Control procedures under scrutiny after missing tool undetected before aircraft released back to service.
Australian carrier Qantas has initiated work on using new technology for tool control, and revised its tool procedures, after an incident in which a maintenance lamp was left inside an Airbus A380 wing.
The aircraft had undergone work at Sydney following arrival from Los Angeles on 7 January this year.
Four personnel were assigned to the task and they had to tow the A380 from its arrival gate to a Qantas run-up bay to free the gate for other aircraft.
Cabin work to rectify minor defects meant the air-conditioning system was de-activated. Given that a cleaning crew was on board, and air temperatures were high, there was “added pressure” on the maintenance team to restore functionality, says the Australian Transport Safety Bureau.
The air-conditioning task required changing a sensor on a heat exchanger in the left wing. Several tools were signed out against the task, but a work lamp was signed out against the aircraft’s registration (VH-OQK).
Two engineers from the team carried out the sensor change, and the work lamp was switched off as they exited the wing. The supervising engineer then inspected the sensor work and all three proceeded to the cockpit to test the air-conditioning system.
Investigators state that the auxiliary power unit unexpectedly failed during start-up, which delayed the test by 30min. Once complete the supervising engineer carried out a foreign-object debris clearance inspection of the wing, using a torch.
“There was a requirement for the aircraft to be at the departure bay earlier than usual,” says the inquiry and, after the A380 was towed back, the supervising engineer had to leave to deal with an unexpected policy issue.
The remaining engineers continued departure preparations, and the team eventually took their first dedicated break, nine-and-a-half hours after beginning their shift.
Shortly afterwards the A380 departed for Dallas-Fort Worth. Maintenance was conducted on arrival by an external organisation, and did not use the Qantas tool-control system.
The aircraft departed for the return service to Sydney and arrived on 9 January. Upon the jet’s arrival, a tool crib operator looked into an unreturned tool report which indicated that a work lamp assigned to VH-OQK was missing.
After contacting the engineer who had signed out the tool, who raised the possibility that it remained in the aircraft wing, a search was initiated. The lamp was found in the wing.
“No adverse consequences, structural damage, or system disruptions resulted,” says the inquiry.
But it points out that foreign objects pose a “significant risk” to the safe operation of aircraft.
Qantas’s maintenance information system did not have an automated way to identify, to individuals certifying the release to service, that tools used were unreturned, it says.
The engineers did not notice the lamp remained in the wing, the inquiry states, adding that the type of tools used for the sensor change and the APU work meant the tools were returned to the crib without the engineers’ realising the lamp was still signed out.
“This occurrence demonstrates that even well-established processes are vulnerable when they rely solely on consistent human performance,” it says, especially since maintenance tasks are often carried out in “challenging environments and under operational pressures”.
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