The Signals Were There
Eight recent industrial failures where the warning signs existed on paper, in someone's head, or in a sensor with no context. Nobody could act on them in time.
Andrea Diaz, Founder & CEO · September 28, 2026 · 8 min read
When something fails in an industrial plant, the investigation almost always finds the same thing: someone knew. A test result sat in a file. A crew followed an informal method nobody wrote down. A detector recorded a rising temperature that no one connected to anything else.
The cases below come from official investigation reports and major news coverage. Each one explains who the company is, what happened, and where the inspection data broke down. Every fact links to its source.
The cases
Filter by the way the data failed.
U.S. Steel, Clairton Coke Works
A U.S. Steel plant near Pittsburgh, Pennsylvania that makes coke, the fuel made from coal that steel mills need to produce iron.
On August 11, 2025, a 70-year-old cast iron gas valve ruptured while workers were cleaning it with pressurized water. Toxic, flammable coke oven gas escaped and exploded.
The cleaning method was not written down anywhere. Employees had been using it informally for three years. The U.S. Chemical Safety Board called it "an ad hoc informal procedure."
The lesson: the most dangerous knowledge in a plant is the knowledge that only lives in people's habits.
Watson Grinding and Manufacturing
A Houston, Texas manufacturer that applies thermal spray coatings to industrial parts, using propylene gas as fuel.
On January 23, 2020, a degraded rubber hose came loose from its fitting and released propylene. A shutoff valve had been left open since the day before, and the gas detection system was not working. The gas exploded.
There was no formal inspection schedule for the hoses and no mechanical integrity program. The only check was a daily visual look and soapy water on the fittings. Workers crimped replacement hoses themselves, with no written procedure.
The lesson: a hose that had lost its flexibility is exactly the kind of observation an inspector notices. It only helps if it is recorded, tracked over time and acted on.
Abbott Laboratories, Sturgis infant formula plant
Abbott is one of the largest infant formula makers in the U.S. Its plant in Sturgis, Michigan produced powdered formula. Its shutdown in 2022 contributed to a national formula shortage.
In September 2026, Abbott agreed to pay about $385 million to settle federal and state claims about conditions at the plant between 2018 and 2022.
According to the Justice Department's allegations, Abbott had documented cracks and pits in the dryers used to make powdered formula, and roof leaks regularly dripped water over equipment. The problems were on record, but the risk kept growing.
The lesson: a documented equipment defect is only useful if it stays visible until it is fixed.
Boar's Head, Jarratt deli meat plant
Boar's Head is a well-known U.S. brand of deli meats and cheeses. Its plant in Jarratt, Virginia made ready-to-eat meats such as liverwurst.
In 2024, a listeria outbreak linked to the plant made 59 people sick in 19 states. The plant was closed.
Government inspectors had recorded 69 violations at the plant in the year before the outbreak, including mold, insects and meat buildup on equipment. The findings were written down, again and again, without leading to lasting fixes.
The lesson: repeated findings on the same equipment are a pattern. Paper records hide patterns.
Philadelphia Energy Solutions refinery
A large oil refinery in south Philadelphia. About 117,000 people lived within one mile.
On June 21, 2019, a corroded pipe elbow ruptured in the unit that used hydrofluoric acid, one of the most toxic chemicals in refining. A series of explosions followed, and a 38,000-pound piece of a vessel was thrown across the Schuylkill River.
The elbow was installed in 1973. By 1995 industry standards had changed and it no longer complied, but "a comprehensive evaluation of unit piping never occurred." The part that failed was never properly flagged in the inspection program.
The lesson: you cannot inspect what is not on your map. Every asset and component needs a place in the inspection program.
National Grid, North Hyde substation (Heathrow Airport)
National Grid runs the high-voltage power network in England and Wales. Its North Hyde substation in west London supplies power to Heathrow Airport, among many other customers.
On the night of March 20, 2025, a transformer at North Hyde caught fire after a high-voltage bushing failed. Heathrow closed for most of the next day, and nearly 67,000 homes and businesses lost power.
An oil test in July 2018 had already shown elevated moisture in that bushing, a sign of a coming fault. The reading was recorded, but according to the official review, "mitigating actions appropriate to its severity were not implemented." Planned maintenance was then postponed several times.
The lesson: a reading without an automatic link to its normal range and to an action is just a number in a file.
Boeing and Alaska Airlines Flight 1282
Boeing builds the 737 MAX in its factory in Renton, Washington. Alaska Airlines Flight 1282 was a new 737 MAX 9 flying out of Portland, Oregon.
On January 5, 2024, a panel that seals an unused emergency exit, called a door plug, blew out of the plane shortly after takeoff. The plane landed safely. Investigators found the bolts that hold the plug in place had not been reinstalled.
The door plug had been opened in the factory in September 2023 without the required paperwork. According to the U.S. National Transportation Safety Board, "the absence of proper documentation of the door plug work meant no quality assurance inspection of the plug closure occurred."
The lesson: if the work is not captured when it happens, the inspection that should follow it never happens.
Norfolk Southern train derailment, East Palestine, Ohio
Norfolk Southern is one of the largest freight railroads in the U.S. East Palestine is a small town in Ohio, near the Pennsylvania border, where one of its trains carrying hazardous chemicals derailed.
On February 3, 2023, a wheel bearing on a rail car overheated and failed. The train derailed, and hazardous materials were later vented and burned.
Detectors along the track recorded the bearing getting hotter: 103 degrees above the outside temperature at one detector, then 253 degrees at the next. Only the last reading triggered an alarm, when it was too late. Investigators found the detectors did not reflect the true temperature of the failing bearing. Hands-on car inspections had also been cut to as little as 30 seconds per car for inbound cars.
The lesson: sensors alone are not enough. A reading needs history, context and human inspection behind it.
Four ways inspection data fails
Different industries, the same patterns.
Stuck in paperwork, never turned into action
Heathrow, Boar's Head, Abbott
Someone saw the problem and wrote it down. But the finding stayed in paperwork, a report or a test result, disconnected from the equipment, its normal range and anyone responsible for fixing it.
What changes it: every reading checked against its range the moment it is captured, and turned into a maintenance or quality record with an owner.
Knowledge lived only in people's heads
Clairton, Watson Grinding, Boeing
How the job was done, and what was checked, existed only in the memory and habits of the crew. No record meant no review, no inspection and nothing for the next person to learn from.
What changes it: capturing work and observations by voice, at the moment they happen, so nothing depends on filling a form later.
Sensor data without operational context
East Palestine
Sensors produced readings, but nobody connected them into a trend, and the hands-on inspections that could have caught the problem earlier had been cut to seconds.
What changes it: combining sensor readings with structured human inspections on the same asset.
Equipment not on any inspection list
Philadelphia Energy Solutions
A pipe that no longer met the standard was never flagged for evaluation. If a part is not on the list, nobody walks by to check it.
What changes it: an equipment hierarchy where every asset and component has a place, mirrored in the plant's own ERP.
"Advanced systems can only work with the information they receive. If work orders are incomplete, asset records are inconsistent, or technicians document work differently across sites, the results become difficult to trust."Jason Penkethman, Plant Services, July 2026
The problem is not a lack of data
None of these companies lacked technology. Several had sensors, test programs and inspection teams. What they lacked was inspection data that was complete, connected to the right asset, compared against what normal looks like, and turned into action.
That is the problem Cosito works on. Inspectors speak what they measure and see, at the moment they see it. Every reading lands on the right asset and component, is checked against its range, and becomes the right record in the plant's own system. The signals are still there. The difference is that someone can act on them.