Australian Transport Safety Bureau report lists series of Qantas protocol breaches over incident involving tools in engine

Australia’s transport safety regulator has criticized national carrier Qantas for a “cascade of errors” in which a 1.25 meter tool was left in an engine for 300 hours of flying.

A report released by the Australian Transport Safety Bureau (ATSB) details how maintenance staff ‘lost’ the ‘turning tool’ in the outboard engine of an A380, and this was only discovered after it was cleared for maintenance, involving multiple trips between Australia and the ONS.

The details were revealed within days of a 737 engine failure that made international headlines, when the QF-520 was forced to land at Sydney Airport with one engine working.

Aviation auditor Professor Ron Bartsch was previously a manager at the Civil Aviation Safety Authority (CASA) and was once head of safety at Qantas.

He is concerned that airline maintenance staff across the industry are overstretched and likened the missing tools incident to “an operation where the surgeon leaves one of the instruments in the body”.

A photo shows the equipment in question: a four-foot-long nylon turning tool, used during a maintenance procedure called a “borescope inspection,” in which engineers visually inspect the inside of the engine and use the tool to maneuver it.

‘A waterfall of mistakes’

What happened has been described by ATSB Chief Constable Angus Mitchell as “a failure on a number of levels and “a cascade of errors, of processes that were not followed.”

The ATSB investigation found there was a litany of missed opportunities to address the problem – including flags raised and ignored by Qantas employees – which ultimately resulted in a regulatory breach after several procedures were skipped.

The series of events began on December 6, 2023 when the Qantas Airbus A380, registered VH-OQI, entered the service hanger at Los Angeles International Airport (LAX) for a three-day scheduled maintenance check.

On the morning of the first day, three engineers were assigned to the boring task and the turning tool was used to inspect the left engine.

According to the report, two of the workers were “unfamiliar with the task” and were initially supervised by the third engineer. The latter left work early for a medical appointment.

Another team took over the job that afternoon. One of those workers left the tool on the engine intake, assuming it would be needed later. He was wrong.

Later that evening, the job was marked complete and an engineer inspected the engine with a flashlight, checking for “foreign object debris.” The engineer missed the turning tool.

A second engineer performed a second check but was also unable to discover the missing item.

At the end of the shift, after 9 p.m., an internal report showed that the tools had not been returned.

The ATSB report found that over the next two days, all relevant LAX service and aircraft personnel were notified of the situation, but the tool could not be located.

The Airbus was cleared for maintenance and returned to the air on the night of December 8. When he landed in Melbourne, the plane was not inspected, despite Qantas staff knowing the tools were missing.

The plane returned to LAX twice, on December 19 and again on December 28. Again – no checks.

By the end of the month, the ATSB report revealed that a Qantas employee had entered false information into the airline’s digital maintenance system to say it had been taken into account by the tool – again in breach of protocol.

On January 1, after 294 hours of flying, the Airbus returned to LAX for the fourth time, and that’s when the tool was found – during routine maintenance – ahead of the engine’s exhaust guide vanes, deformed by the pressure of the airflow.

No engine damage was reported.

Qantas says it won’t happen again

Qantas chief safety officer Mark Cameron said at 7.30pm that he did not believe there was ever any risk to the engine.

“It could have easily become loose and fallen to the ground. It wouldn’t have caused any impact to the engine itself,” Cameron said.

The ATSB refuted that statement.

“It doesn’t matter whether it’s the tip of a screwdriver or a three-foot nylon tool, whatever the composition of the tool itself doesn’t make it a higher or lower risk,” Mr Mitchell said.

Cameron acknowledges that the incident was a failure in the process.

“We worked with our teams… to understand our training and our processes and ensure this wouldn’t happen again,” he told 7.30.

Qantas avoided a fine from aviation regulator CASA, which told 7.30pm that it was “satisfied that Qantas has taken appropriate safety measures in response to the incident, in accordance with their safety management system, and that we have not taken any enforcement action”.

Bad look for Qantas?

However, Qantas denied that the two incidents within a year damaged its reputation for great safety, as Cameron said the airline’s handling of the blown engine in Sydney “improved” the airline’s reputation.

“We know that operational events will always happen,” he added.

“This particular engine has billions of flight hours around the world. It is one of the most widely used engines in the world and we continually ensure that we understand any issues with the engines so that we can proactively address them prior to events. happens.”

The fault is believed to have originated in the right engine’s turbine, which was almost twenty years old and nearing the end of its life.

Both Qantas and the ATSB have launched investigations, in collaboration with engine manufacturer GE.

Mr Mitchell said: “It is very rare that we have seen what we saw recently, but not unheard of”.

“Among the options we look at in our research is not only the lifespan of the engine, but also the maintenance history,” he told 7.30.

Qantas said safety for its passengers and crew remains the airline’s top priority.

‘A constant struggle’

While Qantas denies either incident is part of a ‘trend’, it is theorized that maintenance staff in the sector are significantly overstretched.

Professor Bartsch said that while the industry is back to pre-COVID levels in terms of passengers, the increased demand for staff is burdensome, especially after COVID-related layoffs are enforced.

“The problem is that a lot of people have left the industry, a lot of people have been made redundant, some illegally, and the result of that is an ongoing struggle for airlines and many other aviation sectors to actually recruit and retain people. qualified people to conduct safe operations,” he said at 7:30 p.m.

The union representing aeronautical engineers is the ALAEA. It consists of 2,000 members.

President Rod Wyse said engineers will never put an aircraft into service unless it is “100 percent safe,” but he acknowledged that the workforce is overstretched.

“Ten years is what it takes to become a licensed aircraft maintenance engineer. That is a generally accepted or agreed upon period of time,” he told 7:30 p.m.

“There is a big gap and drastic measures need to be taken to start training.

Qantas said it was ensuring a “pipeline” of skilled workers would be available, with plans to open a technical academy in 2025 to train the next generation of engineers.

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