system and violated established classification rules. On the day of the incident, the vessel experienced two blackouts. The first was caused by a wire disconnecting from a terminal block in the transformer system. Because the transformer was being used in manual mode rather than automatic, the crew had to manually switch to the backup transformer. However, when making this switch, he crew did not restart the flushing pump that had been supplying fuel to the operating generators, starving the generators of fuel and resulting in another blackout, according to HD Hyundai. The shipbuilder contended that had the vessel’s systems been used as designed and manufactured, power would have been restored within seconds, and the second blackout, which led to the tragedy, would not have happened. The NTSB also found fault with the vessel’s operations. Although not causal to the initial underway blackout, the NTSB found that the crew’s operation of the flushing pump as the service pump for online diesel generators was inappropriate because the necessary fuel pressure for diesel generators 3 and 4 would not be automatically reestablished after a blackout- As a result, the flushing pump did not restart after the initial underway blackout and stopped supplying pressurized fuel to the diesel generators 3 and 4, thus causing the second underway blackout (low-voltage and high-voltage- The NTSB found that operational oversight by Synergy, the 'Dali'’s operator, was inadequate. The NTSB noted that routine inspection over the past decade should have identified the loose wire, while HD Hyundai emphasised that it was incumbent on the ship’s owner and operator to engage in regular and appropriate inspection and maintenance to ensure that the systems and components on the ship remained in seaworthy condition. The NTSB also identified contributing factors beyond the vessel’s systems, including the lack of bridge countermeasures and ineffective communications to warn highway workers to evacuate. The agency issued urgent recommendations to multiple federal agencies and bridge owners nationwide to assess vulnerability and implement risk reduction strategies. HD Hyundai stated that the 'Dali'’s shipowner and operator used the vessel’s systems improperly and neglected their continuing inspection and maintenance obligations. They cut corners and violated class rules, which ultimately led to the tragic incident. The company extended its condolences to the families affected and pledged to continue working with authorities to prevent similar incidents.
NTSB-Report Misplaced wire label, vulnerability of bridge and other mishaps in protocols contributed to bridge collapse
A misplaced wire label, the vulnerability of the bridge and other mishaps in protocols likely caused the collapse of Baltimore’s Francis Scott Key Bridge, when the 'Dali' struck it, according to the National Transportation Safety Board. On Dec 10, the NTSB released a 259-page final report on the March 2024 incident, which detailled the events that could have caused an electrical blackout that led to the vessel veering and smashing into the bridge, killing six highway workers. Other contributing factors to the cause of the incident were the crew’s inability to recover propulsion from the loss of electrical power, and the limited time people could act due to the 'Dali'’s proximity to the bridge. There was also a lack of effective and immediate communications to notify the highway workers on the bridge to evacuate. The NTSB did not place blame but determined probable causes of transportation incidents. The final report on the incident was revised and issued with more than 20 recommendations finalized by the NTSB. At a public meeting in November, the NTSB said it believed a wire label was put in the wrong place on a signal wire when the ship was built. That wire label, identifying the line, kept the wire from getting a good connection in a circuit breaker, which in turn ultimately caused the first blackout. The wire label is a small silicone sheath made of thermoplastic material that was heat-shrunk around the wire. It was one of many probable causes determined by the agency after their investigation. The NTSB will issue recommendations to certain groups involved or adjacent to the incident, but the groups were not required to take on these recommendations, just strongly encouraged. The vessel lost steering, the ability to operate the bow thruster, key water pumps, and most of the vessel’s lighting and equipment essential for operations. That first outage lasted 58 seconds. The crew onboard the 'Dali' quickly found the tripped breaker. Power came back within 58 seconds, but restarting a key pump that would have provided fuel to generators had to be done manually, and that didn’t happen. When the generators ran out of gas in their lines, the result was a second blackout. The Francis Scott Key Bridge had nearly 30 times the acceptable level of risk for critical bridges of collapse if it were hit, based on guidance established by the American Association of State Highway and Transportation Officials. The Maryland Transportation Authority, which maintains the bridge, never evaluated that risk. The NTSB also identified 68 other bridges in 19 states spanning waterways frequented by cargo ships that, like the Key Bridge, were built before 1991 and do not have a current vulnerability assessment. Transportation Secretary Sean Duffy would meet with Maryland Governor Wes Moore to discuss the state’s handling of key projects, including the bridge, for which costs have risen. Duffy sent a letter in September to Moore raising concerns over the budget and timeline. The Maryland Transportation Authority said the updated cost estimate to replace the Key Bridge was now projected to be $4.3 billion to $5.2 billion, with an expected opening in late 2030, a two-year delay from the earlier estimate.
NTSB synopsis: Labeling band on a single signal wire caused blackout which led to fatal allision
A labeling band on a single signal wire caused the electrical blackout that led to the 'Dali'’s allision with Baltimore’s Francis Scott Key Bridge on March 26, 2024, the National Transportation Safety Board revealed in a synopsis on Nov 18. The investigation found that wire-label banding prevented the wire from being fully inserted into its terminal block spring-clamp gate, causing an inadequate connection in the electrical system. When the wire electrically disconnected, a high-voltage breaker opened unexpectedly, triggering a cascade of events that resulted in the loss of propulsion and steering as the ship departed from the port of Baltimore. The initial blackout occurred at approximately 01.29 a.m., cutting power to critical systems including steering gear pumps, the fuel oil flushing pump, and main engine cooling water pumps. After the blackout, the vessel’s heading began swinging to starboard toward Pier 17 of the bridge. Despite efforts by the pilots and bridge team to alter the vessel’s trajectory, the loss of propulsion rendered their actions ineffective. When the vessel struck the southern pier supporting the bridge’s central span, a substantial portion of the structure collapsed into the Patapsco River. Portions of the pier, deck, and truss spans fell onto the vessel’s bow and forwardmost container bays. Six members of a seven-person road maintenance crew died in the collapse. One highway worker survived with serious injuries, and an inspector escaped unharmed. One of the 23 persons aboard the 'Dali' suffered a minor injury. The NTSB determined the probable cause to be the “loss of electrical power (blackout), due to a loose signal wire connection to a terminal block stemming from the improper installation of wire-label banding, resulting in the vessel’s loss of propulsion and steering close to the bridge. Contributing to the collapse of the Key Bridge and the loss of life was the lack of countermeasures to reduce its vulnerability to collapse due to impact by ocean- going vessels, which could have been implemented if a vulnerability assessment had been conducted by the MDTA as recommended by AASHTO. Also contributing to the loss of life was the lack of effective and immediate communications to notify the highway workers to evacuate the bridge.” The NTSB investigation identified additional safety concerns beyond the immediate cause. The vessel’s main engine was configured to shut down due to low cooling water pressure—a design that met classification standards at the time of construction but endangered the ship when the cooling pump lost power. Investigators also found issues with the flushing pump being used as a fuel service pump for diesel generators, a role for which it lacked redundancy. The investigation revealed that infrared thermal imaging could have identified the loose wire if it had been used to inspect the 'Dali'’s high-voltage switchboard connections as part of the vessel’s preventative maintenance program. Contributing to the severity of the incident was the bridge’s vulnerability to large vessel strikes. As part of the investigation, the NTSB expanded its focus beyond Baltimore, sending letters to 30 owners of major spans over navigable waterways across the country. The agency urged these bridge owners to evaluate how vulnerable their structures are to strikes from today’s much larger ocean-going vessels and, where necessary, develop concrete risk-reduction plans. This directive requires owners to apply long-standing AASHTO (American Association of State Highway and Transportation Officials) guidance on vessel-collision design, calculate collapse risk probabilities, and consider real-world countermeasures—from fendering and structural upgrades to motorist warning systems and traffic controls. The Key Bridge collapse is being treated not as an isolated incident, but as a wake-up call for every aging, ship-exposed bridge in the U.S. maritime system. The NTSB found that quick actions by the 'Dali'’s pilots, shoreside dispatchers, and the Maryland Transportation Authority to stop bridge traffic prevented greater loss of life. The damage to the 'Dali' exceeded $18 million, with cargo damages undetermined. Bridge replacement costs were estimated between $4.3 billion and $5.2 billion, with completion anticipated in late 2030. Over 34,000 vehicles that formerly traveled over the Key Bridge daily—including 10% trucks and all vehicles carrying hazardous materials prohibited from using Baltimore’s tunnels—must now take extended detours. Grace Ocean and Synergy Marine Group, the vessel’s owner and manager said they would review the Board’s findings “in detail with their technical teams, the vessel owner and counsel. Eight Dali crew members have remained in the United States to support the investigation. Four have now been granted permission to visit their families in early December. The NTSB issued 18 new safety recommendations to multiple organizations, addressing issues ranging from vessel redundancy and electrical maintenance to bridge protection and emergency communication.
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