Posted on 11/15/2024 2:43:33 PM PST by nickcarraway
Emails and tool-tracking software weren't heeded, but nothing scary happened - except to the nylon tool
An Airbus A380 operated by Australian airline Qantas clocked over 290 hours of flight time despite a tool having been left inside one of its engines, according to a report from the Australian Transport Safety Bureau.
The 1.25 meter nylon rod, a "turning tool", was used during an inspection of the left outer engine's intermediate-pressure compressor on December 6 of last year, during a three-day routine maintenance check at Los Angeles Airport (LAX).
It was left in the engine by a maintenance worker who departed his shift early for medical reasons. The worker was told to leave it in place, as it was still in use, and assumed a colleague would ensure the tool was removed.
Over the course of the three-day inspection period, multiple engineers rotated shifts. It was noted that the tool had not been returned after being checked out. Maintenance crews did search for the tool, but it wasn’t found during two inspections – first because it was dark and an engineer didn't use a flashlight, and the second time because the inlet cowl where it sat was not examined.
According to the Safety Bureau report, at least some of the engineers didn't even realize what part they were looking for and thought the missing tool was a larger gearbox turning tool. If it had been the gearbox tool, it would have been reasonable to assume it would be more visible inside the engine.
A missing tool report was lodged in software used to manage maintenance – but the required follow-up never happened. Despite the fact the tool was known to be missing, the giant jet was signed out of maintenance and allowed to fly. Qantas personnel in Sydney even requested removal of the report as it was causing problems – in response, the tool's status was downgraded.
Thirty-four flight cycles and 293.74 flight hours later, the tool was found during another routine scheduled maintenance session – nearly a month after it had been lost. It was found lodged behind the low-pressure compressor (LPC) blades.
Boom Supersonic takes baby steps toward breaking the sound barrier The Safety Bureau noted that there was no observable damage to any engine components. However, the incident did cause damage to the tool, as it was deformed by airflow.
As you’d expect after nearly 300 hours in the challenging environment of a jet engine.
The board noted that had the tool been left in a different position – for example in front of the low-pressure compressor – it may have been more visible to the engineers. It also would have caused more damage in that position, as it would pass through the rotating LPC blades during flight.
The mishap has been chalked up to having a rotating crew of maintenance workers, and bad advice to leave the tool in place – which diminished any sense of ownership and accountability for its whereabouts.
Qantas has taken action. It filed an internal incident report when the tool was found, and briefed staff on the importance of using tracking software – and presumably not leaving them in the engines of an A380. In March it completed an internal investigation and issued engineers a safety directive on tools.
The affected aircraft continues to operate in Qantas's fleet – which is quite a lucky outcome.
The Register spoke to two aircraft engineers about the incident – both of whom requested anonymity.
"Any Foreign Object Debris (FOD) can lead to catastrophic engine failure," summarized one of the aviation professionals. "Standard practice is to check tools in and out to prevent this."
"There would be negligible impact to performance, though the safety risk would be quite large. The odds of a tool such as this causing a catastrophic engine failure would be quite high," explained the other. "While the engine failure wouldn't necessarily lead to loss of the aircraft, the debris could."
"The fact the tool was left on the aircraft is a severe breach of flight line safeguards, where all tools should be accounted for before the aircraft is returned to service," he added.
The crashes of Southwest Airlines Flight 1380 in 2018 and that of United 232 in 1989 were both attributed to uncontained engine failures caused by loose debris, though neither was a result of an errant tool. In both cases, engine components broke apart and debris escaped the engine casing.
The Southwest Airlines incident resulted in one fatality and many injuries, while the United Airlines crash led to 111 fatalities.
The aviation industry has faced much scrutiny lately over safety. Notably, the US Department of Justice lodged a criminal investigation this year against Boeing when an aircraft door plug blew out of a 737 MAX 9 flight in January.
It's also recently experienced labor strikes from well-known airplane makers – including Textron and Boeing – as unionized workers seek better pay and working conditions. ®
Don’t get me started where 10mm sockets end up.
The same thing happened to me when I had my Bentley serviced.;-)
I have found that bulldozers are notorious for swallowing tools into their belly pans such tools never to be seen again.
I have been in aviation going on 25 years now. The worst case I saw was someone left a pile of rags in the wing fuel tank that both the mechanic (A&P) and QA inspector BOTH signed off and used their stamps from the FAA to say the inspection had taken place.
And on the best flight possible to lose an engine halfway: Sydney <—> LA. At least 10 hours over the Pacific.
They bought their tickets.
They knew what they were getting in to.
I say, let-um crash!
Or, under the center of the vehicle; or, in the center of the intersection where the tool fell out during a turn.
They do way a way better job at Uncle Ed’s oil change.
Someone has to do it:
List of pilot-reported problems and the solutions the ground crew had for them.
Problem: Left inside main tire almost needs replacement.
Solution: Left inside main tire almost replaced.
Problem: Test flight OK, except auto-land very rough.
Solution: Auto-land not installed on this aircraft.
Problem: Something loose in cockpit.
Solution: Something tightened in cockpit.
Problem: Dead bugs on windshield.
Solution: Live bugs on back-order.
Problem: Autopilot in altitude-hold mode produces a 200 feet per minute Descent.
Solution: Cannot reproduce problem on ground.
Problem: Evidence of leak on right main landing gear.
Solution: Evidence removed.
Problem: DME volume unbelievably loud.
Solution: DME volume set to more believable level.
Problem: Friction locks cause throttle levers to stick.
Solution: That’s what friction locks are for.
Problem: Suspected crack in windshield.
Solution: Suspect you’re right.
Problem: Number 3 engine missing. (pilot lingo meaning one of the engines was not running smoothly)
Solution: Engine found on right wing after brief search.
Problem: Aircraft handles funny
Solution: Aircraft warned to straighten up, fly right, and be serious.
Problem: Target radar hums.
Solution: Reprogrammed target radar with lyrics.
Problem: Mouse in cockpit.
Solution: Cat installed.
Problem: Noise coming from under instrument panel. Sounds like a midget pounding on something with a hammer.
Solution: Took hammer away from midget.
It’s a Zelensky. Don’t water it.
“Don’t get me started where 10mm sockets end up.”
And for me I seem to have an inexhaustible supply of 11mm sockets, although I don’t think I’ve used one a single time.
Yikes - why was that aircraft not Red X’d?
Don’t they use tool cutouts and chits for tools taken out of toolboxes and the master toolkits?
And then check for tool accountability at the end of the worksheet?
Good grief.
I belong to the 10 millimeter socket of the month club
Re: 19 - yes.
Nice post.
he installed a pressure gauge on the pipe and found out the line pressure regulating valve was passing too much pressure. Why? Because the installed PRESSURE GAUGE was stuck!!!!!
The valve was a PITA to get to and was probably removed 3 or 4 times!! Everybody assumed the relief valve was bad because it was a common issue with this brand.
Same with the Navy. The aircraft is DOWN until all tools, parts, & supplies are accounted for. Every maintenance procedure, including tool control, is written in blood. Same with operations in any other zero defect environment.
It's inexcusable. Some supervisor likely threatened them to get the plane back in service.
11”nobody noticed the empty space on the pegboard???”
Silly post from someone that didn’t read the article ...
The aerospace equivalent to putting black tape over your car's 'check engine' light.
When I was in the Air Force we had a physical "chit" system of tool tracking. You were assigned a ring of 10 "chits" with your name on them (they were literally dog tag blanks) and every time you took a tool out of the tool crib you left your chit in its place.
If everybody didn't turn in all of their chits at shift's end, nobody went home until the missing tool was found. If as in this case the tool was needed by the next shift, then someone from that shift swapped their chit for yours in the tool crib so you could get your chit back and go home.
lol
Disclaimer: Opinions posted on Free Republic are those of the individual posters and do not necessarily represent the opinion of Free Republic or its management. All materials posted herein are protected by copyright law and the exemption for fair use of copyrighted works.