How the NTSB is trying to prevent another major bridge collapse

(CNN) — The collapse of the Francis Scott Key Bridge in Baltimore could be repeated across the country if recommendations aren’t followed, the National Transportation Safety Board said Tuesday.

The board issued 17 safety recommendations this week to prevent an accident like the one last year, where the 213-million-pound cargo vessel Dali lost engine and electrical power as it was leaving the port and struck a pillar of the Key Bridge causing it to collapse.

The NTSB recommended Synergy Marine, the ship’s operator, use thermal imaging to find lose wires on its other vessels, make sure the right pumps are being used, and that engines won’t automatically shut down in situations like this crash.

Other recommendations include new rules for wire labeling, a warning system for drivers crossing bridges in case of emergency, and better recoding systems to capture data on ships in case of a crash.

“In order to see safety change, we need our recommendations implemented,” NTSB chairwoman Jennifer Homendy told reporters after a nearly five hour public meeting. “That’s the next step. We’ve issued the safety recommendations now we need to make sure that they’re implemented, and so we will work diligently.”

The NTSB held the public meeting Tuesday to determine the probable cause of the container ship Dali crashing into the Francis Scott Key Bridge, and its subsequent collapse, killing six people.

The 984-feet long vessel operated in the container liner trade, carrying truck-sized boxes of cargo between Asia and the US East Coast. The bridge was owned and operated by the Maryland Transportation Authority and opened to traffic on March 23, 1977.

The last time the bridge was inspected was in 2024 when it was given a satisfactory rating. Yet the 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 NTSB said. But no one knew that before the collapse, because the owner of the bridge, the Maryland Transportation Authority, never evaluated that risk.

The agency says all of the blame for the bridge collapse is the fault of the ship.

“The MDTA maintains that the collapse of the Francis Scott Key Bridge and the tragic loss of life were the sole fault of the DALI and the gross negligence of its owners and operators,” it said in a statement to CNN Tuesday. “The Key Bridge was approved and permitted by the federal government and complied with those permits.”

In a statement, Synergy thanked the NTSB for its “professionalism and technical rigour” throughout this investigation and said it and Grace Ocean Investment Limited, the company that owns the ship, have cooperated fully with the board.

“We note the Board’s findings, including its observations regarding the vulnerability of the Key Bridge’s main support pier, as well as the comments relating to aspects of the vessel’s electrical arrangements. These matters will be reviewed in detail with our technical teams, the vessel owner and counsel,” the statement said.

Earlier this year, the NTSB recommended risk assessments also be conducted on 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.

Among those on the list are the Golden Gate Bridge in California; Brooklyn, Manhattan, Williamsburg, George Washington and Verrazzano-Narrows bridges in New York City; the Walt Whitman and Benjamin Franklin bridges in Pennsylvania; the Sunshine Skyway in Florida and the Mackinac Bridge in Michigan.

On Tuesday, Homendy noted that despite its recommendations, some of those bridges still have not been evaluated for risk of collapse if a ship like the Dali were to hit them.

One loose wire, among thousands

The NTSB said Tuesday it believes the probable cause of the power outage that led to the crash was a label was put in the wrong place on a signal wire when the ship was built. That sticker, identifying the line, kept the wire from getting a good connection in a circuit breaker – which in turn ultimately caused the first blackout.

As a result, according to Marcel Muse, the NTSB’s investigator in charge, 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.

There were thousands of wires on the Dali, and one loose wire would not have been easily found by the crew.

“The Dali is almost 1,000 feet, and it’s as long as the Eiffel Tower,” Homendy said. “It’s high with miles of wiring and thousands of electrical connections. Locating a single wire that is loose among thousands of wires is like looking for a loose bolt in the Eiffel Tower.”

The crew onboard the Dali quickly found the tripped breaker, the NTSB said. 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.

“To restart it, you would have to go two levels down in near total darkness with a flashlight from the engine control deck to the purifier room on the fourth deck,” Homendy said.

The pump the Dali was using was designed for maintenance and was not intended for use while the ship was underway, so there was no backup system.

At the time of the second blackout, the Dali was just three ships’ lengths from the bridge and despite the pilots reacting properly, they couldn’t regain control in time to avoid hitting it, the NTSB said.

About 10 hours earlier, while the ship was still moored, it experienced two onboard blackouts, one caused by a crew error, according to the NTSB.

Last year, Grace Ocean and Synergy reached a settlement with the Justice Department to pay nearly $102 million to resolve a civil claim alleging that the companies’ cost-cutting and negligence in the ship’s maintenance led to the disastrous collision.

In its filing last month, the Justice Department said that the “tragedy was entirely avoidable,” pointing to alleged failures in the ship’s infrastructure.

Black boxes didn’t give up information easily

Investigators also encountered many issues extracting information from the vessel’s recorders, which are similar to black boxes on airplanes.

Voyage data recorders, known as a VDRs, are electronic systems that continuously record navigational and location data, radar images, basic engine operations, alarm status, bridge audio recordings and VHF radio communications, according to the NTSB.

Sean Payne, an investigator in the NTSB’s vehicle recorder division, said during the investigation, the NTSB encountered several problems that made it hard to extract and use the data efficiently.

“Key issues included unrecorded data during the vessel’s first underway blackout, the lack of recording of communications between the Dali’s bridge and the Dali’s engine room, the digitally destructive mixing of recorded bridge audio channels, inadequate VDR playback software, the inability to download the full data set on board the Dali, and the complex workflow for processing proprietary VDR data in the common formats,” he explained.

Final report coming soon

The final report on the incident will be revised and issued in several weeks and the 17 recommendations will be formally issued and finalized by the NTSB.

“We have a really big voice, and we’re not afraid to use it,” Homendy said. “While we don’t have enforcement power, certainly, we have had a lot of success with voluntary adoption of our recommendations. We’re usually at an 83% closure rate.”

CNN’s Michelle Watson contributed to this report.

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