NTSB Preliminary Report M/V Dali

Professional Mariner Forum
21

Yea I was reading the report on my phone and didn’t read that part right. It also says that SG3 is slower. It took 70 seconds for the pilot to order from port 20 to hard over - makes me think that the rudder hadn’t moved much in that span, or just wasn’t moving fast enough. There requirements for the rudder are 28 seconds from 35-30…but is that just with SG3? It doesn’t go into that detail, but I suspect not.

Also interesting to me - that it took the bow lookout on the long end of 2 minutes to drop the anchor? At least from the time ordered to the time they hit the pier, and the bow lookout had to run to avoid the debris. That’s an eternity to let go an anchor that should have been disengaged and on the brake, ready to go.

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Capt Bugge/Nikolay
BTW, crash maneuver is also a regulatory requirement. And conducted from sea speed full ahead (85% of MCR -max continuous rating which depending on draft/load could be close to 100% of rated rpm) to full astern and distance to be less than 15 ship lengths. Engineers hate this during sea trials. The starting air that is introduced is called ‘braking air’ and as soon as the prop turns astern fuel is introduced. At slow or 8 kts speed, astern running would be accomplished in a very short time.

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23

HR1/LR1 got tripped by failure of TR1. PMS should have automatically connected TR2 but it failed

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24

In those kind of seas, not long at all. The thrust bearings and reduction gear would probably be wiped first and very quickly.

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25

Correct. The motor connected to the ESB has the same requirement. Also to note, this is at full vessel speed and draft.

26

This is what I don’t understand……if TR1 had indeed caused the initial trip through failure how was power restored to the LVbus when the HR1/LR1breakers were manually closed? The report indicates that power was restored for a period until the DGR3&4 breakers opened. After the second power failure the HR2/LR2 breakers were manually closed and power was restored to the LVbus via the standby No.2 generator. Nikolay indicates that this changeover from one set of breakers/transformer to the other should be an automatic function of the PMS……which also failed.

There is something very odd here.

27

Could the fault be with the Power Management System (PMS)? A bad board or something caused the PMS to open the breakers?

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28

What part of “preliminary” report is hard for us to understand?

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29

The preliminary part lol

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30

I have had a very uncomfortable feeling ever since the first notification from NTSB that they have invited Hyundai electrical team to assist with the investigation. Based on the prelim report and queries from Aus, I have a sneaky feeling that perhaps can be classified as a latent defect in the switchboard design.

I was quite surprised that only 2 DGs were on-line for departure – dismissed this as very low reefer load. I may be way off base, but it is possible that there is a restriction on the switchboard to operate only 3 DGs at any given time due to the short circuit rating of the board. Of course this would be programmed into the control system. So perhaps the SOP for the crew is to disconnect all the reefer breakers while the BT is on during maneuvering as was the standard practice years ago. This also means the reefer breakers get plenty of unnecessary cycle times. And every time the reefer breakers (at least 10 in number) are switched on, there is a possibility of upset on the HV board. If this is the case, it certainly is far from ideal. Any restriction in my mind is a defect. Owners have accepted and managers are operating with the restriction.

An independent (US) experienced electrical engineer or company should be engaged by NTSB to dig into this.

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31

the part I am still stuggling with -

0125 - Lose power - heading 142, 9 kts - rudder amidships
“shortly thereafter” EDG on - presume with emergency steering gear
0126 - headin 144 8.6 kts ( no mention of where the rudder is)
0126:13 - Left 20 ordered
0127:23 - Hard left
0129:10 - contact with bridge
Even with a slow steering gear, if it was working there should have been increasing left rudder being applied to a ship doing over 8 kts through the water - even with the engine stopped - there still should be enough water going passed the rudder to have some effect on the heading -
scratching my head a bit on this one

would love to see some pilot information on what the rudder angle indicator was saying at this time ( assme it came back on with the EDG ) - have to believe they both were pretty focused on it in the 30 - 45 seconds after the first rudder order.

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32

It is my understanding that the VDR lost its link to the ECR with the blackout but the VDR recorded the audio communications on the bridge. The VDR uses the same signal input as the rudder angle indicator on the bridge so maybe the rudder position question will be answered.

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I did not note rudder position at time of accident. It would not be the first time that a helmsman confused steering when encountering an emergency situation. Possibly, steered the wrong direction?

Heavy black smoke could be boiler. They tend to really smoke when fans/dampers close and fuel still burning inside. Boiler exhaust is near M/E and A/E exhaust. EGEN exhaust is usually not from main stack.

Although fuel does not seem to be an issue. A very common issue with fuel and these engines, especially the main engines is that viscosity of LSGO is way different than IFO and HFO. If they had a scrubber and use HFO at sea, then switch to LSGO, then the difference in viscosity can become a serious issue. HFO works well, even when injector pumps/plunger valves. If there is wear in the injector pumps/plunger valves, LSGO may “slip” past and result in low fuel pressure, which at dead slow usually results in failure to start. Engineer has to manually increase fuel supply for a dead slow start. I’d look at maintenance of injector pumps.
It is not a question of fuel quality, but of viscosity difference and wear. Some ships have installed FO coolers to increase viscosity of LSGO for this reason. Don’t know if Dali has FO cooler for LSGO.

34

I totally agree if it is something like a low oil pressure shutdown or overheating shutdown or similar. I hate those things and for my own boat it just sets off a loud alarm. What happened here AFAIK is that the engine itself needs electricity to function, just like any modern fuel injected computer controlled engine it stops dead with no electrical power. It wasn’t anything anyone could override, it just won’t work with no generator power will it???

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Not clear when the EDG started and came on-line.

First blackout, says “according to the crew” and that NTSB still investigating the time the EDG started.

image

Second black-out, definitely saying the EDG was providing power continuously through the second blackout.

image

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36

Could that be because the engine never started in astern mode was not considered worthy of mentioning in the very preliminary report?
Misfired staring attempt is not something unheard of for diesel engines, at least in my experience.

Another item from the preliminary report:

If the break was never applied the anchor would not have had any effect on the speed or direction of the M/V Dali in the last minute of the approach towards pier or the impact force.

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37

Hitting a nail on the head.
As an old timer. I have had the same thoughts. Potentially this is an area for review and recommendation.
Typically this is not a decision a Chief Engineer would have made on his own.
Good old days practice, Chief Engineer or Engineer in charge of Watch would contact bridge prior to shut down and request permission from the Master or OOW.
The obvious reason for this practice. The Chief or EOOW do not know where the ship is or what the hazards near by are.
There is no information card for the Shut Downs in the report, Similar to the Maneuvering Card.
Some Auto Shut downs can be overridden Some Auto Shut Downs cant be over ridden.
Which may vary with Ship and or Engine design.

In this particular incident keeping the engine running despite the probability of major engine damage may have been a better option if it was available. Even with the benefit of hind sight. It still leave the problem of no steering. Since the steering will have all lost power.

The EMG could provide power to #3 Steering pump. Helm orders were given. 20 Port later Hard Port.
Missing info, not in preliminary report. Was the #3 steering pump restarted? It was noted response would be slow, No mention of rudder response in report.

Typically steering pumps require manual restart after a blackout. Depends on ship design.

There is no noticeable rudder effect on the vessel track. The Rudder would have a much reduced effect without prop wash.
In order for the option to continue running the engine to be effective. Restarting at least one steering pump would have been required.

Overriding of shutdowns would most likely not be something a Pilot would do although they might advise. This would be the prerogative of the Master or OOW. Supported by the ECR if requested.

Typically there are panels on the bridge console. Where Emergency Shut Down, Emergency Run. Buttons are along with indicator panel and info card for auto shut downs and over rides.

Unfortunately even though some auto shut down can be overridden.
Typically. On ships I’ve sailed on.
Oil Mist Detector.
Main Governor Over Speed.
And
Full Blackout. (If standby gen starts, Auto shut down doesn’t activate. Its on a time delay)
Can not be overridden

Like your chiefs I have never liked this pre determined auto shut down development and believe it is fundamentally wrong.
This incident might show those who designed and approved this why. I don’t hold much hope.

My impression. The Crew did not have a well practiced or trained response to a blackout. If important stuff like steering pumps did not get turned back on.

Reading the instructions when you are about to hit something? In the Dark?
The chance the Bridge crew knew what could and could not be over ridden without reading the instructions?
Especially when every piece of equipment on the Bridge is sounding an Alarm.
Not an engineer but my guess there is a hell of a lot of alarms in the ECR as well.

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Have made an inventory of all comments on m/v Dali and have found one comment, which dovetails nicely with NTSB findings regarding the source of electrical power from the first black out to final allision basis…composition of lights .
image

Exhibit 2 to exhibit 9.

Also have made an inventory of theories, that the preliminary of “preliminary” report has busted:

a) kick astern explaining the shear to stb.
b) bad fuel
c) heiling the crew of Dali as heroes saving lives as Pilot/Pilots are not crew members .So I would rather heil Pilots as heroes.
d) my hypothesis, that may be let go port anchor cought ground exacerbating turn to stb instead of stoping it. I am greatly dissapoinbted by this revelation hoping it would be “eureka” :wink:

Another issue is I have not seen flickering lights due to on/off but saw flickering lights obstructed by bridge construction moments before allision. May be my video was wrong or edited .

Also can not understand why some engineers( including Chief Makoi, were talking about “emergency crash stop” when vsl was on *maneuvering" revs dslahd/sahd.

Such term is used for action done in most cases only one time in ships life and that is during sea trials under full ballast condition in order to find the stoping distance and other maneuvering characteristics. Vsl is brought to full sea speed and then the crash stop is performed. Data from such and other tests are later permanently displayed on the bridge

. Master suggesting to do such test under normal load/operational conditions would cause Cheng and Tech superintendent a heart attack and should have his head examined by specialist.

So I would appreciate somebody explaining, what is a crash stop when vessel is on dead slow ahead please.

Have learned from the report Dali has 3 steering pumps , Have never experienced such configuration . Have always two pumps and for port action , approaches to pilot , anchorages have used always two “on” as helm was moving always twice as fast in comparison with only one pump.

Emcy gen was always supplying pump no.2 on port side .
Cheers.

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I don’t work deep sea. So I don’t know what communication is like between the bridge and the engine room, but I would presume there is a way to communicate to the chief that the plant needs to go all stop if that is a maneuvering necessity from the bridge.

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The days of the Voice Tube are probably over.
The main means of communication. The Telegraph similar operation to the old movies but now may be a smaller plastic version or a series of buttons with bulbs.
The stops corresponding the the Card.
It may even be the same as the control for bridge control, Dual purpose with separate control for control; transfer.
In this case on bridge control setting Dead Slow probably was not not used. It might have been but not mentioned. The engine Stopped on auto shut down.

There will also be at least 1 internal phone system probably set to ECR. Older ship no back up power this ship may or may not have UPS.
There may be a direct phone to ECR. Master Cabin, Chief Cabin.
There will be a Sound Powered Phone. Doesn’t require Power. ECR Master Chief Eng EMG EM Steering BT typically on SP Phone. Similar to old movies. Always works.
Most likely individual Radio ER Deck may be on separate channel with EM Channel or all on 1 channel.
So several possibilities.

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