Pratique

A new report in the Baltimore Sun quotes the chief engineer for Maersk as saying he would be satisfied to set sail if the in-port blackout due to human error had been adequately checked out, but he was still uncertain that the low fuel pressure issue had been sufficiently resolved. Although the NTSB report said the two events (in port and voyage) were mechanically distinct, the Maersk engineer said the pilots should have been told about the initial blackout, which would have raised questions about the seaworthiness of the ship in their minds. The Sun also quoted a marine engineer with NTSB investigation experience who said the design of the power management system might be an underlying cause and needs to be further investigated.

Fair enough, there are other perspectives out there some dependent on the investigation. It’s still early in the investigation.

Yes, that’s reasonable and I’m not expecting 100% of anything. I’m reading elsewhere from people claiming to be cargo ship captains or engineers saying that the Dali should not have left port that day or at least not without taking additional precautions. So there’s no consensus that this was only a bridge problem or that nothing can be done to improve shipboard safety.

I’m a patent attorney so I know all this, but thanks nonetheless. I was just responding to an earlier question. Sorry for the redundant response..

I get it. I'm just not satisfied to be content with the status quo. Maybe others are. I think we can do better if we want to. Maybe I'm a dreamer. This bridge collapse should be a wake up call. But if nothing changes, then it will probably happen again. There are companies who have profited from being innovative and delivering a higher demand product or service. Maybe Amazon is an example? I read about shippers who are frustrated with having their cargoes kicked off of the ship to make way for more profitable loads. So there are plenty of folks who would be interested in seeing some good competition, maybe driving innovation through more efficient ships that can reach more ports. Just spit balling because when I'm a cynic I tend to just sit in a rut. EDIT to say "duh" Disney spends tons of money for things that may never be needed (amusement safety wise) and the competitors (smaller amusement parks) don't, and it has paid off in spades IMHO. But I get that international shipping is a different beast.

You mean mandatory change to the ships. I'm guessing voluntary change is asking too much.

I am reading expert commentary to the contrary, that a ship with that much mass moving at that speed would overcome anything put in its way. So not sure we can say for sure. Obviously more needs to be done. How to prioritize is a hard problem.

Well the ship struck the bridge, not the other way around. The ever larger ships are driving the need to improve the bridges. So the taxpayers should pay to accommodate the shipping industry? Maybe it's all just baked into the economy one way or another. No such thing as a free ride. This is true of the railroads too. They are trying to operate trains a mile long with one engineer on board, alone, to save money. What could possibly go wrong?

Good points, all. I obviously don't have specific technical answers but we know it will cost $$$. That's what it all comes down to. Instead, we now have the cost of replacing a bridge that should never have been struck in the first place. So money here or money there, eventually the costs will be borne by someone. Should it be the shipping industry? We are building new bridges to accommodate them after all. Today the USCG testified to Congress that they will probably do something about marine traffic at the at risk bridges before the final NTSB report comes out. Maybe add more tugs, maybe something else. So it took this to get their attention. Unfortunate since it could have been foreseen.

These are of course pie in the sky and you may have some good counterarguments. One is simply to use tug boats under the (now extinct) bridge for vessels that cannot conn below 8 knots. Is it 100% perfect? No. It is cost effective? No. Is it overkill? Yes. But if one of the tugs had gotten back to the Dali in time, maybe crisis averted. Knowing the existing deficiencies of the bridge, this is something that should appear on the hazard matrix. If it did, then everyone was just playing the odds. Not unreasonable to do, but still a consideration. Another is looking at the admittedly simple electrical schematics in the report and thinking that there should be a way to prevent the propulsion engine and rudder from shutting down so quickly during an electrical outage, given the relatively involved restart process. I don't have a specific solution, but I'm sure that if there is a will there is a way. Again, probably overkill for most situations, but I'm not convinced that it is impractical to do or in conflict with existing requirements. I'm just thinking outside of the box so to speak. I guess I really just don't like hearing "it isn't necessary" because I've never been successful using that argument against anyone else and I was never trained to think that way either. Also, although I left Disney long ago, some of my software continues to run to this day and thankfully no major incidents have happened with it because we were very risk adverse.

I was thinking more along the lines of SOLAS-type things, but point taken about the compartments. I was also thinking about another anecdote for risk analysis, when I once went to Tokyo DisneySea for a design review with my Japanese counterparts. One thing we had been doing for decades in the U.S. was "idiot proofing" the systems as much as possible. The running joke was that you can't outsmart an idiot, but we had developed many time-tested and effective mitigation strategies that the Japanese team had not implemented. Some simple mistakes such as pushing a button at the wrong time would cause bad things to happen under their design. When we brought it up, they seemed offended at the suggestion that their highly trained and disciplined ride operators would ever make a mistake. I shrugged my shoulders (mentally) and then said there could also be an equipment failure, such as a push button shorting closed at the wrong time. They scoffed at that and said they had acquired the best equipment money could buy with a mean time between failure of 20 years. They had some mitigation but it was in downstream control and would not have prevented some bad things from happening. I said, well if it could fail in 20 years it could also fail tomorrow. They didn't like hearing that either. Also, they were using the equipment incorrectly. They bought dual contact switches and were using them to mitigate against one contact failing to close but had not considered the consequences of having one contact weld closed. Again, that would cause bad things to happen. We told them to enter a fail safe state when either contact failed to open or close. They didn't like that idea either. I was scratching my head wondering why they were resisting our recommendations, most of which could be implemented in software, until I realized the reason was that their hazard analysis didn't call for any of it. They had (incorrectly in my opinion) overestimated the reliability of their employees and equipment. When I read the admittedly brief NTSB report about the Dali I can't help thinking about some pretty simple ways the collision could have been avoided if they had been more risk adverse, even though the risk analysis may not have called for any of it. Maybe a new bridge design is all we will ever get out of this incident, but maybe some smart folks will find new ways to mitigate against power failures on board in a more robust way. Just my hope, is all.

Royal Caribbean owns many patents with Nick's name listed as an inventor. Such as this one. So likely he assigned away all of his rights to them.

The other day my wife and I were discussing how transformative the Titanic disaster was on ship design. There is always room for improvement. It's just a question of will and money and risk tolerance. In my experience, people are really bad at risk analysis. We did it at Disney but it was more of a formal exercise than anything else and not the only driver of our design decisions. People tend to discount some things and overvalue other things, and it can be too speculative sometimes especially when there is a lack of hard data. The one-in-a-zillion chance that a ship would take out the Key Bridge has now happened and only the most negative Nellies would say "I told you so." Now it's time to rethink everything. That, I think, was the difference between what Disney does and the Navy does.

Agreed on the bridge design. But curious how a single point of failure (tripped breaker) could render the ship helpless for at least several minutes. My take is that the tolerance for risk in the maritime industry is higher than in the amusement park industry. If the Navy was doing less with nuclear subs than we were doing with high energy amusement rides, then it must be a risk tolerance thing. And I'm sure costs are the main reason. Someone is playing the odds.

I get it, but also not necessarily in agreement. I used to design safety systems for Disney. I once went to a conference and we spent a lot of time talking to another attendee from the Navy who was very interested in learning about how we did things so much better than they did. It blew my mind. I think there are lots of relatively simple solutions to improve fault tolerance. It sounds like an excuse to say there are too many ships so it doesn't make sense to do anything differently. Just my perspective.

Chief, one thing you have not discussed is speed. My understanding is that a ship this size needs to keep it's speed up for navigating through a narrow channel without a tug assist. In this case close to 10 knots. Which is why they didn't have enough time to recover from the blackout. Add to that the loss of steering control and it seems like a recipe for disaster - a breaker trips and the ship is adrift at 10 knots in a narrow channel.

Probably more accurate to say the public is complacent. We are all paying for this though.

A cable stayed design seems like the way to go. Much more redundancy than a truss.

I'm an electrical/software engineer and all of what you say makes sense to me. But the reality is that someone needs to be held accountable for this tragedy and it needs to be explained to the public. The public is unlikely to be satisfied with a technical explanation that nothing within reason could have been done to prevent it, even if that is true. If in the end that it all there is to say, then it seems like something else needs to be done to help prevent it from happening again. Maybe new ship design and/or bridge design. Otherwise it's like telling people in Houston that every flood is a 100-year flood. Hard to trust that it won't happen again soon. And we are assuming now there was no sabotage or negligence even though criminal and civil investigations are still underway. This NTSB report is preliminary fact finding but I agree that it leaves much to be desired and makes me wonder whether the investigators really know what they are doing. Which is just going to make things worse. This report also felt rushed, I would not have expected to see it for another month or two at least.

Except that the first pair of blackouts caused them to switch over to the disused transformer, which may have failed at a most inopportune time. Swiss cheese as you say. Public officials have already accused the ship as being unseaworthy after the first set of blackouts. Maybe not technically true? But difficult to explain away as pure coincidence considering the severity of the incident less than a day later.

I think it was a different pair of breakers after the crew switched over the night before, something about how the breakers had not been used for a few months. But hard to draw conclusions from this.

The first NTSB report is out https://www.ntsb.gov/investigations/Documents/DCA24MM031_PreliminaryReport 3.pdf Dali had two electrical failures in port the previous day, apparently related to human error. "The first in-port blackout was caused by the mechanical blocking of the online generator’s exhaust gas stack. The second blackout in port was related to insufficient fuel pressure for the online generator." The two blackouts while underway were caused by unexpected breakers tripping. Fuel was not contaminated. No conclusions about why the breakers tripped while underway.

"People are saying" is a thing apparently. I've been in situations, more than once, where the boss was summarily dismissed and replaced without explanation. It is unsetting not knowing what's going on or what to expect next. I suspect that the new VP spent all day today talking to her team trying to ease concerns, probably because they have no idea why it happened either or what it means for them. It is telling that the "well wishes" sentiment came from a spokesperson and is not attributed to an executive. Corporate America can be cold, harsh, and unforgiving. I think Nick deserved a better sendoff, but that's just me being compassionate for someone who gave 10 years to the company. in this role. Can't have compassion when you are in charge of big business, now can we?

It’s a fact that Nick was unceremoniously dismissed and immediately replaced with someone from the operations side. The company opened itself up to this speculation. And the most likely reason is probably the actual reason - a change in direction for entertainment. And probably not for the better because that would be too expensive..

Something is up at HQ. Sooner or later we’ll find out. Jason Liberty was interviewed recently and he’s a man on a mission.