Incident Details
On the night of 30/31 December 2016, the operator of a Bombardier DHC-8Q400 aircraft requested an A check from a Maintenance Organization. The aircraft was towed to the hangar of another Maintenance Organization. All necessary tools and materials were drawn from the main store located in the 'Rondo' building. During the inspection, one worker left the worksite to prepare and print required maintenance instruction cards.
After completion of the inspection, all tools and materials were checked before return to the store according to procedure. During this check, the loss of a flashlight was discovered. All areas of the aircraft, the hangar floor around it, toolboxes, and vehicles were inspected, and the relevant document MOE 2.6 'Lost Tool Searching Protocol' was completed. The flashlight could not be found.
The aircraft was towed out of the hangar. After sending reports and completing maintenance documentation, a further search for the flashlight was conducted in the Maintenance Organization's workshops – without result. Shortly thereafter, the Warsaw Chopin Airport Air Traffic Services informed the Maintenance Organization that the flashlight had been found near the runway. The location of the find suggested it had been left in the aircraft and fell out during takeoff.
Findings
The flashlight was lost during an A check procedure. Despite multiple searches in and around the aircraft, hangar, and workshops, it was not located until it was found on the airfield near the runway.
Causes
The investigation identified two causes for the incident: 1. Human error – leaving a tool in the serviced aircraft. 2. Insufficient tool control procedures.
Preventive Actions by the Maintenance Organization
The organization implemented several measures following the incident:
- Immediate inventory of the store in Warsaw.
- All flashlights at the Warsaw maintenance station were equipped with reflective straps to aid visibility in darkness.
- Additional individual training for involved personnel on 3 January 2017.
- A meeting of all store personnel, the Warsaw station manager, and the Maintenance Organization store manager to discuss the incident.
- A Quality Note was prepared for all personnel of the Maintenance Organization.
- The human factors training program in the Maintenance Organization was updated (to be completed within 3 months of the incident).
- The internal store procedure (IP.ST.001) would be reviewed and updated if necessary.
- All station managers of the Maintenance Organization became responsible for equipping flashlights with reflective straps.
- Information on remaining tool issue/return procedures would be sent to personnel via LMM.
- A review of existing procedures regarding the tool and material issue/return process was planned to improve them if needed.
- An additional inspection of all stores at the Warsaw maintenance stations was conducted.
No safety recommendations were issued by the investigation.