What happened
During a scheduled three-day maintenance period at Los Angeles International Airport (LAX) in early December 2023, a 1.25 m long nylon turning tool was inadvertently left inside the outboard left engine of an Airbus A380-842, registration VH-OQI. The tool, which had been used to rotate the compressor during a borescope inspection, became wedged against the low-pressure compressor outlet guide vanes and was deformed by airflow during flight. Following the maintenance event, the aircraft completed 34 flight cycles, totaling 293.74 hours, before the presence of the tool was discovered on 1 January 2024.
The investigation
The investigation examined why the tool was not detected during inspections and why lost tool protocols were not triggered. Maintenance personnel performed foreign object inspections of the engine inlet area, but the tool was not observed. One engineer inspected the area without a torch, while another used a torch but still failed to identify the object.
Several procedural failures contributed to the oversight. The investigation found that a lack of ownership and accountability among the maintenance team was exacerbated by the re-tasking of staff and the decision to leave tools on the task without a formal re-issue of tooling between shifts. Furthermore, when the tool was identified as unaccounted for in a daily report, the lost tool procedure was not initiated. The service engineer responsible for certifying the release to service did not review the tooling report and incorrectly assumed the missing item was a larger component that would have been more obvious if left in the engine.