A maintenance tool left inside a Qantas Airbus A380 engine went undetected for 34 flights spanning nearly 300 flight hours before its discovery during routine maintenance, according to an Australian Transport Safety Bureau (ATSB) investigation report released Thursday.
The incident involved a 1.25-meter nylon turning tool that was left in the outboard left engine of the Airbus A380-842 (registration VH-OQI) during a scheduled borescope inspection at Los Angeles International Airport on December 6, 2023.
The ATSB report revealed that the tool remained undiscovered despite multiple inspections and warnings about missing equipment. The aircraft continued operating passenger flights between Australia and the United States until January 1, 2024, when engineers found the deformed tool wedged against the engine’s low-pressure compressor outlet guide vanes.
“The tool was not located during the end of task foreign object inspections, which resulted in it remaining in the engine,” the ATSB stated in its report. “The Qantas Engineering lost tool procedure was not commenced prior to the aircraft being released to service.”
According to investigators, several factors contributed to the oversight, including staff unfamiliarity with the maintenance task, shift changes, and incomplete follow-up on missing tool reports. The investigation found that required tool control procedures were not properly followed when the maintenance task was handed over between shifts.
Despite flying with the foreign object for 293.74 hours, no damage was observed to any engine components. The incident prompted Qantas Engineering to take immediate corrective actions, including staff briefings on tooling control requirements.
On March 4, 2024, Qantas Engineering’s executive manager issued an internal safety directive requiring all employees to strictly adhere to the company’s tooling control requirements without exception.
The ATSB emphasized that foreign object debris poses a significant threat to aircraft safety, highlighting the importance of proper tool control during maintenance procedures.
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