NTSB Preliminary Report M/V Dali

About 10 hours before leaving port, the container ship, Dali, experienced a blackout during maintenance when a crewmember accidentally closed an inline engine exhaust damper. This blocked the engine’s exhaust from exiting the vessel and stalled the engine, the report states.

Crewmembers restored power by manually closing two breakers, but then a second blackout occurred due to insufficient fuel pressure in one of the ship’s generators. Crewmembers successfully restarted that generator by reopening its exhaust damper.

“While recovering from this second blackout,” the report notes, the crew switched the ship’s electrical configuration to use a different set of breakers than what it had been using for the past several months. It was these new breakers that were in use when the ship departed hours later.

Preliminary Report


As I suspected (and Clay Diamond was on record as saying as per the pilot), they never regained propulsion after the first blackout.

This should put to rest the whole question of whether an ahead bell should have been ordered to allow steering through the bridge or that the “prop walk” when backing turned the vessel to starboard.

Many more “explainations” to follow. The lawyers will entertain. us for years. And draw their checks.Am I wrong JD Cavo?

Interesting that the first blackout was caused by HR1 and LR1 tripping which knocked out the LV bus after which they were manually reset and half a minute later a separate set of breakers DGR3 and DGR4 tripped knocking off both the HVR and LVR. It seems incongruous from a layman’s perspective.

The disturbed water column over the rudder created by the stationary large propeller would have been detrimental to steerage.

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(1089) NTSB Dali Report Has Surprising Findings |Baltimore Bridge Collapse - YouTube

So ME was not started. What was that black smoke from the funnel?
HR1/LR1 and HR2/LR2 must controlled by the power management control system to prevent blackout. Otherwise fuel oil pumps would be stopped as well following to stop AE

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Read the N.T.S.B.’s Preliminary Report on the Baltimore Bridge Collapse - The New York Times (nytimes.com)

The report highlights for me something that has been a point of discussion among the old school chiefs I work with — which was a major point of discussion for them many years ago.

The guys I know who have sailed chief since before shutdowns were popularized and mandated tend to agree that the decision to shut down a propulsion plant should be their perogative, not that of a computer. Because of exactly a situation like this.

It’s all well and good to try and protect the engine, and a properly manned and monitored engine room should have the sharp eyes/ears/noses to know when something is going sideways and make the call to shut it down. But once in a while — hopefully never — a chief might prefer to make the call to run the engine until it blows up, ie to preserve propulsion for the sake of maneuvering in the face of a potential major casualty, at the expense of the engine itself.

The common sentiment in discussion (and I agree) is that taking the ability to make that call away from the chief disallows them to perform what previously was a critical aspect of the job, that is, making this particular critical, split second decision to choose the hopefully lesser of two potential catastrophic results.

Some I’ve spoken with also feel that the presence of system shutdowns lends itself to a less diligent monitoring environment in the engine room — that I won’t comment on but I’d be interested to hear from others here if that (and the rest of my comment) matches their experience or opinion.


I agree with you in principle but there are so many variables, exceptions, and circumstances that make this instance a true outlier. What good is an operating main engine without a rudder, especially since the chief has no idea what the rudder angle might be? A running main might make things 10 times worse.

Versions of this scenario were fairly common in the bad old days of bridge controlled steam. A mate would throttle up like he was driving his pickup truck and leave the plant gasping for breath. Not knowing if the power demand was a legitimate call to prevent a disaster or just a case of incompetence placed the engineer in a tough spot, lose the plant and maybe lose the ship or lose the plant and suffer the misery of a hot restart or save the plant and be the cause of a disaster because you just prevented the only means to prevent one?

As the Dali apparently shows, automation can prevent mishaps as well as cause them. Automatic shutdowns may save an engine but take out a bridge and kill people but failure of that same system might just as easily create the same situation. Maybe AI will be the solution in the future or maybe just keeping all the gens online and breakers closed while in such a “sensitive” area would work and cost almost nothing.


Another point of contention partially explained….

Roughly 2 minutes from Pilot ordering port anchor let-go to the impact with the bridge. Anchor chain never fetched up as crewmen ran from bridge collapse before was able to set the brake. Wording of the report suggests chain was still running out as ship impacted bridge.

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Didn’t automatic shut down stop El Faro’s main ? Running on low lube oil may have saved then

This report leaves a lot to be desired. No explanation on the following:

  • lights flickering before the first blackout
  • Heavy blacksmoke – how could this be anything but the main engine?
  • The course change to stbd after the first blackout
  • Further steerage to the stbd about a minute later
  • last minute bow turning left
  • blackout (third) again after impact

Also from the report Quote ‘Typical for oceangoing vessels, the Dali had an emergency diesel generator (in addition to the four generators) that could be configured to automatically start and connect to the emergency bus if normal electrical power and lighting were lost’ Unquote.

Could be configured?? Seriously?? Surely they know the regulations about auto start and on the board within 45 seconds. Maybe they confuse SHALL with could.

No explanation on the steering gear/rudder position after the pilot orders 20 deg left and later hard port …. With ships speed of around 8 kts at first blackout, we do not see any course correction to port.

Looks like the report is meant for the media … and by the time the final report is issued years later, people would have moved on and not too interested in the true turn of events.

Failed attempt(s) to star it in Astern mode. (??)

I don’t know:
Without an automatic stop, how long would an engine run without lube oil?

El Faro was in the horrible seas near the center of a hurricane.
Her permanent heeling was due to the seawater she had taken onboard before… which prohibited the lube oil suction in these seas.

No information about ME start command or attempt in the report

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Quick question if I may. What could cause such a massive current draw through the LV bus capable of tripping LR1 and HR1? Do you feel that it was the same issue that tripped DGR 3 & 4 after LR1 and HR1 were manually closed and why did they remain closed?

A layman’s question and please forgive my ignorance. Can the LR1&2 and HR1&2 breakers be closed at the same time to feed the LV bus?

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The rudder didn’t move. It says the rudder was midship when they lost power and the steering motors never turned back on. So yes, the pilot ordered hard over rudder, but it never came.

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Hello Aus
Good questions. I think it is unlikely that LR/HR1 tripped on high current. Some other disturbance may have caused it. But it is possible that the current transformers (CTs) on these breakers (or the HV side) is not calibrated correctly and erroneously trips the HV side that cascades automatically to the LV side via most likely an under voltage coil protection on the LV (LR1).
Some disturbance (or intermittent fault) on the HV side seems more probable with voltage/frequency fluctuating that throws off the CT on the HR1. Now what momentary fault on the HV is hard to guess. Not typical when there is steady state. Could be possible as mentioned before, they were securing the BT or maybe a reefer transformer breaker was being closed.
As to DG2 and 3 breakers tripping is again a mystery. Could it be the same reefer breaker? Possible. The trouble in port also supports this.
On the last question, parallel feed from 2 transformers from the same source is avoided because the secondary voltages may not be exactly equal and reactions to change in load/current draw will be different.
Hope this helps. Thanks.


Supposedly the SG motor 3 powered from the ESB came on. And no movement on the rudder?? Points to what we speculated previously - hydraulic lock at blackout.