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Posted by DamnInteresting 11/19/2025

Loose wire leads to blackout, contact with Francis Scott Key bridge(www.ntsb.gov)
430 points | 222 commentspage 2
comeonbro 11/19/2025|
A label placed half an inch wrong on misleading affordance -> 200,000 ton bridge collapse, 6 deaths, tens of billions of dollars of economic damage

Instant classic destined for the engineering-disasters-drilled-into-1st-year-engineers canon (or are the other swiss cheese holes too confounding)

Where do you think it would fit on the list?

ocdtrekkie 11/19/2025||
The image brings to mind the Cisco ethernet boot infographic: https://www.cisco.com/c/en/us/support/docs/field-notices/636...
hexbin010 11/19/2025|||
I can't believe I've never seen this. I literally laughed out loud when I got to the image. Thank you! Absolute gold
protocolture 11/20/2025||||
I love this one.
lostlogin 11/20/2025|||
Someone out there spent ages trying to work this out.

Fucking hell.

bragr 11/19/2025|||
I guess this will still be bellow Therac-25 for CS and CE students, but above for EE, ME, and Civil Engineering.
bell-cot 11/20/2025||
Worth noting: The MV Dali is a 1000-foot-long ship, weighing 50% more than a nuclear aircraft carrier, with a total crew of twenty-two.

That's everybody - captain, bridge crew, deck crew, cook, etc.

So - how many of those 22 will be your engineering crew? How many of those engineers would be on duty, when this incident happened? And once things start going wrong, and you're sending engineers off to "check why Pump #83, down on Deck H, shows as off-line" or whatever - how many people do you have left in the big, complex engineering control room - trying to figure out what's wrong and fix it, as multiple systems fail, in the maybe 3 1/2 minutes between the first failure and when collision becomes inevitable?

jtokoph 11/19/2025||
It’s been noted that automatic failover systems did not kick in due to shortcuts being taken by the company: https://youtu.be/znWl_TuUPp0
kylehotchkiss 11/19/2025||
When shipowners are willing to cut costs with sketchy moves like registering with a random landlocked African country, why should we believe they'll spend any time or effort reading/implementing NTSB guidelines? It isn't like there's some well respected international body like ITAO calling the shots
dboreham 11/20/2025||
My rule for a couple decades: any failover procedure that only gets run when there's a failure, will not work.
acyou 11/20/2025||
We should have federal legislation requiring tugboat assist adequate to recover from complete loss of power and steering, through shipping channels that go under bridges supported by mid span support columns. The mechanism should be that if the Coast Guard catches you without a tug, the ship is permanently banned from the port under threat of seizure and repossession by the US federal government, or your vessel just gets immediately seized and held in port under bond.

Insurance providers insuring ships in US waters should also be required to permanently deny insurance coverage to vessels found to be out of compliance, though I doubt the insurance companies would want to play ball.

dopamean 11/19/2025||
I know a little about planes and nothing about ships so maybe this is crazy but it seems to me that if you're moving something that large there should be redundant systems for steering the thing.
gk1 11/19/2025||
There are.[1] Unfortunately they take longer to employ than the crew had time.

[1] As it happens I open with an anecdote about steering redundancy on ships in this post: https://www.gkogan.co/simple-systems/

dopamean 11/19/2025||
Thanks for this comment!
cjensen 11/19/2025||
Shipping is a low-margin business. That business structure does not incentivize paying for careful analysis of failure modes.

Seems to me the only effective and enforceable redundancy that can be easily be imposed by regulation would be mandatory tug boats.

dboreham 11/20/2025|||
> mandatory tug boats

Which there are in some places. Where I grew up I'd watch the ships sail into and out of the oil and gas terminals, always accompanied by tugs. More than one in case there's a tug failure.

protocolture 11/20/2025|||
>Seems to me the only effective and enforceable redundancy that can be easily be imposed by regulation would be mandatory tug boats.

Way it worked in Sydney harbour 20+ years ago when I briefly worked on the wharves/tugs, was that the big ships had to have both local tugs, and a local pilot who would come aboard and run the ship. Which seemed to me to be quite an expensive operation but I honestly cant recall any big nautical disasters in the habour so I guess it works.

srmatto 11/20/2025||
If anyone was curious what is happening with the replacement, I just found this website: https://keybridgerebuild.com/
1970-01-01 11/19/2025|
So there were two big failures: Electrician not doing work to code; inspector just checking the box during the final inspection.
DannyBee 11/19/2025||
No. Lots more : It's because they were abusing a non-redundant pump to supply fuel to the generators. Which then failed, which ....

From the report:

> The low-voltage bus powered the low-voltage switchboard, which supplied power to vessel lighting and other equipment, including steering gear pumps, the fuel oil flushing pump and the main engine cooling water pumps. We found that the loss of power to the low-voltage bus led to a loss of lighting and machinery (the initial underway blackout), including the main engine cooling water pump and the steering gear pumps, resulting in a loss of propulsion and steering.

...

> The second safety concern was the operation of the flushing pump as a service pump for supplying fuel to online diesel generators. The online diesel generators running before the initial underway blackout (diesel generators 3 and 4) depended on the vessel’s flushing pump for pressurized fuel to keep running. The flushing pump, which relied on the low-voltage switchboard for power, was a pump designed for flushing fuel out of fuel piping for maintenance purposes; however, the pump was being utilized as the pump to supply pressurized fuel to diesel generators 3 and 4\. Unlike the supply and booster pumps, which were designed for the purpose of supplying fuel to diesel generators, the flushing pump lacked redundancy. Essentially, there was no secondary pump to take over if the flushing pump turned off or failed. Furthermore, unlike the supply and booster pumps, the flushing pump was not designed to restart automatically after a loss of power. As a result, the flushing pump did not restart after the initial underway blackout and stopped supplying pressurized fuel to the diesel generators 3 and 4, thus causing the second underway blackout (lowvoltage and high-voltage).

IncreasePosts 11/19/2025|||
The terminal blocks could also have been designed to aid visual inspection.
nightpool 11/19/2025||
No, there was a larger failure: whoever designed the control system such that a single loose wire on a single terminal block (!) could take down the entire steering system for a 91,000 ton ship.
DannyBee 11/19/2025|||
They didn't.

If you read the report they were misusing this pump to do fuel supply when it wasn't for that. And it was non redundant when fuel supply pumps are.

Its like someone repurposing a husky air compressor to power a pneumatic fire suppression system and then saying the issue is someone tripping over the cord and knocking it out.

bragr 11/19/2025|||
There's a 3rd failure: the failure to install/upgrade dolphins that could deflect a modern containership, despite the identified need for such. That proposed project seems cheap in retrospect.
nightpool 11/19/2025||
Yes, 100%. Lots of failures across the board here. Especially with large ships and how many different nations they might be registered in, I can't imagine it's easy to have a lot of regulatory oversight into their construction, mechanical inspection or maintenance schedules. I'm curious how modern ports handle this problem, feels like it could cause a ton of issues beyond just catastrophic ones like this one.
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