When Catastrophe Starts with a Loose Wire
- Patrick Hurley
- Nov 19
- 2 min read
A Tough Lesson in Risk Management
The NTSB’s preliminary findings on the Francis Scott Key Bridge collapse reveal a pattern familiar to anyone who has spent time in operational risk management: most major incidents aren’t caused by exotic design flaws — they result from small, preventable oversights.
According to the investigation, the 984-foot container ship Dali experienced two blackouts after a single loose electrical wire—a wire that wasn’t fully seated in its terminal clamp because of the way it was labeled and banded. That seemingly minor installation issue triggered cascading system failures, loss of propulsion and steering, collision with the bridge, and ultimately the deaths of six workers.
The deeper story isn’t about maritime systems or infrastructure engineering.
Major failures usually come from small things
Risk professionals often focus on high-complexity scenarios, rare events, and sophisticated systems. But history repeatedly shows that large-scale failures usually begin with:
Wrongly installed minor components
Missed inspection and lack of supervision
Rushed maintenance or repairs
Procedural steps skipped “just this one time”
Complex systems do not need complex failures to fail.
Operations matter as much as, or even more, than design
Even the most resilient designs fall apart if operational practices and maintenance habits are weak. In this case, it wasn’t the ship’s engineering concept that failed — it was execution.In risk-management language: controls fail at the point they’re least respected, not where they’re most sophisticated.
Risk evolves, but many organizations don’t
The NTSB also highlighted an overlooked factor: the bridge owner had not fully reassessed impact risks despite decades of increasing vessel size.
This is another classic risk-management issue:
Context changes
Scale changes
Operating environments change
But organizations continue using old assumptions
A risk posture that made sense 20 years ago may be dangerously obsolete today.
The fundamentals still matter most
What this incident reinforces is simple:
Pay attention to the details
Build a culture that values discipline
Validate assumptions regularly
Treat maintenance and routine procedures as core controls, not afterthoughts
Recognize that low-probability disasters often originate in high-frequency tasks
Risk management is far less about predicting the future and far more about ensuring the basics are done thoroughly, consistently, and without exception.
A loose wire isn’t just a loose wire
It’s a symbol of how minor oversights can lead to major catastrophes. Whether you manage a team, an organization, a project, or a global operation, the takeaway is the same:
Your risk exposure often lives in the mundane, not the dramatic.
Great risk management is not about brilliance. It’s about a risk mindset - discipline, knowledge, proficiency, humility, and consistent focus on, and execution of, fundamentals.
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