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On Plane Crashes and Corrosion Mitigation Procurement

WEDNESDAY, APRIL 10, 2019

By Warren Brand


“The kinds of errors that cause plane crashes are invariably errors of teamwork and communication.” — Malcom Gladwell from his seminal book, Outliers: The Story of Success

 

I’m fascinated by failures. Some would say obsessed. While Chicago Corrosion Group’s focus is primarily in the corrosion mitigation field, I study modes of failures from every conceivable industry.

And I spend a lot of time focusing on failures within aerospace, because they are so well researched, documented and understood. And if I can understand why airplanes and spacecraft (the most complex machines ever created) fail, then I can do a better job of understanding corrosion mitigation failures. And if I can understand failures better, then I can do a better job of helping my clients design systems to prevent them.

I’ve just finished reading a book called, Why Planes Crash, An Accident Investigator’s Fight For Safe Skies by David Soucie. Soucie was a former FAA investigator obsessed with flight safety. He would likely agree that his obsession started when managing a helicopter ambulance firm, when he declined to purchase what are called “wire strike protection systems” for the firm helicopters. These systems, as the name implies, cut or otherwise reduce the impact if a pilot accidentally flies into power lines.

A friend of the author, who was also a pilot for the firm, hit some wires on takeoff, killing all the passengers and leaving the pilot gravely ill in the hospital. Among the pilot’s last words were to Sucie. I’m paraphrasing, but they were something like, “Dave. This could have been prevented.”

The author spent the rest of his career working on improving flight safety. Like the author—though no lives are at risk—I am obsessed with preventing paint and coating failures.

Let me take a moment to explain why looking at flight failures is an appropriate analogy for corrosion mitigation (and, anything else involving design for that matter). Going back to Malcom Gladwell’s quote from the top of the blog: “The kinds of errors that cause plane crashes are invariably errors of teamwork and communication.”

Of the hundreds, likely thousands, of corrosion mitigation failures I’ve personally worked on or read about, if there was one common denominator to all of them: poor communication at the early stages of conception, which, unfortunately, often continue throughout the project.

Images: The National Transportation Safety Board

And I spend a lot of time focusing on failures within aerospace, because they are so well researched, documented and understood. And if I can understand why airplanes and spacecraft (the most complex machines ever created) fail, then I can do a better job of understanding corrosion mitigation failures.

Let me share just one incredible example from Sucie’s book.

Way back in 1988 (I remember hearing about it when it actually happened), Aloha Flight 243 was flying at 24,000 feet at roughly 350 miles per hour. All was well with the Boeing 737 until, when, without any warning, a chunk of the fuselage tore off the top of the plane. It looked as if a giant had taken a bite out of the top of the plane, just behind the cockpit.

Miraculously, the pilots were able to safely land the plane with only one fatality.

Everyone in the investigation was focusing on the “root cause,” which was quickly identified as corrosion and metal fatigue associated with rivets and the aluminum fuselage. However, when looking deeper, investigators found a more complex issue.

When Boeing designed the plane back in 1967 (roughly 20 years earlier), they assumed the aircraft would be flying roughly two-hour flights on a regular basis. Based on the flight time, engineers assumed a certain number of cycles of pressurizing and de-pressurizing the plane. So, in a given 24 hours of flying, with a two-hour flight, the plane would complete 12 cycles.

But when the jet was tasked with shorter duration flights, landing and taking off more frequently, the number of cycles naturally increased.

The true root cause began in 1967 when engineers made assumptions about the aircraft usage, which, at the time, were apt. But there was no apparent system for retaining and sharing the cyclical assumptions aerospace engineers made more than 20 years earlier when the plane was built. Further, general fatigue and corrosion issues were known, and the aircraft was being maintained, but the extent of the corrosion and fatigue was underestimated.

Communication of the engineer’s cyclical expectations were not, apparently communicated forward.

Teamwork

Gladwell also attributes most aviation mishaps to failures of communication and teamwork. In the Aloha crash, the National Transportation Safety Board report sites the first contributing cause as, “The failure of Aloha Airlines management to supervise properly its maintenance force…”

The true root cause began in 1967 when engineers made assumptions about the aircraft usage, which, at the time, were apt. But there was no apparent system for retaining and sharing the cyclical assumptions aerospace engineers made more than 20 years earlier when the plane was built. Further, general fatigue and corrosion issues were known, and the aircraft was being maintained, but the extent of the corrosion and fatigue was underestimated.

I would characterize teamwork as synonymous with collaboration. And I think anyone in the corrosion mitigation, coating and painting field would agree, that teamwork is very hit-and-miss once a project begins.

In fact, I would argue (and have in past blogs) that the third-party inspection system is fundamentally flawed in that it creates an inherent atmosphere of adversity between the contractor and inspector, rather than one of collaboration. This is not a necessary connection, but rather the default within the industry.

And, in fact, we don’t typically provide traditional third-party inspection services for just that reason. We provide, what we have termed, third-party inspection and associated consulting services. Our inspectors (all of whom are senior and have extensive experience) are told that they have the authority to communicate with the contractor and owner.

If the inspector has experience or thoughts that would benefit the overall project, he is told to share them (I can hear traditional third-party inspector advocates cussing me out). Further, they are told, whenever possible, to facilitate a framework of teamwork (collaboration) among all stakeholders, where everyone is motivated to provide optimal painting, coating or associated work, for the exclusive benefit of the client.

The technical aspects of our work within the corrosion mitigation field is far less complex and challenging than anything in aerospace or aviation. And yet failures continue to happen at an alarming rate. Where commercial air travel is the safest mode of transportation in the history of mankind, we still have trouble painting bridges and coating floors.

And it’s not a matter of more resources or costs. It’s a matter of thinking, communicating more clearly and effectively and cultivating teamwork during paint and coating operations.

ABOUT THE BLOGGER

Warren Brand

Warren Brand’s coatings career has ranged from entry-level field painting to the presidency of two successful companies. Over nearly three decades, he has project-managed thousands of coating installations and developed specs for thousands of paint and coating applications. NACE Level 3 and SSPC PCS certified, Brand, an MBA and martial-arts instructor, now heads Chicago Corrosion Group, a leading coatings consultancy. Contact Warren.

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Tagged categories: Coating Materials; Consultants; NACE; Protective Coating Specialist (PCS); Protective coatings; Specification writing; SSPC; Asia Pacific; Corrosion; Corrosion protection; EMEA (Europe, Middle East and Africa); Latin America; North America; Quality Control

Comment from gavin bowman, (4/11/2019, 2:53 AM)

Good stuff again Warren


Comment from Gordon Kuljian, (4/11/2019, 10:26 AM)

Couldn't have said it better. Too many times I see a culture of adversity between inspectors and contractors; when it should be one of collaboration and teamwork to achieve the end result. There's no need for the adversity in our business, yet it is unfortunately prevalent in some sectors.


Comment from Kevin Keith, (4/12/2019, 9:38 AM)

As a Resident Engineer, I tell my inspectors not to fight with the Contractor; leave the fighting to me. If things are wrong, then document what is happening and I will determine what course of action to take. This helps set the tone for a collaborative working relationship on a project. Most of the time, as you stated, this results in a better product and end result. Sometimes, however, this approach doesn't work and an adversarial approach is needed to correct the situation. In my experience it only takes one or two clashes to straighten things out in a project and either start or resume collaborating on the project. It takes judgement and experience to determine what approach to take. There are examples of too much collaboration and too little in our industry. I don't think the problem is culture, rather it is people who take one extreme side or the other.


Comment from Warren Brand, (4/12/2019, 9:55 AM)

Hi Gavin. Thanks for the kind words.


Comment from Warren Brand, (4/12/2019, 9:56 AM)

Hi Gordon. Thanks for taking the time to respond.


Comment from Warren Brand, (4/12/2019, 10:02 AM)

Hi Kevin. Thanks for taking the time to respond. I agree with the bulk of what you wrote, particularly pointing out that sometimes being adversarial is required. I disagree with your comment the the problem is not culture. While I don't mean to be adversarial ;-) I have found that there is a very, well-established attitude and culture among some inspectors that they are out to catch the contractor doing something wrong. And from talking with many inspectors and instructors, I get the sense that this is what's being taught to inspectors as well. And that contractors are forced to try and do things so the contractor won't catch them. I suspect this varies to some extend by industry. I would welcome any other comments along these, or any other lines. I'd love to be proved wrong.


Comment from Gordon Kuljian, (4/15/2019, 12:00 PM)

Warren - I teach a number of classes for SSPC including inspection classes. One thing I stress is that once you have your certificate and wallet card, this is not to be thought of as a "sheriff's badge". i.e. The spirit of in-process coatings inspection is not to make life difficult for the contractor, rather it is to work with them in a teamwork fashion to give the owner a good product in the spirit of the specification. I also stress that there is no place in the industry for unprofessional behavior. Since no slides in the curriculum ever state that, I feel its my duty to mention it, since we see the ugly side a bit too often.


Comment from Warren Brand, (4/17/2019, 6:52 PM)

Hi Gordon, thanks very much for chiming in. And I applaud you for the way you teach. Not a "sheriff's badge" is funny and apt. Perhaps I'm wrong, and the way new inspectors are being taught has changed? Would love to hear more comments...


Comment from Kevin Keith, (4/18/2019, 8:26 AM)

I completely agree with Gordon and I don't remember being taught to be adversarial at SSPC Level 1 or 2. Granted that was 10 years ago, but I don't think things have changed that much. I think the culture component is more of a personal desire to be a hero and be the person who stands up to your principles, instead of the one who solves the problem. The behind the scenes work that gets a project finished correctly, under budget, and on time rarely gets publicly noticed. Neither approach is completely wrong, but being completely on one end or the other is wrong. Stopping a job because of a half mil of profile isn't right, but ignoring rust and mass areas of staining in a near white blast to get the job done is also wrong. This is why resident engineers, the ones with years of insight on construction, contractors, and materials, should be certified as Coatings Inspectors; so they understand paint and what can and can't be done. Their inspectors should be their eyes (actually all senses) and documenting the work thoroughly. At the end of the day, the RE should read the reports, interview the inspectors and determine how to proceed; based on sound judgement and facts; not knee jerk reactions.


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