DALLAS – The Australian Transport Safety Board (ATSB) has released the official report into how a Qantas (QF) Airbus A380 flew for almost 300 hours and 34 flights with a tool lodged in one of its four engines. The report includes recommendations that QF must follow to prevent future such events.

On December 6, 2023, an Airbus A380-842s arrived at Los Angeles International Airport (LAX) at the end of a routine scheduled passenger flight from Sydney (SYD). The airline performed a turnaround maintenance check on the aircraft (registered VH-OQI) while on the ground at LAX before it flew back to Sydney, and the flight was completed without incident.  

The aircraft then flew for 294 hours and completed 17 round-trip flights before its next scheduled maintenance check, which coincidentally was performed in Los Angeles on January 1, 2024.  

During this inspection, an engineer found a 1.25 m (4 ft) nylon tool wedged against the low-pressure outlet guide vanes in one of the plane’s four Rolls-Royce engines. The tool is used to turn an engine compressor during borescope inspections.

A review of the aircraft’s maintenance records showed the ATSB that the tool had been left in the engine during its previous check in Los Angeles. The investigators also realized the tool had been missed during a shorter maintenance check performed on the aircraft in December 2023. Crews also overlooked it during their pre-flight external inspection checks before each of the 34 flights.  

The ATSB reported that while the tool itself had suffered damage and was “deformed” due to its location within the engine and “by high energy airflow,” it had not damaged any components of the engine itself.

ATSB Comments

“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,” he added.

The ATSB investigators’ report states that an engineer who believed the tool would be needed later in the maintenance left it in the engine. Subsequent engineers, however, did not notice it, and despite filing a missing tool report at the time (a mandatory requirement in the event a tool goes missing), it was not found until the later inspection.

“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,” the ATSB report said.

Follow-Up

The report says that following the incident, Qantas Engineering management briefed all staff on the importance of ensuring tools are returned and actioned by store personnel. QF implemented a new safety directive to comply with tool control requirements.

Qantas said that the flexible plastic turning tool had no effect on the engine’s operations and that the airline had cooperated fully throughout the ATSB investigation.  

“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.”