Technical Analysis (Engineering) of NTSB Preliminary Report M/V Dali

244,

This will be the worst four minutes of their lives. A watershed if you will.
Hopefully, both Pilots get back on the horse………particularly the apprentice. Let us not forget that within this short period and under intense pressure they had the wherewithal to get a message out in order to minimise loss to others. They did well.

Sadly, six people passed and this has been a hellishly expensive lesson for many.

Lessons will be learnt.

Yeah
That takes some thinking outside the box when a bridge is coming your way in slow motion but there is bugger all you can do about it.
Lots and lots of people would just freeze but to keep thinking about what you can do to minimise the damage takes a certain type of individual.

Let’s just hope lessons will be learnt.

There is encouraging signs with the introduction of escort towage.

I share both your and 244’s sentiments and thank those who have put so much time into trying to understand the cause .
You may remember the book A minute of Time concerning the collision between HMAS Vampire and the aircraft carrier HMAS Melbourne. A minute is a very long time to watch an impending disaster. Four minutes doesn’t bear thinking about.

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I’m just a A320 pilot who is a layman in the maritime world and became interested in this accident but I would agree based on the information presented here.

My impression is alot of safety critical electrical equipment and systems were added to ships but the electrical system design philosophy itself was not redesigned during this process to be more robust and reliable. That’s just my impression and could be wrong of course.

I’m not trying to directly compare our electrical system in the airline world to a ship system, but as a example, we use 2 Transformer/rectifier units simultaneously and a 3rd is available and will be automatically used if 1 or 2 of the other TR’s fail. We basically have a split/open bus system that can connect itself automatically if we are down to one generator.

There is of course other redundancies, as an example the computers which manage the engines called FADEC’s have their own small generator that runs off the engine they are running so they are normally not dependent on the rest of the electrical system although they can draw power from it if their dedicated generator fails.

Anyways my 2c not sure if relevant or not.

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Had a few Cheese Beano’s myself back in the day.
Shields,
Or more accurately, The Ship, The Westoe, The Chelsea Cat, Rupert’s, Shore Line, Ferry Man and even the Jungle and a whole load of others I cant recall the names.

Fortunately,
“Bugger all you can could do” was never a position I was ever in.
They did give warning. No mention of whistle sounding. Doesn’t mean it didn’t.
The nearest situations I can think of. New Orleans. Must have been at least 25 years ago.
So “they did what they could do”
Like as not when all said and done. “All the could have done”

The rest.
Planning and requirements. The Escort Tug is not a new idea.

The Pilots were informed, The Ship was ready for sea with no deficiencies.
It started out a routine run. With an Apprentice.
The Blackout.
The Pilots Advice was no longer going to be affective.
My opinion, The Pilots did pretty much everything the could have done.
The final report will probably find something they missed. I doubt it will be critical. Of the Pilots.

The response to The Blackout is the ships crews area of expertise.
Pilots Advice, Masters Orders.
Not so sure about the crew response. Will wait for the report.

The breaker stuff just doesn’t add up to me. Partly cause I’m deck not engineering.

Its a Preliminary Report. So lots of stuff missing.

Ok Stupid Deck Guy questions for Engineers.

First part. The Report explains the cause of two in port blackouts.
Suggesting both resolved?

Just a precaution. The Transformer and breakers which had been in use. Were turned off Opened?

A decision was made to use. The other transformer and other 2 two breakers were closed.
Reasonable precaution I guess. We think we fixed it but JIK lets use the other one.

Technically not a deficiency?

I read the preliminary report and saw the simplified circuit diagram.

Now it doesn’t really add up to me.
Am I correct the in 2 service generators. Did not actually stop?

If the original breakers had been closed.
Could the other Transformer and original breakers could have quickly restored power.?
Would breakers for critical systems like the ME pumps steering ect have been already to go?
Or
Would they need to be reset?

My thought which could be entirely wrong. Power would have been available right away. Or at least some enough to prevent an auto shut down of ME?

Or would there be a good operational reason not to do this?
IE we might blow these breakers as well because we don’t know why those ones opened?

If I was asking questions. What the Master knew and understood about the earlier problems.
And the Engineering decisions prior to departure.

The Master reported everything was Ok no problems to the pilots. Ship was ready for Sea.
Presumably the CE and Master believed it was all good problem solved ship was ready for sea.

As a Master I would expect to be informed by a CE about problems, I would have noticed the Blackouts earlier. I would have had a few questions. Even so if I ask the Chief if everything is good.
Usually if CE says yes every thing is good I accept it.
The precaution?
I would expect to be informed prior to departure. Of changes to DG ect.
Would you as a CE explain this to a Master?
As a Master I would include this in a pre departure briefing.

We had a problem, we changed something, it should be ok,

The guys on watch at midnight plus are not the same guys on watch when earlier problems arose? UMS day workers?
So all of this would or should be in ECR log and part of watch handovers? Reasonable assumption?

Now the big question. Yep I’m on the couch with a computer.

If you are just taking a precaution?
Would you not include a plan for what we should do if the problem reoccurs?

My spider sense would be tingling. We have been in port. We had problems. We made changes.
To me its not going to stop me sailing. The CE said everything is OK.
I would tell Pilots.

This may cause an issue. The Pilots might not be happy.
I don’t believe a Pilot would refuse to sail but I do believe they would like to know.
They might want to know what the plan was if we had a blackout.

Who knows maybe they might not have dismissed the tugs at the regular spot. This would have cost money.

As a Master, I have requested a tug to stand by, My boss was ok with it because even though it cost him money. He doesn’t want me denting his boat.

As a CE or a Pilot what would you expect?
Would you have been happy?
As it was?
What would you have wanted to be happy?

I would have wanted a plan. I would want my Bridge Team and ECR to be ready. JIK.
The tug, discuss with Pilots. Maybe Maybe Not.

My reading the report. Power was available. Am I wrong?

Subject: Steering gear – evolution of rules.
Further to my post on the parent of this subject regarding the 3 pump arrangement on the Dali, I researched the steering gear reqts (and evolution). Awhile back (think it was New3M) asked about the speed of the steering gear with only the SG pump 3 operational. I had replied incorrectly that it has to meet the same requirement as the main pumps and capable of 35-30 in 28 secs. In the PR they refer to the speed of the SG with pump 3 being slower. I was unfamiliar with this arrangement where the SG pump connected to the ESB could be a slower rudder speed.

In my sailing career and later onshore in the marine business all the way from 1978 to 2008, my experience has always been 2 identical pump systems with 1 connected to the ESB. Both meeting the 35-30 in 28 secs (largest ship was 276m/40m/4800 TEU). Quite a few people here were also surprised to see there are 3 motors.

The requirement for the main steering gear and the aux steering gear has always been there. In lieu of a separate aux SG, the reqts for the aux SG can be met if an identical system replicating the reqts of the main SG is provided.

In the 1984 Solas amendment, the speed for the aux SG was defined. 0.5 deg/sec and 15 to 15 in 1 minute at greater of half speed or 7 kts. The amendment also required piping failure of one system to not affect the other system thereby requiring isolation valves.

Possible as the container ships got bigger with deeper drafts, the rudder and therefore SG pump motors also got much bigger to the point where the motor got too big for the emergency switchboard. I would think these are direct on line started and rather than sizing up the EDG which would come with its own headaches, a neat way is to take advantage of the rules.

Maybe all three of the Dali (and others of similar size) SG pumps are sized to provide the speed of 0.5 deg/sec and any 2 in operation meets the requirements of 2.32 deg/sec (35-30 in 28 secs). Probably why SOP was to operate all three during maneuvering.

Would a faster (almost 5 x faster) rudder about 45 seconds after the first blackout made a difference? Given they only had 3 minutes to contact, maybe all the difference.

Hi AV
Would you agree the split board operation is not possible as the feed to ESB does not have the feature indicated on your diagram?

PR=NTSB Preliminary Report.
ME=Main Engine.
Technical terms of the diagram see below.

Reading between the lines to fill the gaps of the PR I expect that power was available without any interruption during the whole voyage as there is no mention that any of the DG was shut down though various breakers tripped which caused the blackouts.

As the PR mentions it, during the 1st blackout the supply of the HV BUS (see below) was never interrupted as DG3 and DG4 were still both running normally. In case of voltage or frequency fault the generators would have been automatically disconnected, which did not occur.
Only the LV BUS was affected due to the unexpected disconnection of TR1.

There was always enough electrical power available (unless DG3 and DG4 would have been stopped before DG2 automatically started at the beginning of the 2nd blackout but the PR does not mention anything about when DG3 and DG4 were shut down) but that power could not be routed due to breakers which unexpectedly tripped for reasons not addressed in the PR.

All AC is 60 Hz, HV=High Voltage 6600V, LV=Low Voltage, in the diagram 440 V.
Dead=Not powered (no voltage present); Live=Powered (operating voltage present),

DG1:
Diesel Generator 1, 4400 kW, 6600 V HV.
DG2:
Diesel Generator 2, 4000 kW, 6600 V HV.
DG3:
Diesel Generator 3, 4000 kW, 6600 V HV.
DG4:
Diesel Generator 4, 4400 kW, 6600 V HV.
DGR1:
Diesel Generator 1 Breaker, connects DG1 to the 6600 V HV BUS.
DGR2:
Diesel Generator 2 Breaker, connects DG2 to the 6600 V HV BUS.
DGR3:
Diesel Generator 3 Breaker, connects DG3 to the 6600 V HV BUS.
DGR4:
Diesel Generator 4 Breaker, connects DG4 to the 6600 V HV BUS.
HV BUS:
6600 V High Voltage Bus, supplies the service step-down transformers TR1 and TR2, the BT (Bow Thruster) and, not shown, the 6600/440 V step-down transformers supplying the reefer container sockets.
It is not clear if the ME (Main Engine) lube oil pumps are fed by a separate step-down transformer, I do not expect them to be 6600 V HV motors, I would even rather expect them to be 440 V LV motors supplied by the 440 V LV BUS but that would contradict the PR.
HVR:
High Voltage Bus Tie Breaker, connects the left part of the 6600 V HV BUS to the right part of the 6600 V HV BUS, HVR remained always closed.
HR1:
Transformer 1 High Voltage Breaker: Supplies the 6600 V High Voltage windings of the step.down transformer 1.
TR1:
Transformer 1, large step-down service transformer which converts 6600 V HV (High Voltage) to 440 V LV (Low Voltage). TR1 and TR2 and not used in parallel.
LR1:
Transformer 1 Low Voltage Breaker: Supplies the 440 V LV BUS.
HR2:
Transformer 2 High Voltage Breaker: Supplies the 6600 V High Voltage windings of the step-down transformer 2.
TR2:
Transformer 2, large step-down service transformer which converts 6600 V HV (High Voltage) to 440 V LV (Low Voltage). TR1 and TR2 and not (!) used in parallel.
LR2:
Transformer 2 Low Voltage Breaker: Supplies the LV BUS (440 V).
LVR:
Low Voltage Bus Tie Breaker, connects the left part of the 440 V LV BUS to the right part of the 440 V LV BUS, LVR remained always closed.
EG:
Emergency Generator, small Low Voltage (440 V) diesel generator starting automatically when LV BUS voltage drops below a Min Threshold longer than an Min Delay.
EBUS:
Emergency Bus (440 V), is fed by the LV BUS when LV BUS voltage present, is disconnected from LV BUS and fed by the EG when the EG is running.
LV BUS:
Low Voltage Bus, supplies all 440 V loads excepted those fed by the EBUS and the reefer container sockets, those are fed by several transformer fed by the HV BUS but are not shown in the diagram.

BT:
Bow Thruster, 3000 kW High Voltage (6600 V) motor, breaker shown closed. Closed breaker implies that the power control cabinet of the BT is supplied by the HV BUS but it does not mean that the BT itself is running. No information is provided about possible use of the bowthruster.

  1. LEAVING PORT

ME (Main Engine): Running (formally not known exactly when started).
DG1: Not running.
DG2: Not running (probably already configured in stand-by for automatic start).
DG3: Running.
DG4: Running.
DGR1: Open.
DGR2: Open.
DGR3: Closed.
DGR4: Closed.
HV BUS: Live.
HVR: Closed.
HR1: Closed.
TR1: Operating.
LR1: Closed.
HR2: Open.
TR2: No operating.
LR2: Open.
LVR: Closed.
LV BUS: Live.
EG: Not running (in standby for automatic start).
EBUS: Live, powered by LV BUS.

Summary:
Everything is normal.

  1. FIRST BLACKOUT
    PR: “about 0125”; StreamTime LIVE: 2024-03-26/01:24:32 EDT
    “>” depicts changes since the previous state.

ME (Main Engine): > Shuts down automatically due to loss of auxiliary systems no longer being powered.
DG1: Not running.
DG2: Not running (probably already configured in stand-by for automatic start).
DG3: Running.
DG4: Running.
DGR1: Open.
DGR2: Open.
DGR3: Closed.
DGR4: Closed.
HV BUS: Live.
HVR: Closed.
HR1: > Open.
TR1: > Not operating.
LR1: > Open.
HR2: Open.
TR2: No operating.
LR2: Open.
LVR: Closed.
LV BUS: > Dead.
EG: > Starts automatically.
EBUS: > Dead until powered automatically by EG when emergency power available.

Summary:
The 1st blackout is partial and only affects 440 V LV as the LV BUS lost power after TR1 was disconnected as HR1 (and LR1) tripped. Emergency Generator EG starts automatically and supplies the 440 V EBUS (StreamTime LIVE Video: 2024-03-26/01:25:01 EDT, cannot be seen well).
It is not known if the transformers supplying the reefer container sockets were automatically disconnected.
DG3 and DG4 are still running and powering the 6600 V HV BUS.
The hydraulic steering gear loses power and all 3 previously running hydraulic pumps stop.
Once emergency power is available, hydraulic pump 3 of the steering gear starts and allows rudder control at reduced speed.

  1. END OF FIRST BLACKOUT
    StreamTime LIVE: 2024-03-26/01:25:31 EDT
    “>” depicts changes since the previous state.

ME (Main Engine): Not running, unknown if unsuccessful attempts to restart it were made.
DG1: Not running.
DG2: Not running.
DG3: Running.
DG4: Running.
DGR1: Open.
DGR2: Open.
DGR3: Closed.
DGR4: Closed.
HV BUS: Live.
HVR: Closed.
HR1: > Closed.
TR1: > Operating.
LR1: > Closed.
HR2: Open.
TR2: No operating.
LR2: Open.
LVR: Closed.
LV BUS: > Live.
EG: Still running and supplying the EBUS.
EBUS: Powered by the EG.

Summary:
Power is fully restored as the service transformer TR1 (which caused the blackout as it was disconnected) was reconnected by the crew closing manually HR1 and LR2.
Emergency Generator EG is still running.
It is not known if the transformers supplying the reefer container sockets were automatically disconnected if disconnected as the 1st blackout happened, there is no information available.
PR does not mention if the steering gear resumed regular operation with all 3 hydraulic pumps.

  1. SECOND BLACKOUT
    NTSB (calculated): Ca. 01:27:01; StreamTime LIVE: 2024-03-26/01:26:36 EDT
    “>” depicts changes since the previous state.

ME (Maine Engine): Not running, unknown if unsuccessful attempts to restart it were made.
DG1: Not running.
DG2: > Starts automatically due to HV BUS power loss.
DG3: (Probably) Running (PR mentions nothing about shut down).
DG4: (Probably) Running (PR mentions nothing about shut down).
DGR1: Open.
DGR2: Open but will closes automatically after the automatic start of DG2 when voltage and frequency stabilized. Low Voltage is not restored automatically as neither TR1 nor TR2 is fed (the PR does not mention that TR1 was disconnected again, probably immediately when the 2nd blackout occurred).
DGR3: > Open.
DGR4: > Open.
HV BUS: > Dead.
HVR: Closed.
HR1: (>) Probaby open (not confirmed as PR does not mention if it was opened).
TR1: Dead.
LR1: (>) Probably open (not confirmed as PR does not mention if it was opened).
HR2: Open.
TR2: No operating.
LR2: Open.
LVR: Closed.
LV BUS: > Dead.
EG: Still running and supplying the EBUS, the PR does not mention if the EBUS remained powered without interruption since after the start of the EG or if it was the EBUS had to be reconnected to the still running EG immediately after the 2nd blackout. Due to the short delay the EBUS probably never switched back to LV BUS suppy and kept supplying the EBUS without interruption.
EBUS: Powered by the EG (see above).

Summary:
A 2nd blackout occurs due to the disconnection of both DG3 and DG4 as DGR3 and DGR4 tripped for unknown reasons.
Emergency Generator EG is still running and supplies the 440 V EBUS.
Nothing is known about the supply of the transformers supplying the reefer container sockets.
The PR does not mention if HR1 and LR1 opened but they probably opened automatically as the HV BUS lost power in order to be ready to restart TR1 or TR2 when the HV BUS is powered again.
DG2 which was already in stand-by starts automatically when the HV BUS goes dead and supplies the HV BUS when DGR2 closes automatically.
DG2 did not start during the 1st blackout as the HV BUS remained powered by the still running DG3 and DG4 as DGR3 and DGR4 remained both closed, which means that during the 1st blackout everything connected to the HV BUS remained supplied without any interruption, only the LV BUS went dead during the 1st blackout.
The 2nd blackout is a total blackout (excepted for the still running EG supplying the EBUS) as both DG3 and DG4 are disconnected.

  1. End of Second Blackout (NTSB: 01:27:32; StreamTime LIVE: 2024-03-26/01:27:10 EDT)
    “>” depicts changes since the previous state.

ME (Main Engine): Not running, unknown if unsuccessful attempts to restart it were made.
DG1: Not running.
DG2: Running
DG3: (Probably) Running (PR mentions nothing about shut down).
DG4: (Probably) Running (PR mentions nothing about shut down).
DGR1: Open.
DGR2: > Closed automatically.
DGR3: Open.
DGR4: Open.
HV BUS: > Powered by DG2.
HVR: Closed.
HR1: Open (not confirmed but PR but at least HR1 or LR1 must have been open as DGR2 closed).
TR1: Dead.
LR1: Open (not confirmed but PR but at least HR1 or LR1 must have been open as DGR2 closed).
HR2: > Closed manually.
TR2: > Operating.
LR2: > Closed manually.
LVR: Closed.
LV BUS: Powered.
EG: Still running and supplying the EBUS, PR does not mention when EG is shut down.
EBUS: Powered by the EG, supply reverted to LV BUS before EG is shut down.

Summary:
The 2nd blackout ends when TR1 (and not TR2 which was previously in use) gets powered when the crew manually closes HR1 and LR1.
Emergency Generator EG is still running and supplies the 440 V EBUS but is not known when it will be shut down.
The PR does not mention when DG3 and DG4 which were initially running are shut down.

There is some odd automatic text reformatting.

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It depends, some modifications of the automation may be required, but the major components required for split operation are there, generators, switchboards, transformers. What I want to highlight is the fact that for commercial ships we only have requirements for duplication of equipment, but not for redundancy or continuity of service. As others have said here, this fact should be acknowledged and preventive actions should be taken, either by engineering measures or by providing tug assistance during passage of such high risk areas.

Large hydraulic motors can become a problem for DOL start as a the kVA rating of a diesel generator must be much higher than the kW rating of motor which is started directly (DOL).
Here maybe 3 pumps of around 132 kW could be in use, just guessing.

Can you please confirm the detail about the lower RPM of the 3rd pump when supplied by the EG instead of the LV BUS as mentioned in the PR? Would be odd to use a 2-speed motor here as the speed of the plunger cylinders of ram steering gears does not depend on the pump RPM.

While the basic principle remains the same, the hydraulic systems are very different, especially also when it comes to emergency procedures. The basic hydraulic diagrams are useless, one must check the detailed hydraulic diagram which is fairly complex.
Suprisingly, the largest steering gear features 3 pumps while many very large ones have 4 pumps.

I have a doubt about 2 points in the PR:

I am not sure that when powered by the EBUS Pump No. 3 is operated at lower RPM as clearly stated in the reports. That the angular speed of the rudder stock will be lower with only one pump is obvious but that is unrelated to the RPM of any pump.

The idea that the lube oil pumps would be supplied by the HV BUS would mean that either a step-down transformer is used or that the main lube oil pumps would be High Voltage motors, and that would be surprising for maybe a 150 kW motor.
Can you confirm that the PR is correct?

Hi Sercos
First of all welcome to the group and forum. We have no details about the vessel aside from the very little available on the internet. The PR does not shed any more light.

I think all three pumps are single speed motors and rated the same. Probably 150kW +/-
The lube pumps mentioned in the PR maybe the hyd oil pumps for the main engine used during start up and slow steaming. And yes, odd that the lube pump of no more than 150kW would be powered from the HV board.

I will now read your long post … :slight_smile:

Hi AV
Off topic a bit.
On a drill rig or ship in 10,000 ft of water on DP station keeping with a tight watch circle, and the riser connected to the bedplate full of drilling mud circulating, with the riser tensioners providing heave compensation to keep the riser in tension and the drill string with the drill bit inside the riser another 10-15K ft below the below the seabed, yes operating the vessel with 5 engines in each engine room at close to full load with the bus-tie open may make sense.

In my experience, following extensive FMEA studies and trials they are operated with the bus tie closed (actually there are 2 bus ties for a ‘ring main’ configuration’) and the breakers are fast acting to split in microseconds in case of any fault.

KISS principle is best applied to merchant ships with 15-20 crew.

Blimey,
Cheese Beano

Now that’s a blast from the past

Dali would have had around 20 to 25 crew

Unless the tugs are going through the Bay Bridges, the horse is out of the barn, the barn fell over, and now the gate to the fenced field is wide open too and the horse is looking that way.

  • a few days ago I saw a ship go under with no tugs present, so there is that…

Yes, the DP vessels tend to be operated with a closed bus tie mainly due to fuel efficiency reasons. With a closed bus tie the numbers of running generators can be decreased and their load factor goes up for maximum fuel efficiency.

I have posted more than once that while I have no experience working on wiring on anything bigger than a tugboat, my experience with flying leads me to think the system as described is severely lacking in redundant/fail safe engineering.
Even on an ancient $30,000 old beater airplane, if say the fuel pump craps out on final you won’t notice because the other one driven a totally different and not-interconnected way keeps working.
(gravity plus one pump or one mechanical and one electrical)

That’s because if your plane falls out of the sky you could possibly fall on someone’s house. Most people can relate to that.
Or even worse you could actually be on the plane that falls out of the sky and while it’s not the fall that kills you it’s the sudden stop at the end.

Ships have accidents all the time but most of the time it does not impact Joe public.
Joe public gets very upset when a few dicky birds get oil on them but fail to realise that these big evil ships that pollute the atmosphere and kill dicky birds provide almost everything that Joe public needs to enjoy Joe public’s privileged lifestyle.
If a few third world sailors get killed providing this lifestyle then who really gives a shit.
So we continue to put obstacles in the way of ships such as unreliable shore power regulations and the implementation of that stupid scrubber system that takes sulphur out of the air but discharges it into the sea. Hey ho no one sees that so good :+1:
Let’s change over to low Sulphur fuel despite the problems it creates for the poor guy’s that have to operate a system never designed for it.
All in the laudable case of cleaning up the air.
All this despite the fact that shipping is the cleanest and lowest cost most efficient way of transporting goods around our planet bar none.
If a ship p drops one litre of oil in the water then all hell breaks loose.
If a plane has to dump 200tonnes of fuel into the atmosphere no one bats an eyelid.
All this while pumping noxious gases into our upper atmosphere every single day.
But hey ho we don’t need these evil foreign owned ships because all they do is pollute and knock down our bridges.
But we really need our 2 weeks in the sun because that is actually essential for our wellbeing.

Rant over

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