A tool used to turn an engine compressor during borescope inspections has been left inside and was found a month later.
On 6 December 2023, an Airbus A380-842 aircraft, registered VH‑OQI and operated by Qantas Airways Limited, was undergoing a 3-day scheduled maintenance check at Los Angeles International Airport (LAX), United States.
On day one of the maintenance check, during a scheduled borescope inspection of the outboard left engine, a tool was left in the engine inlet. On the evening of 8 December, the aircraft was released to service and departed for Melbourne, Victoria.
On 1 January 2024, the aircraft returned to the LAX maintenance facility for a 3-day scheduled maintenance check, where the missing tool was discovered in the outboard left engine low‑pressure compressor. The aircraft had flown 34 cycles totalling 293.74 hours with the tool in the outboard left engine.
What the ATSB found
The ATSB found that the tool was not located during the end of task foreign object inspections, which resulted in it remaining in the engine. The Qantas Engineering lost tool procedure was not commenced prior to the aircraft being released to service and the certifying engineer did not follow up on the lost tool, prior to releasing the aircraft to service.
What has been done as a result
On 2 January 2024, a Qantas Engineering internal incident report was raised with an immediate action to brief staff on the importance of ensuring that all tooling is returned and actioned by tool store personnel. A Qantas Engineering internal investigation was completed and on 4 March 2024, the executive manager for Qantas Engineering released an internal safety directive for immediate action requiring all Qantas Engineering employees to meet the company tooling control requirements without exception.
