Qantas Leaves a 1.25m Tool Inside Aircraft: Ron Bartsch Interviewed

The Australian Transport Safety Bureau (ATSB) has criticised Qantas for a “series of errors”, resulting in a 1.25 metre tool being left inside one if its A380 aircraft.

The aircraft was permitted to engage in several international trips between Australia and the United States before the tool was eventually discovered on 1 January 2024.

The ATSB announced on their website:

The 1.25 m long nylon tool, used to turn the engine’s intermediate‑pressure compressor during borescope inspections, was found wedged against the low-pressure compressor outlet guide vanes during a scheduled maintenance check at Los Angeles on 1 January 2024. It was determined that that the tool had been left in the engine during previous scheduled maintenance in Los Angeles on 6 December 2023.

It turns out that the aircraft had flown 34 cycles, altogether 293.74 hours, with the tool in the engine prior to its discovery on 1 January.

Source: Australian Transport Safety Bureau

How could a 1.25 metre tool have been left in an aircraft?

The ATSB stated that maintenance engineers had failed to commence a “lost tool procedure” before the aircraft had been released to service.

It also found that engineers had not noticed the tool was left in the aircraft engine’s low-pressure compressor case when conducting checks for foreign objects. This is what should have been done at the completion of a borescope inspection task.

In the ATSB’S published report, a service engineer commented that they were aware a tool was identified as missing on day one of servicing.

However, there was a belief that “the tool was a larger, gearbox turning tool that required physical fitment to the engine and could not possibly be fitted to the aircraft without being visible. Therefore, the tool could not be on the aircraft”.

The service engineer therefore certified the relevant Certificate of Release to Service (CRS) and released the aircraft for flight, upon the incorrect belief that the tool was not on the aircraft.

You can read the ATSB’s report in full here.

What are the safety dangers of tool being left in an aircraft’s compressor case?

If there is foreign object debris (such as a tool) in places where they shouldn’t be upon the aircraft, there is considerable threat to the safe operation of an aircraft.

Foreign object debris can cause a wide range of safety hazards, such as dents, punctures or structural damage to the aircraft’s fuselage or wings. In the worst case scenario, it can lead to injuries to aircraft or airport personnel, or passengers.

Thankfully, no engine damage was reported.

Like a “surgeon leaving an instrument inside the body”: Ron Bartsch

Avlaw Aviation Consulting Founding Director Ron Bartsch was interviewed by the 7.30 Report on the ABC about this incident.

Professor Bartsch described the incident as akin to “an operation where the surgeon leaves one of the instruments inside the body”.

Source: ABC

He did, however, show some concern for the airline maintenance staff, expressing that they may be overstretched.

Following the incident, Qantas Engineering raised an internal incident report and an internal safety audit directive for immediate action was released.

The Civil Aviation Safety Authority (CASA) stated that they were satisfied with Qantas’ safety action in respect to the incident. For that reason, no enforcement action was taken.

Mark Cameron, Qantas’ head of safety, told the 7.30 report: “We have worked with our teams … to understand our training and our processes to make sure that this wouldn’t happen again”.