Source : Perth Now news
A work light was accidentally left in the wing of a Qantas-operated aircraft which flew to the US and back before the mistake was even discovered by crews.
The Australian Transport Safety Bureau (ATSB) report into the maintenance blunder revealed the light was inadvertently left in a Qantas-operated A380 after maintenance was carried out on the aircraft’s air conditioning system at Sydney Airport on January 7 this year.
The plane flew to Dallas then returned to Sydney, before the light was removed two days later.
An ATSB investigation found workers failed to follow procedures on foreign object control and tool accountability processes.
ATSB Chief Commissioner Angus Mitchell said workers did not find the light during their foreign object clearance inspections at the end of the maintenance.
“The work light’s absence was not noticed when the maintainer returned the tools, or during the unreturned tool check at the end of the shift,” he said.
Despite the work light being unaccounted for, investigators found a licensed aircraft maintenance engineer issued a certificate to release the aircraft to service.
“Contributing to this, the operator’s maintenance information system did not provide a prompt or control to alert the certifier to the unreturned tool, or the un-actioned unreturned tool report,” Mr Mitchell said.
Since the incident occurred, Qantas issued a safety directive to address changes to its tooling control procedures.
“Even well-established processes can be vulnerable when they rely solely on consistent human performance, particularly during maintenance tasks, which are often conducted in challenging environments and under operational pressures,” Mr Mitchell noted.
“Tool control systems and procedures must account for this variability, with safeguards to detect and recover from errors.”A A Qantas spokesman said the event was reported to the ATSB and since then they have strengthened our tool control procedures.
“(This includes) introducing a mandatory pre-clearance check to confirm all tooling is accounted for following maintenance,” a spokesman said.
