On December 6, 2023, an Airbus A380 from Qantas, registered as VH-OQI, entered a scheduled inspection at Los Angeles International Airport (LAX), United States. During the maintenance tasks, a tool was left behind inside one of its engines. The aircraft flew 34 cycles, accumulating 293.74 hours of flight before the piece, a 1.25-meter-long nylon turning tool, was discovered on January 1, 2024, during a new inspection.
According to the final report by the Australian Transport Safety Bureau (ATSB), the tool was not detected during foreign object inspections at the conclusion of the task. Additionally, Qantas Engineering’s lost tool procedure was not activated before releasing the aircraft back into service, allowing the aircraft to fly without a full tool inventory check.
On December 6, 2023, the VH-OQI underwent a three-day maintenance inspection, which included a borescope inspection of the left outer engine, or engine 1. During this task, a turning tool was used which, due to a shift change and lack of follow-up, was left inside the engine. Maintenance technicians, failing to conduct a complete check at the end of the task, allowed the aircraft to be certified for its next flight without confirming the return of the tool.
On December 8, the aircraft was released to fly to Melbourne despite daily tool reports indicating that the device was missing. A service engineer, who incorrectly believed that the missing tool was too large to be inside the aircraft without being visible, decided to authorize the flight without conducting the necessary inspection. Over the following weeks, the Airbus A380 flew 34 cycles, accumulating 293.74 flight hours, without the tool being detected in the engine.
Finally, on January 1, 2024, the aircraft returned to LAX for another scheduled inspection, during which technicians discovered the tool inside the engine’s low-pressure compressor.
The investigation revealed that poor communication and task handover between shifts contributed to the loss of accountability and follow-up for the tool, particularly when staff changed shifts during the engine inspection process. In an interview, the service engineer stated that they had incorrectly assumed the missing tool was larger and visible, which led to bypassing the lost tool procedure and certifying the aircraft without thoroughly verifying the tool report.
Qantas corrective actions
Following the incident, on January 2, 2024, Qantas issued an internal report reminding its staff of the importance of tool control and return. On March 4, 2024, an internal safety directive was issued requiring all Qantas maintenance personnel to fully comply with tool control requirements without exception.
