SureSight · Case Studies

When inspection fails

Six incidents, drawn from official investigations and public reporting. In each one, the safeguard that failed was not a design code or a material spec — it was the gap between an inspection on paper and what actually happened in the field. Each case study ends with how SureSight closes that specific gap.

Airplane cabin interior showing the opening in the fuselage where the door plug separated, with oxygen masks deployed
Aerospace Manufacturing · USA · 2024

Four bolts, no record: the Alaska Airlines 1282 door plug

A door plug was opened for rework at the factory and closed without its four retaining bolts. No removal record was made, so the inspection of the closure never happened.

VERIFIED REASSEMBLY · REWORK TRACKING
The Martinez oil refinery in California, seen at dusk
Refining · USA · 2025

The wrong flange: the Martinez refinery fire

A contract crew opened Flange 4 instead of Flange 3 on a 600°F hot-oil system. Three-day fire, ~$924M in damage. Nothing at the point of work verified which flange was being opened.

POINT-OF-WORK VERIFICATION · PERMIT-TO-WORK
Diagram of a procedure with skipped steps above two sign-off stamps
Aviation Maintenance · USA · 2003

The inspector who was also the trainer: Air Midwest 5481

A mechanic in training skipped nine steps while rigging elevator cables, and his trainer signed off the inspection. 21 people died. The record showed two stamps and a finished job.

STEP-BY-STEP VERIFICATION · INDEPENDENT INSPECTION
Satellite view of the Camp Fire smoke plume and active fire fronts on November 8, 2018
Electric Utilities · USA · 2018

Seventeen years without a climb: the Camp Fire transmission tower

A worn hook on a transmission tower broke and started a fire that killed 85. The tower had not been climbed for inspection since at least 2001, despite visible wear.

RECORDED IMAGERY · FLAGGED WEAR
The failed white liquor storage tank at the Longview facility, its steel shell buckled and collapsed
Pulp & Paper · USA · 2026

A finding without follow-through: the Longview tank failure

An inspection called the tank "not fit for continued service" ten months before it failed, killing 11. The gap wasn't detection — it was follow-through.

CLOSED-LOOP FINDINGS · INTERIM MONITORING
A worker guides a steel trench protection box into an open excavation
Construction · USA · 2023–2025

The daily inspection that didn't happen: a $1.2M repeat

After a trench fatality and a federal settlement, a random OSHA inspection found the same failures again — including no daily excavation inspections.

VERIFIED DAILY INSPECTIONS · AUDIT-READY RECORDS