A Qantas Airbus A380 operated multiple flights with a tool inside one of its engines. Maintenance engineers did not commence the lost tool procedure prior to the aircraft being released to service. An ATSB investigation report provides details of the incident.
The 1.25 m long nylon tool is used to turn the engine’s intermediate‑pressure compressor during borescope inspections. It was found wedged against the low-pressure compressor outlet guide vanes during a scheduled maintenance check at Los Angeles on 1 January 2024.
The Incident Timeline
The incident began on December 6, 2023, when Airbus A380-842, registered VH‑OQI underwent scheduled maintenance. The maintenance activity was performed at Los Angeles International Airport.
Engineers accidentally left the tool in the left outboard engine’s inlet during a borescope inspection on the first day.
Two days later, without anyone noticing the missing tool, the aircraft received clearance to fly and departed for Melbourne. By the time of its discovery in January 2024, the A380 had completed 34 flight cycles, accumulating nearly 294 flight hours with the tool inside.
Surprisingly, while the powerful airflow had warped the tool, the engine sustained no damage during these flights, highlighting the robust design of modern aircraft engines.
Investigation Findings
ATSB Chief Commissioner Angus Mitchell explained the situation. “Our investigation revealed two critical oversights.Engineers failed to detect the tool during foreign object checks after the borescope inspection. Then they didn’t initiate the required lost tool procedure when the tool went missing.”
The investigation highlighted the importance of following established maintenance protocols and the potential risks associated with overlooking standard safety procedures.
This incident served as a wake-up call for the industry regarding the critical nature of tool control and accountability during maintenance operations.
Rectification Actions
In response to the maintenance incident, Qantas Engineering implemented comprehensive measures to prevent similar occurrences in the future.
The airline immediately conducted extensive staff briefings to reinforce the importance of proper tool management and accountability. These sessions emphasized the critical nature of ensuring all tools are properly accounted for and returned to the tool store after maintenance work.
The company also strengthened its tool control protocols, requiring more rigorous documentation and verification processes for all maintenance equipment.
Additionally, Qantas issued an internal safety directive that reinforced existing company tool control policies and introduced new oversight measures to ensure compliance.
Mitchell emphasized the broader implications of the incident. “Foreign objects pose serious risks to aircraft safety. That’s why we have strict regulations and procedures for maintenance. Proper tool control serves as a crucial defense against human error.”
He added that this event serves as a reminder to the entire aviation industry about the importance of maintaining strict adherence to maintenance procedures and tool control protocols. The full ATSB Report can be accessed here.
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