The Australian Transport Safety Bureau (ATSB) has revealed that a Qantas Airways Airbus A380-842 made 34 flights, representing a total of 293.74 flight hours, with a tool left in one of the its engines after a maintenance operation. The incident, reported this Friday by Air Journal, took place at Los Angeles International Airport in December 2023, and the tool was discovered almost a month later, on January 1, during a re-inspection of the device.
The tool, a nylon rod 1.25 meters long and 2.5 centimeters wide, is commonly used during inspections to turn engine compressors. The initial maintenance, carried out over a period of three days in Los Angeles, included an inspection of the left outboard engine intermediate compressor. However, during this procedure the rod was left in the engine's low pressure compressor housing.
A human error
Despite two visual inspections of the engine before the plane was returned to service, the tool was not spotted. Shortly before the end of the maintenance, the tool store personnel noticed the object was missing and reported the incident. Unfortunately, the aircraft was cleared to resume flights, and no corrective action was taken in this short time. The certifying engineer did not follow up on the report or activate the internal procedure for managing missing tools.
On December 8, 2023, the Airbus A380 took off for Melbourne with the tool still lodged in its engine. The aircraft then continued normal operations, completing 34 flight cycles. It was not until further maintenance on January 1, 2024 that the rod was discovered at LAX.
Quantas Corrective Actions
The ATSB investigated this incident and concluded that Qantas Engineering's tool control protocols were not properly applied. Faced with this incident, Qantas immediately took corrective measures. An internal incident report was issued on January 2, 2024 to raise staff awareness of the importance of respecting tool controls.
Subsequently, on March 4, 2024, a strict directive was issued by the Executive Director of Qantas Engineering. This requires that all employees of the division rigorously respect tool management procedures, without exception.
