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Single Loose Wire Caused Dali’s Catastrophic Bridge Strike, NTSB Concludes

A labeling band on a single signal wire caused the electrical blackout that led to the containership Dali’s collision with Baltimore’s Francis Scott Key Bridge in March 2024, killing six highway workers, the National Transportation Safety Board revealed Tuesday.

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 984-foot vessel’s 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 Singapore-flagged containership departed Baltimore Harbor.

“The Dali, at almost 1,000 feet, is as long as the Eiffel Tower is high, with miles of wiring and thousands of electrical connections,” said NTSB Chairwoman Jennifer Homendy. “Finding this single wire was like hunting for a loose rivet on the Eiffel Tower.”

The initial blackout occurred at approximately 0129 local time on March 26, 2024, cutting power to critical systems including steering gear pumps, the fuel oil flushing pump, and main engine cooling water pumps. After the blackout, the Dali’s heading began swinging to starboard toward Pier 17 of the Key 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 sustained 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.

“But like all of the accidents we investigate, this was preventable,” Homendy said. “Implementing NTSB recommendations in this investigation will prevent similar tragedies in the future.”

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. The Key Bridge opened in 1977, and vessels have grown substantially larger since then. The Dali measured 984 feet—ten times the size of the Blue Nagoya, a containership that caused only minor damage when it contacted the same bridge after losing propulsion in 1980.

National Bridge Safety Review Launched

As part of the Dali 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.

Damage to the Dali exceeded $18 million, with cargo damages undetermined. Bridge replacement costs are 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, issued a statement thanking the NTSB “for the professionalism and technical rigour it has applied throughout this investigation.” The companies said they would review the Board’s findings “in detail with our 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.

New Safety Recommendations

The NTSB issued 18 new safety recommendations to multiple organizations, addressing issues ranging from vessel redundancy and electrical maintenance to bridge protection and emergency communications:

To the U.S. Coast Guard

  • Study redundancy for large ships near ports: Research and publish guidance on how large, single-engine cargo ships can maintain propulsion and steering when operating in restricted waters near channels and bridges.
  • Strengthen IMO’s safety management code: Request that the International Maritime Organization upgrade the ISM Code to fully incorporate the four pillars of modern safety management (safety policy, risk management, safety assurance, and safety promotion), similar to aviation SMS standards.
  • Fix voyage data recorder shortcomings: Propose new IMO rules requiring VDRs to record key data that remains powered during blackouts, engine-room/bridge phone communications, multiple bridge microphones on separable channels, and use playback software that exports to open formats.

To Nippon Kaiji Kyokai (ClassNK)

  • Share technical lessons with all class societies: Distribute findings from the Dali case urging other classification societies to warn against improper wire-label band placement, promote infrared thermal imaging for detecting electrical connection problems, highlight risks from partially open emergency-generator radiator dampers, and review emergency generator start design rules.

To the American National Standards Institute (ANSI)

  • Upgrade international VDR standards: Propose changes to IEC 61996-1 requiring VDRs to record data from systems powered during blackouts, engine-room to bridge communications, multiple bridge microphones on independent channels, and include enhanced playback software requirements.

To ANSI Accredited Standards Committee A10

  • Add emergency communications for bridge work zones: Update ANSI/ASSP A10.47 to require fast, reliable emergency communication methods to warn and evacuate workers on bridges over navigable waterways, including protocols for law enforcement presence.

To the Harbor Safety Committee National Steering Team

  • Standardize emergency procedures for pilots: Establish clear procedures and contact lists enabling pilots to instantly reach shoreside authorities during emergencies, ensuring quick, coordinated response.

To HD Hyundai Heavy Industries

  • Fix wire-label installation practices: Incorporate proper wire-label banding methods into standard operating procedures to prevent labels from interfering with terminal block insertion.
  • Warn owners about vulnerable engine configurations: Identify all active HHI-built ships with Hyundai-MAN B&W 9S90ME-C9.2 engines configured to shut down on low cooling-water pressure and alert current owners about this configuration and the Dali accident circumstances.

To Synergy Marine Group (Dali’s Operator)

  • Use thermal imaging in electrical maintenance: Implement infrared thermal imaging for routine monitoring of electrical components to detect inadequate connections.
  • Reconfigure vulnerable engines: Identify ships with Hyundai-MAN B&W 9S90ME-C9.2 engines and ensure they are not configured to automatically shut down due to low cooling water pressure.
  • Ensure proper fuel pump usage: Develop SMS procedures ensuring crews use designed fuel-oil service pumps for diesel generators rather than non-redundant flushing pumps.
  • Keep transformer breakers in Automatic mode: Create procedures requiring high-voltage breaker control modes to be set to Automatic during normal operations to enable faster power restoration after blackouts.
  • Address radiator damper issues: Notify crews on ships with similar emergency-generator setups that partially open radiator dampers can delay or prevent automatic generator starts.

To WAGO Corporation

  • Add warnings to terminal block documentation: Update data sheets for terminal block model 280-681 and similar products to warn that improperly placed wire-label banding can prevent proper wire insertion and clamping.

To Bridge Owners (Caltrans, MDTA, TxDOT, and Others)

  • Evaluate motorist warning systems: Assess whether each high-risk bridge needs automatic motorist warning/closure systems that trigger when threats like errant ships or structural movement are detected.

To AASHTO

  • Update vessel-collision design guide: Revise the Guide Specifications for Vessel Collision Design to include guidance on motorist warning systems, incorporating FHWA research on sensing and alert technologies.

To the Federal Highway Administration

  • Research bridge hazard-detection technology: Study technologies that detect errant vessels and abnormal bridge movements, trigger closures, and automatically warn motorists—then share results with AASHTO for incorporation into design guidance.

Previously Issued Recommendations (March 2025)

In March 2025, the NTSB issued urgent recommendations addressing bridge vulnerability to vessel strikes:

  • H-25-1 (Urgent) to FHWA: Create an interdisciplinary team with the Coast Guard and Army Corps to provide guidance helping bridge owners assess and reduce collapse risk from ship strikes.
  • H-25-2 (Urgent) to Coast Guard & Army Corps: Support FHWA in establishing that interdisciplinary bridge-risk team.
  • H-25-3 (Urgent) to Multiple Bridge Owners: Calculate AASHTO Method II annual frequency of collapse from vessel strikes for each identified bridge and report whether it exceeds the risk threshold.
  • H-25-4 (Urgent) to Multiple Bridge Owners: Where collapse frequency exceeds the AASHTO threshold, develop and implement comprehensive risk-reduction plans using guidance from the federal team, with both short- and long-term measures.

A synopsis of actions taken Tuesday, including the probable cause, findings and recommendations, can be found on ntsb.gov. The complete investigation report will be released in the coming weeks. 

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