WASHINGTON, D.C. — On Tuesday morning, the National Transportation Safety Board (NTSB) met and heard presentations from several staff members on the investigation into the DALI crash into the Francis Scott Key Bridge in March 2024, revealing the causes that led to the catastrophe.
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"The fact is, none of us should be here today," says Chair Jennifer Homendy. "This tragedy should have never occurred. Lives should have never been lost. As with all accidents that we investigate this was preventable."
The board provided 25 findings and 18 recommendations to several agencies including the U.S. Coast Guard and Synergy Marine Group.
The catalyst of the DALI's failure, its first of several blackouts that morning, the NTSB found to be a loose wire among the thousands of cables that run through the ship.
"Locating a loose wire in the thousands of miles of wiring is like looking for a loose bolt in the Eiffel Tower," said Homendy in appreciation of the work of the engineering investigators.
The Board heard presentations about several aspects of the investigation, including factors that contributed to the collision like outdated and in some cases improper systems aboard.
NTSB investigators found that if the high voltage breaker had been set to automatic, the initial blackout would have only latest 10, not 58 seconds. A flushing pump was also used "inappropriately" as a fuel service pump, causing residual issues.
"This was a complex, multi-modal investigation," Homendy says.
The DALI was equipped with an emergency generator, which was designed to kick in in the event of a loss of power, according to the staff presentations about the container ship.
Just four minutes before the crash, a breaker opened at around 1:25 am, and the DALI experienced a low-voltage blackout, causing the main engine to shut down and the propeller to stop 8 seconds later. The engine and the thruster remained off after this point.
The ship made contact with the bridge at 1:29:09 a.m.
PREVIOUS REPORTING: Could a loose cable have caused the DALI power outage leading to Key Bridge crash?
That signal wire had its label placed on a part that made it difficult to connect the wire during the construction of the vessel, and "resulting in an inadequate connection."
While the company operating the vessel did require inspections of the switchboards, the NTSB found that it lacked practical guidance to checking all of the thousands of wires and terminal connections on a vessel.
One recommendation made by the Board is to use thermal imaging technology to spot faulty wires in the future.
Recording issues discovered
Another issue brought up during Tuesday's presentation the were problems investigators encountered recovering data and audio from the ship's vessel data recorder (VDR), similar to a black box on airplanes.
Several streams of data were not recorded during the blackouts on the ship, and the recorded bridge audio was "destructively mixed."
Bridge vulnerability and worker safety
In discussing the bridge portion of the investigation, the findings released in March of this year were reiterated.
"If MDTA had calculated the Key Bridge vulnerability, MDTA would have been aware the risk of collapse was almost 30 times greater than the acceptable risk threshold," read one of the slides in the presentation.
13 out of the 68 bridges identified by the NTSB earlier this year as not having had a vulnerability assessment have done so and been found to be above the acceptable risk threshold. Others are still undergoing the process.
This presentation also included a discussion of highway worker safety, and how the workers were not notified by MDTA police about the danger.
Investigators also determined that the MDTA police began closing the bridge to traffic but failed to call the inspector on scene to alert the construction crew. If they had done so at the same time, the crew would have had about a minute and a half to evacuate— possibly saving lives.
"However, there are no ANSI [American National Standards Institute] for highway workers to receive emergency information before or during dangerous or life-threatening events within work zones," said an NTSB staffer.
The Board recommended that bridges should have some sort of alert system, including flashing lights to warn of impending threats.
The NTSB staff said that the following were not found to be factors in the accident:
- Environmental or waterway conditions
- Vessel complement and mariner credentialing
- Impairment from alcohol or other drug use
- Fuel quality or fuel switchover
- Vessel's ability to get underway after in-port blackouts
- Bridge construction with non-redundant steel tension members
There was discussion of an amendment to the probable cause, the proximity to the bridge, to emphasize that the crew worked in a timely manner to try to resolve the issue, and that they just didn't have time, which was added.
“The crews actions were as timely as could be and they were appropriate and also impressive considering the circumstance but they’re just, because of the proximity of the bridge it just couldn’t get everything started back up again," NTSB Board Member Michael Graham.
The meeting concluded just before 2:30 p.m. The final report is expected to be released in a few weeks.