The Australian company’s mechanics lost a tool while servicing the device in Los Angeles in late 2023. It flew almost a month before the tool was found.
Thirty-four flights and 294 hours in the sky… with a forgotten instrument inside the engine. A relationship of the Australian Transport Safety Bureau published on Thursday 14 November reveals an accident involving a Qantas Airbus A380 in late 2023, following maintenance. The lost tool, which measured 1.25 meters but fortunately did not cause any damage to the engine, was found only a month after it was put back into commercial service, during a new routine check.
At the beginning of December 2023, the Qantas A380 spent three days at Los Angeles airport for a scheduled maintenance check, carried out by the Australian company’s technicians. The investigation determined that it was on December 6 that the tool was used in a left engine of the plane, during a visual inspection. The maintenance worker assigned to the instrument leaves work early for a medical visit. Their pair is assigned to another task and a new pair takes over, without the tools being returned and then reassigned.
The instrument searched, but after the departure of the plane
At 3pm the daily tool inventory confirms that the tool is still assigned and has not been returned. It was one of the two officers who inspected the engine that afternoon, who was unfamiliar with this operation, who left the lathe tool in the engine, thinking it would be used again later. At the end of the day the tool was not located, despite visual inspection of the device with a flashlight.
Daily inventories for the next two days still indicate the tool is missing. Despite this, authorization was granted to resume commercial service and the plane was able to leave on the evening of 8 December for Melbourne. The officer to whom he was assigned, as well as his supervisor, were absent for several days after December 6. Only when the supervisor returned, when the A380 had already left the workshop, did the search for the tool begin and a report was drawn up formally reporting its disappearance.
However, no device inspection will be carried out to locate the missing instrument, neither in Australia nor in Los Angeles, where it returned twice, on December 19 and 28. Only on 1 January 2024, when the A380 returned to the workshops for a new scheduled maintenance, the tool was located in the engine and removed. The investigation report indicates that the tool was deformed but did not cause damage to any engine components.
Qantas told investigators it took action following the incident. An internal incident report was issued on January 2 to raise awareness among engineers of the issue, followed by a reminder of procedures in early March.
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How can airlines improve maintenance protocols to prevent incidents like the Qantas A380 oversight?
Time.news Interview with Aviation Safety Expert Dr. Emily Tran
Editor, Time.news: Welcome, Dr. Tran! Thank you for joining us today to discuss the recent incident involving Qantas and their A380. Just to set the stage, could you briefly summarize what happened during this maintenance check in Los Angeles?
Dr. Emily Tran: Absolutely! In December 2023, a Qantas A380 underwent a scheduled maintenance check at Los Angeles airport. During this process, a maintenance worker mistakenly left a tool measuring about 1.25 meters inside the left engine after taking over for a colleague. This oversight went unnoticed for quite some time, resulting in the aircraft operating for thirty-four flights over a period of nearly a month before the tool was finally discovered during a routine inspection.
Editor: That’s quite concerning, especially with such a large aircraft. Fortunately, it sounds like there was no damage, but what does this incident say about maintenance protocols in aviation?
Dr. Emily Tran: It highlights a critical gap in safety procedures and communication among maintenance crews. Tools and equipment should always be accounted for before the completion of maintenance tasks, ideally through a double-check system. In this case, a misunderstanding occurred when one worker had to leave early for a medical appointment, and proper re-assignments were not communicated effectively.
Editor: So, you’re suggesting that the issue was partly due to human error compounded by a lack of established protocols?
Dr. Emily Tran: Yes, exactly. In high-stakes environments like aviation, we must favor redundancy in checks to prevent such oversights. A robust inventory system could have flagged the tool as still assigned when it shouldn’t have been, especially after the shift change.
Editor: This might also raise questions about the broader implications for passenger safety. What do you think the potential risks are when maintenance procedures aren’t strictly adhered to?
Dr. Emily Tran: While this specific incident resulted in no visible damage, the risks associated with neglecting maintenance protocols can be dire. Even a seemingly harmless tool left in an engine may lead to more severe mechanical failures, which can compromise flight safety. This incident is a wake-up call for airlines to reinforce their safety training and operational procedures.
Editor: After this incident, do you think we should expect changes in regulations or practices within the aviation maintenance industry?
Dr. Emily Tran: There’s likely to be increased scrutiny of maintenance practices, especially with regulatory bodies wanting to prevent similar events. Airlines may implement more stringent guidelines regarding tool inventory checks and introduce new technologies for better tracking. Moreover, we might see more emphasis on crew training programs to reinforce the importance of communication and accountability in these environments.
Editor: Thank you, Dr. Tran. It’s essential that both the industry and the public remain aware of these vital safety measures. Before we wrap up, what advice would you give to crew members involved in maintenance operations?
Dr. Emily Tran: My primary advice would be to adhere to the motto that “safety is everyone’s responsibility.” Coordination and communication are key. Every member of the crew must feel empowered to speak up if something appears amiss. Additionally, utilizing checklists and conducting debriefs after shifts can reinforce accountability.
Editor: Great points! Thank you for your insights today, Dr. Tran. This incident has opened a much-needed dialogue about maintenance practices in aviation, and we appreciate your expertise.
Dr. Emily Tran: Thank you for having me! It’s crucial we continuously evaluate and improve our safety protocols to ensure the safety of all passengers.