Created Thursday, Nov 14th 2024 12:01Z, last updated Thursday, Nov 14th 2024 12:01Z
A Qantas Airbus A380-800, registration VH-OQI performing flight
QF-11 from Sydney,NS (Australia) to Los Angeles,CA (USA) with 435 passengers and 26 crew, completed the flight without apparent incident.
The aircraft subsequently went into maintenance, where it was discovered a tool had been left in the left hand engine (Trent 972) during previous maintenance between Dec 6th and 9th 2023. The tool had been missing since.
On Nov 14th 2024 the ATSB released their final report concluding the causes of the incident were:
Contributing factors
- An aircraft maintenance engineer and a licenced maintenance engineer did not observe an engine turning tool that was left in the low-pressure compressor case during their foreign object inspections after maintenance on the engine.
- The lost tool procedure was not commenced by the involved aircraft maintenance engineers when the tool was identified as missing.
- The service engineer certified a certificate of release (CRS) with the tool unaccounted for. As a result, the aircraft flew 34 cycles and 293.74 hours with the turning tool in the outboard left engine low-pressure compressor.
The ATSB summarized the sequence of events:
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.
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.
The ATSB released following safety message:
Foreign object debris and damage poses a significant threat to the safe operation of aircraft. Regulations, procedures, and training have been put in place and refined to limit the risk of foreign object damage, especially from introduced objects during maintenance. As a result, the correct application of tool control is an important, fundamental, and necessary aspect of the maintenance process to mitigate any human errors that may arise.
Related Flight:
QF11,
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