2010-12 · NASA ASRS report 922661
A Maintenance Technician failed to accurately account for all the tools used to perform maintenance on the aileron of a BE1900. His newly purchased ratchet screwdriver was later discovered in the aileron hinge cove where the task was performed.
I was assigned to work on an aircraft that was scheduled for a C1 external wing inspection. The task was to work on a discrepancy that was found by the inspector that states: 'R/H (right hand) aileron O/B (outboard) bonding jumper is frayed'. I grabbed a ladder and got access to the bonding Jumper. I determined the tools I needed to do the job. The access to the hardware attached to the aileron was very limited. I decided to remove it first. I went to my toolbox and grabbed my small ratchet screw driver that I just brought a couple days ago and for which I did not have a shadow cut in my box for accountability. I also grabbed a 1/4 inch socket; a small extension and a regular ratchet. I then found that the ratchet screwdriver had no grip on the screw head so I laid the ratchet screw driver on top of the wing and went back to my box to find a more suitable tool and then completed the task. After installation; I moved the right aileron up and down many times to check for clearance. I also went in the cockpit and moved the yoke left to right and right to left a couple of times. Everything checked normal. I went to the right wing and took all the tools; which were on top of the ladder; and laid them in their shadow in the toolbox. I forgot the small ratchet screwdriver on top of the wing.I did an inventory of my tools and did not notice the missing tool since there was no shadow cut for it. It was now very early in the morning. I signed the Job Card and put it with the aircraft paper work on the podium. The Inspector checked the right aileron and the area and conducted a primary control surface check and everything checked normal. Before leaving work I opened my box and inventoried my tools and still did not notice the missing tool. I went home that morning. I came to work that evening as scheduled. In the maintenance meeting; we were told that a tool was found on an aircraft and we needed to check for a missing tool. After the meeting was over; I went to my box and checked and did not notice any missing tool. A couple minutes later the Supervisor approached me and told me that they found a ratchet screwdriver at right hand aileron and that it was mine.Since then; I tried to remember all of my steps of that evening and kept thinking how this incident could have evolved to a disaster. To avoid this type of incident in the future; we need to: update tool accountability lists when adding a new tool before accomplishing any task; allow random tool box inspection by a Supervisor to check if accountability list is updated; never lay a tool on an aircraft surface--use a small box or bag; return tools to tool box as soon they are not needed; check all area covered after finishing a task.
I inspected the bonding strap installation and found no discrepancy or foreign objects in the vicinity of the outboard hinge cove. A full travel sweep of the flight controls as part of the A check task card was also performed and revealed no abnormalities. The inspection was completed and the aircraft returned to service.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.
Loading the flight search…
Pick an aircraft model — Boeing 737, Airbus A320, A380, Boeing 787 Dreamliner and more — enter your origin airport, and FlightFinder shows every route that plane flies from there with live fares.
We support Boeing 737/747/757/767/777/787, the full Airbus A220/A319/A320/A321/A330/A340/A350/A380 family, Embraer E170/E175/E190/E195, Bombardier CRJ and Dash 8, and the ATR 42/72 turboprops.
Search and schedules are free. Pro ($4.99/month, $39/year, or $99 one-time lifetime) unlocks the enriched flight card — on-time stats, CO₂ per passenger, amenities, live gate & weather — plus My Trips with push alerts.
Live schedules come from Amadeus, AeroDataBox and Travelpayouts. Observed routes (which aircraft actually flew a given city pair) are crowdsourced from adsb.lol ADS-B data under the Open Database License.