The tiny sticker on a wire on the ship was slightly in the wrong place.
Over a decade at sea, this label had steadily jogged the wire loose from the node where it was attached.
A little before 1:30 a.m. on March 26, 2024, as the ship was pulling out of the Port of Baltimore, this wire, one of thousands plugged into hundreds of terminal boxes on a 984-foot-long ship, disconnected. This set in motion a frantic four minutes of blackouts and backup system failures, culminating in a catastrophic collision with the Francis Scott Key Bridge.
These findings were announced by investigators with the National Transportation Safety Board on Tuesday, more than a year and a half after the ship, a cargo vessel known as the Dali, struck the bridge. The crash sent thousands of tons of debris into the water, killed six workers who were filling potholes on the bridge and brought traffic into one of the nation’s busiest harbors to a standstill.
“This tragedy should have never occurred,” Jennifer Homendy, the chairwoman of the board, said at a board meeting on Tuesday. “Lives should have never been lost. As with all accidents that we investigate, this was preventable.”
The events leading up the crash — a series of power outages that left the Dali drifting uncontrollably toward the bridge — have been clear for more than a year. But the circumstances surrounding those power outages have been the subject of deep scrutiny and high-stakes litigation.
On Tuesday, the board voted to accept the investigators’ findings and recommendations. The final report will be released in the coming weeks.
The investigators said that the loose wire on Node 381, which tripped a breaker when it became disconnected, was the cause of the initial power outage on the ship. This conclusion was also raised by the owner and operator of the Dali, Grace Ocean Ltd. and Synergy Marine Group, in a lawsuit against the maker of the ship, Hyundai Heavy Industries.
But the N.T.S.B. investigators described a series of problems following the outage that prevented the members of the crew, despite their concerted efforts, from resuming control of the ship.
“The actions of the pilots and the bridge team in response to the emergency were executed in a timely manner,” said Capt. Bridget Quinn, an N.T.S.B. marine accident investigator. “But the vessel’s loss of propulsion close to the Key Bridge rendered their actions ineffective.”
While the crew scrambled to restore power following the initial blackout, they faced several critical problems. They had to manually reset two crucial circuit breakers, delaying restoration of power to the ship by nearly a minute, though the breakers could have been configured to automatically reset in 10 seconds.
When the ship regained power, the two generators that had come online began to stall. A pump was used to supply the generators with fuel, but it was a kind of pump that was not designed for such use. It stopped working during the initial blackout and had to be manually restarted. The ship’s power went out once again.
A pilot aboard the Dali called a dispatcher, who in turn reached the Maryland Transportation Authority Police and urged them to clear the bridge as the ship approached. The police immediately shut the bridge down, most likely saving many lives.
But no one called the roadwork crew that was on the bridge. The police had the cellphone number of an inspector with the crew, but, investigators said, an officer instead planned to drive to the work crew to deliver a warning in person. If the police had called the inspector as soon as the first warning was received, investigators said, the workers, who were sitting in their vehicles on break, would probably have had enough time to drive to safety.
Grace Ocean and Synergy Marine, both based in Singapore, said in a joint statement that they had fully cooperated with the authorities, also pointing out that at least eight members of the Dali’s 23-man crew, nearly all of whom were from India, had remained in the United States after the crash “to support the investigation.”
In a statement, Hyundai Heavy Industries, which is based in South Korea, said that “once a vessel is delivered, the owner and operator bear the responsibility for routine maintenance” and that it was not the one to blame for the loose wire.
Many of the findings announced on Tuesday had come to light in reports and lawsuits filed over the previous year and a half.
The N.T.S.B. issued a preliminary report in May 2024 that described the power outages leading up to the accident and revealed that the Dali had experienced two electrical failures on the day before the accident.
A lawsuit filed last summer by the U.S. government against the Dali’s owner and operator charged that the ship had suffered from poor maintenance and “jury-rigged” fixes to serious problems.
The N.T.S.B. also blamed Maryland officials for the accident, saying in a report released last March that the state had not conducted a critical vulnerability assessment for the Key Bridge in recent years.
In a statement on Tuesday, the Maryland Transportation Authority said that the accident was “the sole fault of the Dali and the gross negligence of its owners and operators.” The statement did not address the lack of a warning to the road crew on the bridge.
Maryland officials initially said that a new bridge could be built by 2028 at the cost of up to $1.9 billion, but on Monday, the state transportation authority raised cost estimates to between $4.3 billion and $5.2 billion and put off the completion date to 2030. Officials attributed the updated estimates to an increase in construction costs and a plan to add huge protective fenders around the new bridge’s piers.
The discussion on Tuesday reflected the hugely complex global supply system and underscored the threats posed to outdated U.S. port infrastructure by increasingly large cargo vessels.
Although many of the implications of the findings were global, the immediate cause of the disaster was anything but.
“The Dali is almost 1,000 feet, as long as the Eiffel Tower is high, with miles of wiring and thousands of electrical connections,” Ms. Homedy said. “Locating a single wire that was loose among thousands of wires is like looking for a loose bolt in the Eiffel Tower.”
Campbell Robertson reports for The Times on Delaware, the District of Columbia, Kentucky, Maryland, Ohio, Pennsylvania, Virginia and West Virginia.
The post Investigators Zero In on Cause of Ship Outage Before Bridge Crash: A Misplaced Label appeared first on New York Times.
