The Australian Transport Safety Beareu says that a tool left inside the engine of a Qantas Airbus A380 superjumbo posed a “significant threat to safety” after the double-deck aircraft flew around the world on 34 flights before the tool was eventually found by chance.
The tool remained concealed behind the fan blades of the airplane’s Number 1 engine for nearly a month before engineers at Los Angeles International Airport happened upon the tool by chance during a three-day routine maintenance inspection.
By this point, the plane had transported thousands of passengers on 34 ‘cycles,’ totaling nearly 294 hours of flight time with the tool wedged inside the outboard left-hand engine.
Accident investigators were called in after it was discovered that the tool had been accidentally left inside the engine when Qantas engineers in Los Angeles were carrying out a borescope inspection of the Number 1 engine’s intermediate-pressure compressor.
The inspection started at around 7 am on December 6, 2023, and involved inserting a 1.25 m long by 2.5 cm wide nylon rod, known as a turning tool, behind the engine’s fan blades.
At 1 pm, however, the engineer who had signed out the turning tool left work early for a medical appointment before going into three rostered days off. The turning tool was still inside the engine at this point, and other engineers were assigned to complete the borescope inspection later that afternoon.
The task was only completed after dark, but despite two separate engineers carrying out an inspection of the engine once the borescope task was complete, the turning tool wasn’t spotted.
The tool was quickly identified as missing, and a report was completed, but engineers at Qantas’ Los Angeles maintenance base never commenced the ‘Lost Tool’ procedure, and on December 11, the aircraft flew from LAX to Melbourne on a scheduled passenger flight.
Weeks later, engineers in Sydney had the missing tool report removed so that a ‘Certificate of Return to Service’ could be issued for the aircraft as it carried on flying around the world.
It was only on January 1, 2024, when the plane returned to Los Angeles and reentered the engineering facility for routine maintenance, that the tool was located by chance.
“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,” commented ATSB Chief Commissioner Angus Mitchell following the publication of the final accident report into the incident.
“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.”
Qantas had already completed an internal investigation prior to the publication of the final report, and the airline “briefed staff on the importance of ensuring all tooling is returned and actioned by tool store personnel.”
