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Qantas Airbus A380 flew for 294 hours with tool lodged in engine: ATSB report

Umito November 14, 2024

The official report into how a Qantas Airbus A380 flew for almost 300 hours and 34 flights with a tool lodged in one of its four engines has been released by the Australian Transport Safety Board (ATSB). The report contains recommendations that the Australian airline should follow in order to avoid such events in the future.

On December 6, 2023, one of Qantas“A fleet of 10 Airbus A380-842s arrived at Los Angeles International Airport (LAX) at the end of a scheduled passenger flight from Sydney (SYD). Airline engineers have begun a check maintenance on the aircraft (registered VH-OQI) while it was on the ground at LAX before its return flight to Sydney which took place without incident.

The affected aircraft then flew 294 hours and completed 34 sectors (17 round-trip flights) before its next scheduled maintenance visit which was also carried out while the aircraft was on the ground in Los Angeles on January 1, 2024, i.e. almost one month after his previous check.

However, while inspecting the plane’s four Rolls-Royce engines, an engineer discovered a 1.25m-long nylon tool wedged against the low-pressure outlet guide vanes of one of the engines. These blades joined together from the fan, visible when looking at the engine from the front, constitute a key element of jet turbine engines. The tool is of the type used to spin an engine compressor during borescope inspections, during which a detailed examination of engine components is carried out.

Spyros Vasileiou Shutterstock

After reviewing the plane’s maintenance records, the ATSB concluded that the tool had been left in the engine during its previous check in Los Angeles, approximately 26 days before it was finally discovered. Investigators also found that the tool was not detected during a shorter maintenance check performed on the plane at the end of a three-day maintenance period in December 2023. It had not neither been noticed by the crews during their external pre-flight checks before each flight. of the 34 flights.

The ATSB reported that although the tool itself had suffered damage and was “deformed” due to its location in the engine and “by high energy airflow”, miraculously it had not caused no damage to the engine components itself.

Qantas rated by ATSB

What did the ATSB say?

“The ATSB investigation found that maintenance engineers failed to notice that the tool had been left in the engine’s low-pressure compressor housing when checking for foreign objects at the end of the borescope inspection task,” said ATSB Chief Commissioner Angus Mitchell.

“Additionally, maintenance engineers did not begin the lost tool procedure once the tool had been identified as missing, and the certification engineer returned the aircraft to service with the carried tool disappeared,” he added.

The ATSB investigators’ report said the turning tool had been left inside the engine inlet by a Los Angeles engineer who thought it would be needed later during maintenance. However, later engineers did not notice it and, despite filing a missing tool report at the time (a mandatory requirement when a tool goes missing), it was only found when the engine was inspected as part of scheduled maintenance in Los Angeles. almost a month later.

“Debris and foreign object 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 damage from foreign objects. foreign bodies, particularly those coming from objects introduced during maintenance. Properly applying tool control is fundamental to mitigating any human error that may occur,” the ATSB report concludes.

ATSB

The report goes on to say that following the discovery, Qantas Engineering management informed all staff of the importance of ensuring tools were returned and used by store staff. The carrier also launched an internal investigation which led to the implementation of a new safety directive regarding the importance of complying with tool control requirements.

In response to the report’s findings, the airline said in a statement that the turning tool, a piece of flexible plastic, had no effect on the operation of the engine and that it had cooperated fully throughout. the ATSB investigation.

“We take this extremely seriously and although there has been no damage to the engine, it is essential that the correct lost tooling processes are followed,” a spokesperson said. “Since this event, we have issued an internal safety directive reminding our engineers and tool shop team members to follow these processes to ensure this does not happen again. »