Airbus A380 flew for 300 hours with metre-long tool left inside engine An Airbus A380 operated by Australian airline Qantas clocked over 290 hours of flight time despite a tool having been left inside one of its engines, according to a report from the Australian Transport Safety Bureau. The 1.25 metre nylon rod, a "turning tool", was used during an inspection of the left outer engine's …
I imagine within seconds after first starting that engine either the tool would disintegrate into hundreds of tiny harmless (we hope!) pieces and/or the engine would exhibit some serious symptoms that would trigger a few alarms in the cabin if not on the ground to the ears of nearby engineers, so it could never have passed through when passengers were on board let alone during flight.
Nope. The damage would happen when it got dislodged and said hello to high speed rotating components.
The most likely times for this to happen is when the aircraft bounces or the engine radically changes thrust demand.
So that'd be during landing, turbulence, or an abort. In other words, when the pilots have the greatest need of working engines.
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>Photo shows something that's not twisty enough to be a duck.
Perhaps just a very well endowed duck
What, the British Dental Association?
Ah, but remember Ducks float. And therefore are made of wood, and are therefore witches. Which have gnarled, twisty features.
So twistyness alone cannot determine if something is a duck or not, because the science above says that Witches are Ducks, and witches are twisty.
Depends on where it was left. If it had been left directly in front of the LP compressor it would have been sucked straight into the blades on startup. I doubt that would have happened without noticeable effect. If it did somehow hang on during start and taxi, I'd give it a good chance of getting sucked in during run op to take-off power, at which point it would probably result in an abort well short of V1 with minimal risk.
That is not to understate the risk of this incident, leaving tools in engines is a very big no-no. But things would have to line up astoundingly badly for this to have resulted in a crash. (Loss of a single engine shouldn't result in a crash either, but it's still one more engine than you'd be wanting to lose)
1. "...it was dark and an engineer didn't use a flashlight." This person should never have been hired/should have been fired for lacking common sense, or, if you will, lacking the ability to recognize problems ("I'm searching for something in the dark.") and solve them appropriately ("I should compensate by using a bright, non-flame-based light source.").
2. "...at least some of the engineers didn't even realize what part [should be, "tool" --AOD] they were looking for..." This is an organizational communications failure.
3. "A missing tool report was lodged ... but the required follow-up never happened." / "Qantas personnel ... requested removal of the report as it was causing problems ..." This is an attitude failure of Qantas and contracted-maintenance-company (if any) personnel.
I learned this lesson as a youth. I had been doing some maintenance on my parents' car while chatting with a friend who was a helicopter crew chief in the Marines. After putting everything away and closing the bonnet, I started the engine -- and heard a horrible clattering sound! I shut off the engine, opened the bonnet, looked around inside, and found a box-end wrench I'd mislaid and forgotten. My friend gave me a look, and said, "Always count your tools."
From then on, I always have.
The tool being left in place when the mechanic left for their medical issues since it was still needed was the first of the multi-fails. If somebody else needed it, THEY could check it out of the tool crib and be responsible for it. There's a really good reason for the procedures regarding tools used around aircraft. Mechanics are required to have all of their tools "shadowed" with a full inventory posted on/in their tool boxes. The paperwork has boxes to tick in the procedures where mechanics must check their tools before signing off the aircraft.
A missing tool at the repair facility should have sent up flares and sounded sirens, not been glossed over. Especially one used internally on an engine.
I would have expected that engine monitors would see reduced performance in the engine looking at where the tool wound up.
Terrifying for a light aircraft pilot, the thought that a tool floating about inside could tumble when the aircraft manoeuvres and lodge in a control rigging. At that point a pilot can only attempt secondary effect control and if that doesn’t work, the plane would go into a dead man’s zone and the pilot and passengers would spend a few terrifying seconds knowing their imminent fate.
https://aerossurance.com/safety-management/c208-flying-control-tool-fod/
https://www.flightsafetyaustralia.com/2021/08/forgotten-tool-led-to-rejected-take-off/
Doesn't have to be in an aircraft to relive this. Was innocent(-ish) trundling along the NC500, maybe possibly perhaps a wee lil tad above national speed limit, with an unsecured spare wheel in the boot of my station wagon. bridgecornerflatoutcompressionBUMP - huge impact to the back of my seat, breaking my zen. spare wheel made its way from the back of the car to rear passenger footwell. Obviously no one on the back bench, even my kids puke when I go that fast.
Still .. uncomfortable. A smaller object could easily have made its way into the windscreen, onto my lap or even down to the brake pedal.
Very uncomfortable.
screwed some proper eyelets into the boot that very evening.
loose objects finding their way under pedals...
One of the many Tesla Cybertruck recalls...
https://www.theregister.com/2024/04/22/tesla_accelerator_fix/
"The tool being left in place when the mechanic left for their medical issues since it was still needed was the first of the multi-fails. If somebody else needed it, THEY could check it out of the tool crib and be responsible for it."
I agree, but from the article, it doesn't say why the tool was left there, only that someone was told to leave it. Who knows what the medical reason was, it could have been a serious life threatening condition that needed immediate attention. Perhaps someone said "wait until I remove the tool" while someone else (who was suddenly an emergency first responder) replied "leave it, I'm doing CPR, you get an ambulance!"
Just speculating. On the face of it, this reads like a classic "Swiss cheese" incident, where any one of the things mentioned would have resolved it. I hope the engineer is ok.
"I agree, but from the article, it doesn't say why the tool was left there"
The article does say it was left as it was still needed after the mechanic that had checked it out had left. All that's said was the mechanic had left his shift early for medical reasons. If it was by ambulance with vigorous CPR being applied, I'd expect that would have been mentioned. Whatever the issue, there was a question raised and answered about the tool.
I've never consciously done this, but I have a feeling I've been doing this unconsciously ever since I started working on cars. It feels like common sense to make sure your socket set is complete, your spanners are accounted for and any other tools are back where they came from before starting up. Even then, I'll still have a thorough look around the engine bay both before and immediately after starting the engine, just to make sure everything is clean and running freely.
I will admit, I don't quite go to the lengths of a physical checklist.
It's one of the things you notice with properly trained tradesmen: they will always take the time at the end of a job to check that they haven't left something behind, which is one of the aims of cleaning up after themselves. Yes, this will mean going through an apprenticeship that comprises of endless rounds of making the tea, being sent on quests to find spotted paint, etc., but also the chance to make mistakes, learn from them and learn how to avoid making them. Then the MBAs come along with their time and motion studies and ask for those tend minutes at the end of the shift could be used more productively…
Managers and customers also need to appreciate this. Or learn the hard way.
Last hose I replaced required me to take apart the engine intake manifold and injector assembly just so I could get to it. Bloody annoying, as the replacement hose only cost a few quid and was only held in with spring clips. Would have been a ten second job if I could only get to it.
10mm sockets don't count, they behave in undeterministic ways, like quantum particles that spontaneously appear and disappear. If you listen very carefully in the darkness of night in your garage you can sometimes hear 10mm sockets pop in or out of existence in random places.
"If you listen very carefully in the darkness of night in your garage you can sometimes hear 10mm sockets pop in or out of existence in random places."
If we could tap into that, I bet it would be even more powerful than vacuum energy. We need another Hawking to work on that. Extend the virtual particle pair hypothesis with black hole radiation (Hawking Radiation).
"I also lost a 10mm socket in the engine bay that despite looking hard for, never found."
10mm sockets are the exact size to slip through where the universe gets thin. The best advice is to buy in bulk and keep them in multiple places so they don't all disappear at the same time.
I will admit, I don't quite go to the lengths of a physical checklist
If you have a complete set of tools with places for everything I suppose you don't need that. Those of us who don't have that, and have already lost pieces of sets that do come with places for everything (like socket sets) don't have that luxury. Fortunately I don't work on my car, or very often anything with any high speed parts so the chances of that biting me beyond "what happened to that damn 5/16" socket I know I had it when I last used these tools a couple months ago".
My socket set is complete apart from one 5mm socket that seems to have departed this universe when the whole box got spilled into the guts of a camper van conversion. Found the rest of the set, but never that socket. Said van has since been written off in a motorway collision, so that socket is well and truly gone.
My other tools are a mish-mash of inherited pieces that don't have a set home, so with those I have to be more careful.
"Even then, I'll still have a thorough look around the engine bay both before and immediately after starting the engine, just to make sure everything is clean and running freely."
I didn't do that once. Now when I work on the car, I don't set anything down on the engine, but a cart I have next to where I'm working. I try to form good habits with things like that so it's an automatic thing. The adage, "a place for everything and everything in its place", is a good one. I'm not perfect so I run into issues like knowing I have some thing, but either didn't put it away properly or hadn't decided on where it should live. Having to dash to the hardware store several times in the course of a project is a problem, but if you need to have it done before the sun goes to bed, at least you know where in the store that thing you need lives. There's a price for them being so organized and me not so much. Of course I'll find that thing not too long after buying another.
I have always done the same with my parachute repacking. A set number of tools, straps, weights at the start then the same number at the end. Not good to need a reserve chute or an issue with your main canopy because there is a holding strap keeping the risers together.
Darwinism in a way - you only ever make this mistake the once..
"My friend gave me a look, and said, 'Always count your tools.' "
And it's standard operating theatre practise - you count everything (instruments, swabs etc) before starting and count everything at the end to make sure you've not left anything in the patient.
Though people being people, mistakes do happen.
This Qantas incident, however, is a classic example of how a string of simple errors can produce a situation with a potentially catastrophic outcome. Thankfully it didn't on this occassion.
"...I was still awake enough to say "LEFT HAND!"
I was going to have a procedure done on mu right eye.
They asked me twice, and both times I tapped my head, beside the eye in question, and said "this one".
Because I will surelly NEVER trust this kind of answer to something like "the left one".
Yep - always double check.
Just this month I've had an ulcerative eye lesion and was horrified to receive a letter cc'd to my GP from one of the dr's I've seen (never the same person twice... oh how I love the NHS), which was discussing my right eye.
The lesion is in my LEFT eye.
A different medical use for marker on skin.
A few years ago my foot was badly swollen and painful with some kind of infection. The doctor prescribed an antibiotic. He then took out a marker and drew an irregular line on my foot -- basically a contour line. His instructions were to expect the swelling to increase a little more over the next day or so (I think; it's been a few years) -- "but if it goes past the line, get to Emergency". (In fact it didn't; all was well in the end.)
I'm sometimes asked when teaching people how to sail why they have to learn new terms like 'port' and 'starboard' "when everyone already understands 'left' and 'right'". They usually get it when I point out 'port' and 'starboard' are *always* relative to the boat, whereas 'left' and 'right' could be relative to the speaker *or* to the boat, and give the example of someone at the bow facing back to the helm and shouting "rock to the left', and the poor bugger on the helm having to make an instant guess whether it's their left or the boat's left, with a 50/50 chance of a nasty crunch sound.
Indeed.
The "vessel's left" term used to be larboard, but that led to a different sort of confusion, and so a word that didn't sound like starboard was chosen instead. For those interested, here are the etymologies of all three terms, including the specialized sense of port.
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"For example, “takeoff” is only used when takeoff clearance is given. At all other times “departure” is used. "
Radios can still be horrible and people don't always articulate distinctly so aviation has evolved to have standard phrases where the sound "shape" is distinct. If you reply to Air Traffic Control incorrectly, they don't need to hear the words, but that the sounds are wrong for the expected response.
"And it's standard operating theatre practise - you count everything (instruments, swabs etc) before starting and count everything at the end to make sure you've not left anything in the patient."
A week ago after dental treatment. Dentist & assistant counting the instruments. Me, sitting up but looking down: "There's on of the floor".
"And it's standard operating theatre practise - you count everything (instruments, swabs etc) before starting and count everything at the end to make sure you've not left anything in the patient."
There will usually be a nurse that's tasked with keeping track of instruments used. Definitely worth the expense.
There will usually be a nurse that's tasked with keeping track of instruments used. Definitely worth the expense.
A friend was that nurse, especially for the long (fourteen hour or more) orthopedic operations, that sometimes entailed a shift change among the support staff of nurses and techs. She scrubbed in as the second shift on one of these marathons. The first shift had made a proper mess of the sponge count. These little items are very easy to miss, once they are blood soaked and deep in the patient. They are brought to the ER in bags of ten, and the count is frequently updated, as more are used. The used ones are supposed to be counted as removed, and noted in groups of ten as well. SOMEHOW the first shift person had screwed up the count.
My friend could not make the count of sponges in and sponges out come out equal, but could not find the error, or where it had occurred (in the requisitioning of new packs? In the counts of used ones?) After the surgery, the head surgeon and she re-counted all the used sponges, ripping open the many used sponge bags to see if the miscount was there, a disagreeable and difficult task, as they stuck together and were hard to separate. They both signed off when they thought they had the right count, best efforts and all.
Long story short, at least one sponge was missed, the patient died, and as usual in US malpractice lawsuits, everyone who was anywhere near gets named in the suit, out to the guy mopping the corridor. That's when I found out that getting a metal instrument, a clamp, a needle, is bad but not always fatal, the body walls it off and continues on. A sponge is a focus for infection and much more likely to kill you before it can be found.
I don't think she was held liable, but it haunts her still, into retirement.
"found a box-end wrench I'd mislaid and forgotten."
Embarrassed garage owner: A few hundred yards after collecting my car after a service it developed a loud rattle from the front O/S wheel. Returned to garage where the hub-cap was removed along with the socket spanner that had been left on a wheel nut.
There is a dent in the top of a front wing on my car. To the uninformed, it looks a lot like the sort of damage that would occur when the owner - having diagnosed and fixed a tricky intermittent fault - slams the bonnet in triumph* without checking for spanners in the way.
*Skoda.
Well, when I did have a Triumph, the whole bonnet, wings etc. hinged up as one unit from the front. Which was great as you can sit on a front wheel and tinker. And if you do need to change the engine (for instance) you undo three bolts, lift the whole body assembly clear and you can get at everything.
Ah that takes me back. My first car, a Mk II Spitfire - as you say, a delight to work on in terms of access to stuff. Just a pity about their "interesting" handling where cornering would change from "all's fine here" to "why am I facing the wrong way" in what seems like a negative period of time and no intermediate steps. They were awesome for autotests though.
>1. "...it was dark and an engineer didn't use a flashlight." This person should never have been hired/should have been fired for lacking common sense,
Their toolkit probably doesn't include a flashlight because one isn't required for that service.
Or do you propose that they just have a spare flashlight in their pocket, along with a multitool and a few spare parts. Of course that would require them to have a system for ensuring that none of the spare tools from their pockets were left in an engine - but what are the odds of that !
Or do you propose that they just have a spare flashlight in their pocket
I always carry a small flashlight and would happily carry a spare as well. You never know when the lights may go out or you find yourself in the dark trying to find or check something. And I get 15 minutes of super hero fame when turned on as others are moving towards panic in unexpected and unwelcome darkness.
You might think there's little chance of it being useful but you'll be surprised.
.... started developing an on-again, off-again loud clattering noise at about the 120K mark after I had been driving her for about 60K miles. Poking around with a large screwdriver as a stethoscope, I pin-pointed the noise as coming from somewhere around the lifters, so I figured it was time for a rebuild (what we used to call a "ring and valve"). The dismantle started with the intake manifold ... where I found a half-inch drive Craftsman ratchet with a short extension and a 9/16 inch socket nestled in the valley.
Removed the tool, and replaced the intake, and all was well for another 80K miles, when I dropped in a 460 (needed the extra torque for logging work).
I still have the truck ... and the ratchet, extension and socket, which still smell of used engine oil some 50 years on ...
Fifteen years ago it absolutely would not have been the typical Qantas administrative response. Amazing how much damage a culture of no motivation but the dollar sign can to do an organisation once famous for its maintenance and safety record.
Q remains the only time I've requested a chargeback on a credit card. During early Covid, or course, and Q cancelled the flight so the law is clear. No, we have lovely vouchers to offer you or you can go through these amazing phone-in hoops to get the refund. Oh, and separate hoops for the base ticket price and for the extra cost for seat upgrade, despite being bought at the same time and part of the same ticket charge. They didn't dispute the chargeback. I'm sure people have similar Air Canada tales of woe too.
Yes, what a tool.
I was just thinking what was so amazing about flying with a 1.25m tool in it when aircraft normally fly with more than a few 2+ metre tools inside them.
Have to wonder whether septic mechanics would have located the tool if they were looking for a 50 inch one.
Shows how easily the pressures of conducting business can override safety.
That aircraft should not have been allowed to move 1 inch until that tool had been accounted for. That it did and flew 34 cycles speaks volumes about the motivations in play.
It also speaks volumes about the thoroughness of "walk arounds". That location where the tool was found is visible between the fan blades, if one makes the effort to look. I doubt they took the fan off to take this photograph! If one enlarges it one can clearly see that we're looking through the engine and out the other end of the bypass duct, with the tool stuck at the bottom of it. It means that, in the walk arounds before each one of those 34 flights, no one really looked "in" the engines from the front. Most likely they simply looked "at" the engines, which to be frank is ****ing pointless. I also think that it'd have been visible from the back end of the engine too, had anyone looked forwards through the bypass duct.
Granted, the engines on an A380 are pretty high up and you'd need a ladder to have a proper look. However, considering there was a tool missing you'd think that someone would have made the effort.
Qantas likes to pride itself on never having had a crash. Well, they came far too close to having one on this.
Fortunately, the risk of this being ingested by the engine core (where it could cause real damage) was pretty low. The flow of air through there tends to move things outwards. To have reached the engine core, the tool would have to have migrated inwards against the flow of air. One of the issues facing engine designers is actually getting air to flow into the engine core in the first place, when it doesn't want to. It's largely why the fan blades themselves have a twist - starting nearly straight at the root to let the air reach the inlet for the core itself, and twisting further out to have a shape that'll actually generate thrust.
What would have happened eventually is that the tool would have disintegrated, probably on take off (peak thrust), blowing lumps of nylon all over the runway, probably without harming the A380 in any noticeable way (unless there are any delicate sensors jutting out into the bypass duct further back). However, the next aircraft to take off could be hitting that debris, maybe suffer a bunch of tyre blow outs, and have itself a take off crash. That is the risk I think Qantas ran.
This really has nothing whatsoever to do with Boeing.
Assuming these engineers weren't, at some point in their careers, "trained" by Boeing.
I remember hullabaloo when Qantas first outsourced some maintenance on their then all Boeing fleet (to Bangkok I think) foreshadowing these sort of failures.
Enshittification is incredibly contagious and global both in scope and geographically but at an altitude of 10km this is not a comforting thought.
A question remains: will Rain Man scratch Qantas from his list of acceptable airlines to fly with?
Yep, and it's very simple concept. You count the tools out, reason says you should have the same number back when you're done. Tools do not evaporate, or melt, or get spirited away by the little tool pixies.
It's absolutely horrifying that Qantas fooled themselves into acting as they did. Clearly they considered the "ah, Barney must've taken it home" scenario type to be far more likely than the "we've left it somewhere where it oughtn't be" scenario. If they were prepared to consider that it was possible for a tool to go missing in a "safe way", then their whole mindset was wrong. That in turn means that in fact they never had a tool counting culture in the first place - not a real one - and that they have been operating dangerously for a long time. This time, it actually went wrong, and they're just lucky it wasn't a disaster.
If one has a safety measure - such as tool counting - you have to exercise the safety measure. What they need is an inspector who - during the course of work - nicks a tool and then times how long it is until the maintenance crew notice. If they change the work shift without noticing, fail. Depending on the tool, if they don't notice within a few minutes - fail.
Why didn't they just ask the engineer who checked it out where he left it before they signed off the plane, unless his medical appointment turned out to be with a pathologist?
Do they not record who checks tools out?
Even then, the guy that told him to leave it in place should have been aware of where "in place" was...
This is always the problem when you are reliant on other people not doing stupid things for your continued well-being. Saw a story in the week of a chap in the Netherlands who stored 800kg of fireworks in his house. Imagine living next door. Or that time(s) when scrap metal scavengers did not understand what a radiation hazard warning looks like and proceeded to open discarded x-ray radiation sources, with lethal consequences for many unsuspecting victims around them.
A couple of very sad/tragic cases of this:
https://www.bbc.co.uk/news/articles/c51y1g08d3lo
A guy who was scavanging metal from a derelict site unaware that 11KV switchboard he was attemtping to recover metal from was live!
Or this very tragic one:
https://www.bbc.co.uk/news/articles/cd6vw5nz961o
It makes one wonder, what went wrong for a person who is in the back of a police car - for what ever reason - to be able to let themselves out on the side of a motorway?
"It makes one wonder, what went wrong for a person who is in the back of a police car - for what ever reason - to be able to let themselves out on the side of a motorway?"
In the US, nearly all police cars have "child locks" that don't allow the door to be opened from the inside. Whiles there's generally a switch in the jam to set or defeat that function, police departments have found it prudent to remove those switches since clever criminals will find a way to flip it while getting in the back.
My initial thought, when reading the starting sequence of events (somebody going off-shift) and ineffective handover, goes back to the Piper-Alpha tragedy. There were multiple failures there, too, but the initiator of the subsequent chain of events was due to a flange not being tight at the end of a shift, with a presumption that it would be checked and the job finished by others. PTW (permit to work) rules were tightened up across the N Sea - a lot of frustration with all the extra admin and paperwork but N Sea O&G installations are, whilst presenting very serious hazards, are nowadays some of the safest places to work. Aviation has often been help up as an example of an industry with sound H&S practices but, from my experience during audits and assessments, there is scope for a lot of improvement. Unfortunately, the commercial side has to be considered and people want to fly.
Oh and the photo in the article looks as though the rod is against the LP compressor vanes, not the blades. Vanes are stationary and direct air onto the blades (that rotate on their discs).
Anonymous for, what I hope, is seem as good reason...
So, he was half way through a procedure and left the tool in there.
I guess this means that that remainder of the procedure wasn't completed then ?
After all, if someone else came in with another identical tool to finish it, then they would have found the first one still in place. However, since they didn't then I can't see how they would have finished the procedure. Similarly, if they continued with existing tooling, presumably a step on their procedure is to remove the tool at some point ?
I wonder what was left disconnected / removed / not in its normal operating condition ???
What's amazing to me is that the rod wasn't shredded during engine start-up and that it rotated into a position 90 degrees to the direction it was probably inserted.
Given the strength and toughness of nylon, if it hadn't bent round, it would have been an interesting fight between the power of the APU used to start the engine, and the shear strength of the nylon rod. (i.e. without rotating the rod round 90 degrees, it would have likely caused a failure during engine start up, and not a catastrophic failure during flight.) Either way, modern jet engines are tough beasts, capable of ingesting thousands of golf ball sized hailstones in a few seconds, and sometimes surviving ingesting quite large birds...
"Either way, modern jet engines are tough beasts, capable of ingesting thousands of golf ball sized hailstones in a few seconds, and sometimes surviving ingesting quite large birds..."
And the occasional member of airport ground staff....
sounds like those searching for the tool didn't know what it looked like or what it was used for,
also seems like they didn't know why it was missing.
the story of why they where searching should have been shared.
Something like: a tool that looks like this & is used to do x is missing. It was checked out by x on x day to do x job but was never checked in. X had a medical emergency during his shift. Can you go find X tool, start by looking at x part of the plane where x was working and would have used the tool.
Also sounds like the engineer who was taken off shift did their best to ensure the tool was removed. Whomever knew X hadn't removed it should have told the shift supervisor that X mentioned about removing the tool but was told to leave it as their medical emergency was being dealt with.
This is an all too common occurrence when things are outsourced. common sense goes out the window & important information is lost due to procedures that force the round peg over the square box slicing off the edges of the peg and leaving gaps in the box.
Doesn't need to be a problem with outsourcing. Place where I work, getting one manager to talk to another is a massive struggle. The number of times I've had to follow up myself because managers can't fucking manage...
I swear I have no idea how the company manages to function like that, and sadly the most incompetent of them are the ones pulling the strings so it's not like they can be culled for their attitude of complete and total indifference to anything that doesn't directly concern them.
Anonymous for obvious reasons.
Neither Southwest nor United have had any recent _crashes_ due to engine failures...
Yes they have had engine failures that have warranted emergency landings. Yes, in one case the debris caused a window to break and the poor passenger seated next to the window died as a result. But none of these cases could be classed as a "crash" - so why try to sensationalise those incidents?
Two-engined aircraft are designed to be able to continue flying with only one engine - potentially for as long as 5 hours, and engine shutdowns/failures in flight are relatively common in the grand scheme of things - 5 or 6 times so far in November, no injuries, no major damage to anything on the aircraft...
A long-ago co-worker, then in the USAF reserve, explained that one always counted tools before and after working on a plane. A missing tool, if not found, could mean that the facility would X-Ray the plane looking for the stray tool. I assume that crew who let things get to that point were handed a broom and sent to sweep the runways.
"A long-ago co-worker, then in the USAF reserve, explained that one always counted tools before and after working on a plane. "
Common practice now is for mechanics to have "shadowed" all of the tools in their tool box. Special tools are often on carts with shadow markings with the entire cart coming to the aircraft rather than the one or two tools needed being taken from the cart while leaving the carts where it's stored. The really swank way to manage tools is to have precision cut foam. A quick visual inspection is all it takes to see that a tool is missing. If the tool is intentionally missing, a note is put in place to explain its absence. The job order will have a tick box that all tools have been accounted for as part of the sign off.
"Qantas personnel in Sydney even requested removal of the report as it was causing problems – in response, the tool's status was downgraded."
Oof. I've been on the other side of a few requests like that-- luckily at the time I had a boss willing to back me up when I said things like "so tell me the whole story of why you need this change" and "what no we are not going to 'help' you with that."
I expect the missing-tool incident went something like this:
https://m.media-amazon.com/images/I/71dmyRCtkTL._SL1500_.jpg
Back in the days when TV sets were living room furniture (aka, large wooden boxes on legs), I lost one of my favourite long, flat bladed screwdrivers whilst on a field service call. Annoyed, I replaced it and thought nothing more of it. Until a year later, when I attended said TV set for another call, removed the back, and to my delight, found the lost screwdriver.
On another occasion, I was servicing the car, and must have put a 13mm socket down on a windscreen wiper arm. Didn't realise it was there until it started to rain on the subsequent test drive, and I turned the wipers on. I watched the socket fly off into a farmers field. Didn't get it back.
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