Don’t neglect the details (or the importance of chronic unease)

Dan Reinke
Individual Associate – Safex International

On March 26, 2024 the containership Dali, drifting without power, slammed into a major bridge in Baltimore, Maryland. Six construction workers on the bridge were killed and many more would have perished if not for the quick action of responders who shut down vehicle traffic to the bridge before the accident. Bridge replacement costs are approximately $5 billion and will take until late 2030.

In November 2025 the US National Transportation Safety Board (NTSB) released the results of their incident investigation. They found that a single loose wire on the Dali caused a breaker to unexpectedly open, beginning a sequence of events that led to two vessel blackouts and a loss of both propulsion and steering near the Francis Scott Key Bridge. Investigators found that wire-label banding prevented the wire from being fully inserted into a terminal block spring-clamp gate, causing an inadequate connection (see Figure 1 below).

Figure 1 (Source: NTSB)

A lesson from this event is the importance of chronic unease and having strong responses to weak signals. This was not the first time the ship had lost power. It had, in fact, lost power several times while in port just before the accident.

In our explosives production and processing operations we work diligently to prevent catastrophic events such as the Dali incident. There are several aspects of a strong process safety system that might prevent events caused by hard-to-detect gaps, including:

• Strong safety leadership, incorporating lessons from High Reliability Organizations (HROs);
• Good process knowledge;
• Robust hazard analyses, reflecting current equipment and activities;
• Understanding and adhering to applicable codes and standards;
• Strong competency programs, especially for persons designing, operating and maintaining critical equipment and systems;
• Good near miss reporting culture, with thorough investigation of incidents and significant near misses;
• Effective Inspection, Testing and Preventive Maintenance (ITPM) programs

Strong Safety leadership incorporating lessons from High Reliability Organizations (HROs)

A strong safety culture starts at the top and pervades throughout the organization. Research into HROs has found a number of common characteristics, including exhibiting chronic unease and taking strong responses to weak signals. This Dali incident can be a good reminder to us all to review our operations, looking for potential hazards or system weaknesses that might otherwise be overlooked.

Good process knowledge

It is not clear if the ship captain and crew knew that the intermittent power failures could lead to a loss of propulsion and steering. The person installing the wiring in 2014 likely didn’t understand the potential consequences of improper placement of the wire labels. Looking at your operations, do your leaders, engineers, maintenance personnel and front-line operators adequately understand their process operations, equipment and potential failure scenarios?

Robust hazard analyses, reflecting current equipment and activities

While we all analyze our processes for potential hazards and failure modes, sometimes these reviews are treated more as required meetings and paperwork rather than critical activities to protect our people and facilities. In light of the Dali incident, review several of your hazard analyses with fresh eyes. Are all feasible failure scenarios identified and analyzed? Are the safeguards identified in these reviews effective and reliable? Are the right people with good knowledge of the operations and equipment participating in the reviews? Is adequate time allocated and leadership provided to allow for critical analyses?

Understanding and adhering to applicable codes and standards

Lessons from major incidents often find their way into government regulations, customer requirements and industry codes and standards. Some businesses look for ways to get around these standards, but good companies look to not just comply with the letter of the requirements but also understand the underlying drivers of the standards. How well do your engineers and managers understand these codes? Do they participate in industry organizations like SAFEX in order to learn from incidents and industry best practices?

Strong competency programs, especially for persons designing, operating and maintaining critical equipment and systems

NTSB investigators believe that the improper wiring labels were installed during initial construction of the Dali, which began in 2014. The initial installation appears to have been a human error and subsequent inspections did not detect the error. In your operations, are your front-line production and maintenance personnel adequately trained to identify and report potential safety and operational concerns, including regularly scheduled refresher training with real-life examples? Are engineers and managers well versed in applicable codes, standards and industry best practices?

Good near miss reporting culture, with thorough investigation of incidents and significant near misses

The Baltimore accident serves as a reminder of the value of operational cultures that encourage reporting of unsafe conditions and events, especially for those situations that could lead to ignitions or other energetic events. The NTSB investigation (link) can be used as a case study to facilitate discussions in your operations on what your team would see as lessons learned and how those lessons may apply to your activities. Do your employees feel free to report safety concerns and are they adequately investigated and addressed?

Effective Inspection, Testing and Preventive Maintenance (ITPM) programs

In the case of the Dali power failure, investigators noted that a well-executed thermal imaging program on the ship’s electrical panels may have allowed the fault to be detected. In the US, building electrical codes call for panel imaging to be conducted at least every five years. This is just one of possibly hundreds of safety-critical ITPMs that may apply to your operations. Strong ITPM programs include training of personnel in ITPM procedures, tracking to make sure items are properly completed and learning from ITPM measurements to be able to predict and prevent critical failures.

Conclusion

Often, when working with energetics there is little room for error. These materials can be very sensitive and unplanned initiations can have major consequences (such as the October 2025 melt pour facility incident in McEwen, Tennessee). We should look to learn from any relevant incidents, including those outside of our industry, incorporating those lessons into our own operations.