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A Qantas A380 flew 34 times with a 1.25-metre nylon tool left inside one of its engines, the ATSB has found.
The tool, used to turn an engine compressor on VH-OQI during borescope inspections, is believed to have been left inside during routine maintenance on 6 December 2023 and was not found until a scheduled maintenance check at LAX on 1 January 2024, almost a month later.
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Despite having flown for around 294 hours with the tool inside, there was no damage found to the engine, though the tool itself was “deformed by high energy airflow”, according to the ATSB’s final report.
The turning tool had reportedly been left inside the engine inlet by an engineer who believed it would be needed later in the maintenance, but later engineers did not notice it, and despite a missing tool report being filed, it was not found until the engine was again inspected as part of scheduled maintenance in Los Angeles.
“The ATSB investigation found that maintenance engineers did not notice the tool had been left in the engine’s low-pressure compressor case when conducting checks for foreign objects at the completion of the borescope inspection task,” said ATSB chief commissioner Angus Mitchell.
“Further, maintenance engineers did not commence the lost tool procedure once the tool had been identified as missing, and the certifying engineer released the aircraft for service with the tool unaccounted for.
“Foreign object debris and damage can pose a significant threat to the safe operation of aircraft, which is why regulations, procedures and training are in place to limit the risk of foreign object damage, especially from introduced objects during maintenance.
“Correctly applying tool control is fundamental to mitigating against any human errors that may arise.”
Following the discovery, Qantas Engineering briefed staff on the importance of ensuring tools are returned and actioned by store personnel and launched an internal investigation that led to a new safety directive about complying with tool control requirements.
The airline said that the turning tool, a piece of flexible plastic, had no effect on the engine’s operations and that it had co-operated with the ATSB probe.
“We take this extremely seriously and while there was no damage sustained to the engine, it is critical that the correct lost tool processes are followed,” a spokesperson said.
“Since this event, we issued an internal safety directive reminding our engineers and tool store team members to adhere to these processes to ensure this doesn’t happen again.”
