When Systems Fail: What the Baltimore Bridge Collapse Teaches Us About the Value of Commissioning

Alex Mathers P.E., CxA, NEBB CP 

Alex@GMCCx.com 

Commissioning: the difference between built and reliable 

The tragic Baltimore bridge collapse is a stark reminder that the built environment is only as strong as the systems that support it. The operation of any complex infrastructure including bridges, buildings, campuses, and mission-critical facilities depends on rigorous verification, testing, and validation. In other words, the core principles of building commissioning matter more than ever. Commissioning isn’t just a quality-control step at the end of construction; it’s a structured, proactive process that ensures systems operate reliably under real-world conditions, reducing the risk of failures that jeopardize safety, operations, and long-term performance. 

What Happened 

In November 2024, the NTSB revealed that the entire catastrophic failure of the 984-foot container ship Dali, which lost power, propulsion, and steering before striking the bridge, was ultimately traced back to a single improperly installed wire connection. Investigators found that wire-label banding prevented a signal wire from being fully inserted into its terminal block spring-clamp gate, causing an inadequate connection in the vessel's electrical system (NTSB official report, November 19, 2024). The NTSB described this as a misplaced thick white label at the end of a small cable that pushed it from having a secure connection (CBS Baltimore, November 18, 2024). 

This one wire, among thousands on the ship, caused the initial low-voltage blackout which triggered a cascade of electrical and mechanical failures the vessel could not recover from in time. NTSB Chair Jennifer Homendy emphasized that "this tragedy should have never occurred...this was preventable" (WBAL-TV, November 18, 2024) and described finding this single loose wire among thousands as "like looking for a loose bolt in the Eiffel Tower" (CNN, November 18, 2024). 

Why It Went Undetected 

The investigation revealed that thermal scanners that could have detected the loose connection were not used as part of routine maintenance, and there were no instructions on how to check individual wire connections (CBS Baltimore and The Hill, November 18, 2024). This defect existed from the time the ship was built ten years ago and went undetected through vibration and movement until it finally failed at the worst possible moment. While we at GMC Cx are skeptical that a thermal scan on low voltage signal (communication) wiring would be effective, the underlying issue of non-inspection is notable. 

How This Relates to Our Work 

This is the type of failure our critical commissioning process is designed to catch. A seemingly insignificant installation error that creates a latent defect capable of catastrophic cascade failure. While we work with HVAC systems rather than marine electrical systems, the fundamental principle is identical: improper terminations, whether it's a wire not fully seated in a terminal block or a sensor connection with inadequate contact, can cause control system failures that cascade through entire building automation networks. 

Consider similar scenarios in our world: 

• A loose wire at a VFD terminal causing intermittent drive faults that eventually lead to a chiller plant shutdown in a data center  

• An improperly terminated temperature sensor creating erratic readings that cause a pharmaceutical cleanroom to lose environmental control  

• A BACnet MS/TP network with a poor shield connection that initially works but fails under electrical noise, taking down an entire BAS trunk  

• A damper actuator with inadequate terminal contact that causes random positioning failures, compromising building pressurization or life safety smoke control 

Our Commissioning Processes are Designed to Prevent This 

Our pre-functional and functional testing procedures, where we test connections, control sequences, and document proper installation before systems go live, are specifically designed to identify these "needle in a haystack" issues before they become operational failures. Just as proper inspections could have identified the Dali's loose connection during maintenance inspections (The Hill, November 18, 2024), our commissioning protocols include: 

• Visual inspections of all control panel terminations  

• Continuity testing and megger testing on critical circuits  

• Systematic verification of all terminations in control panels, actuators, and sensors  

• Point-to-point checkout of every I/O connection  

• Functional testing under actual operating conditions rather than assuming correct installation 

The Bottom Line 

The Dali incident demonstrates that no installation detail is too small to matter: a wire label in the wrong position caused over $5 billion in damages, six deaths, and disrupted an entire port's operations for months. This underscores why we insist on thorough documentation, why we verify rather than trust that installation was done correctly, and why we test systems under actual operating conditions rather than assuming they'll work. 

Every terminal we verify, every control sequence we test, every sensor checked is our opportunity to prevent a cascade failure, whether that's a chiller plant going down in a data center, life safety systems failing in a hospital, or environmental controls failing in a pharmaceutical facility. The NTSB investigation proves what we already know from experience: quality installation, verification, and systematic commissioning aren't optional luxuries, they're essential safeguards against preventable failures, and the cost of proper verification is always orders of magnitude less than the cost of failure.