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Tool left in A380 engine after maintenance inspection highlights importance of tool control


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The turning tool as found in front of the low-pressure compressor outlet guide vanes

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
Publication Date
14/11/2024

rtoldman wrote: ↑Fri Nov 15, 2024 10:36 pmcould this have been picked up off the ground?

The aluminum ladder left in the test cell one day at GE was completely ingested...

Nik_SpeakerToCats wrote: ↑Sat Nov 16, 2024 3:47 pm One of my neighbours is a senior 'Staff Nurse', has conveyed several 'educational' tales.

One story concerns a theatre nurse whose task, per that famous Falklands Mission reporter, was to wield a check-list, meticulously count them out, then count them in again.

Apparently, just as a surgeon was 'closing up', this normally unflappable lady had hysterics.

Her tray now held an extra, unlisted item...

Nik_SpeakerToCats wrote: ↑Sat Nov 16, 2024 12:16 am Snark #1:
At least it wasn't ubiquitous 10 mm box-spanner...
/
Snark #2:
I'm confident the term 'BOEING !!!' was oft repeated during those urgent safety briefings...
/

Belushi TD wrote: ↑Mon Nov 18, 2024 2:30 pm

Nik_SpeakerToCats wrote: ↑Sat Nov 16, 2024 12:16 am Snark #1:
At least it wasn't ubiquitous 10 mm box-spanner...
/
Snark #2:
I'm confident the term 'BOEING !!!' was oft repeated during those urgent safety briefings...
/

Snark #3:
Now we know where the 10 mm wrenches disappear to when they go missing.

kdahm wrote: ↑Mon Nov 18, 2024 3:37 pm The 10mm wrenches are easy to find. Usually only takes a couple of minutes if they're not in the assigned spot. Its the bloody 10mm 1/4 drive sockets that go wandering and can't be found.

Which is why I bought three standard and two deep socket, so I can usually get one while the others wander back in.

kdahm wrote: ↑Mon Nov 18, 2024 3:37 pm

Belushi TD wrote: ↑Mon Nov 18, 2024 2:30 pm

Nik_SpeakerToCats wrote: ↑Sat Nov 16, 2024 12:16 am Snark #1:
At least it wasn't ubiquitous 10 mm box-spanner...
/
Snark #2:
I'm confident the term 'BOEING !!!' was oft repeated during those urgent safety briefings...
/

Snark #3:
Now we know where the 10 mm wrenches disappear to when they go missing.

The 10mm wrenches are easy to find. Usually only takes a couple of minutes if they're not in the assigned spot. Its the bloody 10mm 1/4 drive sockets that go wandering and can't be found.

Which is why I bought three standard and two deep socket, so I can usually get one while the others wander back in.

kdahm wrote: ↑Mon Nov 18, 2024 3:37 pm

Belushi TD wrote: ↑Mon Nov 18, 2024 2:30 pm

Nik_SpeakerToCats wrote: ↑Sat Nov 16, 2024 12:16 am Snark #1:
At least it wasn't ubiquitous 10 mm box-spanner...
/
Snark #2:
I'm confident the term 'BOEING !!!' was oft repeated during those urgent safety briefings...
/

Snark #3:
Now we know where the 10 mm wrenches disappear to when they go missing.

The 10mm wrenches are easy to find. Usually only takes a couple of minutes if they're not in the assigned spot. Its the bloody 10mm 1/4 drive sockets that go wandering and can't be found.

Which is why I bought three standard and two deep socket, so I can usually get one while the others wander back in.

Poohbah wrote: ↑Fri Nov 22, 2024 4:47 am We had a missing tool report signed off as "tool stolen" at my last duty station, and I knew it was BS.

Well, I mailed the report to COMNAVAIRPAC as I was processing out, along with a lot of other stuff outlining how they were breaking lots of regulations, and it got there after I was a civilian.

My sources tell me the AIRPAC inspection team found the missing tool under the floorboards, wedged in some cables, and about two inches from a bellcrank.

Heads rolled.

jemhouston wrote: ↑Fri Nov 22, 2024 11:55 am

Poohbah wrote: ↑Fri Nov 22, 2024 4:47 am We had a missing tool report signed off as "tool stolen" at my last duty station, and I knew it was BS.

Well, I mailed the report to COMNAVAIRPAC as I was processing out, along with a lot of other stuff outlining how they were breaking lots of regulations, and it got there after I was a civilian.

My sources tell me the AIRPAC inspection team found the missing tool under the floorboards, wedged in some cables, and about two inches from a bellcrank.

Heads rolled.

Did enough roll?