The 294 hours a Qantas A380 spent with a plastic tool left in its left outboard engine are a sobering reminder of the importance of tool control and the ever-present possibility of systems breakdown.
An Australian Transport Safety Bureau (ATSB) report published this month details how on 6 December 2023, the Qantas aircraft underwent a three-day scheduled maintenance check at Los Angeles International Airport, in the US.
On day one of the maintenance check, a 1.2-metre-long nylon tool used to turn the engine during a borescope inspection was left in the engine’s low-pressure compressor case. It was lying across several outlet guide vanes at the bottom of the engine. On 8 December, the aircraft was released to service and took off for Melbourne, Victoria.
On 1 January 2024, the aircraft returned to Los Angeles for a scheduled maintenance check, where the missing tool was discovered. The aircraft had flown 34 flights with the tool in the engine.
Dynamic air pressure had bent the tool but no part of it had contacted moving parts of the engine, which was undamaged. The ATSB concluded the tool had not moved since being left.
The ATSB found Qantas Engineering’s lost tool procedure had not been enacted before the aircraft was released to service and the certifying engineer had not followed up on the lost tool.
Qantas Engineering raised an internal incident report on 2 January, with an immediate action to brief staff on the importance of ensuring all tools are returned. Qantas Engineering began an internal investigation at once and on 4 March 2024, released an internal safety directive for immediate action requiring all its employees to meet the company tooling control requirements without exception.
Tool control is an ever-present hazard when aircraft of any type are being maintained or repaired. Flight Safety Australia has covered the subject several times, most recently in 2022, and in 2021.
The ATSB report identifies several human factors involved in this incident.
Download our maintenance safety poster for the hangar to keep tool control top of mind.
