An A380 operated multiple flights with a tool inside one of its engines, after maintenance engineers did not commence the lost tool procedure prior to the aircraft being released to service, an ATSB investigation report details.
The 1.25 m long nylon tool, used to turn the engine’s intermediate‑pressure compressor during borescope inspections, was found wedged against the low-pressure compressor outlet guide vanes during a scheduled maintenance check at Los Angeles on 1 January 2024.
It was determined that that the tool had been left in the engine during previous scheduled maintenance in Los Angeles on 6 December 2023.
Between the two maintenance checks, the Qantas aircraft had flown 34 cycles, totalling 294 hours, with the tool in the engine. Although the tool was found to have been deformed by high energy airflow, there was no damage observed to the engine itself.
“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,” ATSB Chief Commissioner Angus Mitchell said.
“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.”
After the tool was discovered, Qantas Engineering immediately briefed staff on the importance of ensuring all tooling is returned and actioned by tool store personnel.
The operator also completed an internal investigation, which resulted in an internal safety directive regarding complying with company tool control requirements.
“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,” Mr Mitchell noted.
“Correctly applying tool control is fundamental to mitigating against any human errors that may arise.”
Read the final report: Foreign object debris event involving Airbus A380, VH-OQI, at Los Angeles International Airport, United States, on 1 January 2024