On 6 December 2023, an Airbus A380-842 aircraft, registered VH‑OQI and operated by Qantas Airways Limited, was undergoing a 3-day scheduled maintenance check at Los Angeles International Airport (LAX), United States. 

On day one of the maintenance check, during a scheduled borescope inspection of the outboard left engine, a tool was left in the engine inlet. On the evening of 8 December, the aircraft was released to service and departed for Melbourne, Victoria. 

On 1 January 2024, the aircraft returned to the LAX maintenance facility for a 3-day scheduled maintenance check, where the missing tool was discovered in the outboard left engine low‑pressure compressor. The aircraft had flown 34 cycles totalling 293.74 hours with the tool in the outboard left engine.

What the ATSB found

The ATSB found that the tool was not located during the end of task foreign object inspections, which resulted in it remaining in the engine. The Qantas Engineering lost tool procedure was not commenced prior to the aircraft being released to service and the certifying engineer did not follow up on the lost tool, prior to releasing the aircraft to service. 

What has been done as a result

On 2 January 2024, a Qantas Engineering internal incident report was raised with an immediate action to brief staff on the importance of ensuring that all tooling is returned and actioned by tool store personnel. A Qantas Engineering internal investigation was completed and on 4 March 2024, the executive manager for Qantas Engineering released an internal safety directive for immediate action requiring all Qantas Engineering employees to meet the company tooling control requirements without exception.

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The incident took place at 31,000 feet as the flight was near Lake Berryessa, about 70 miles north of San Francisco.

United Airlines says as flight 2428 from Newark, New Jersey, was descending into San Francisco International Airport last Thursday, it “slowed its descent to account for another aircraft at a lower altitude.”

Both injured passengers were taken to the hospital, United said in a statement. The seatbelt sign was on at the time.

An FAA incident report says one passenger received serious injuries and another minor injuries last Thursday when the pilots responded to a traffic collision avoidance system resolution advisory or “TCAS RA.”

Audio from LiveATC.net captured the pilots declaring a medical emergency, telling air traffic controllers in Oakland that “someone might have broken an ankle and there’s passengers that got hurt when we had an RA.”

In a statement, the FAA said “there was no loss of safe separation.”

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The Airservices Australia controller was found lying across two chairs with a blanket covering them at 5.15am on December 9, 2022, a report by the Australian Transport Safety Bureau (ATSB) said.

The controller had completed multiple night shifts with reduced extended rest periods, “which likely reduced their ability to obtain restorative sleep,” the report said.

ATSB chief commissioner Angus Mitchell said the controller had increased their chances of falling asleep “by lying across two chairs, not moving, and not undertaking activities to maintain mental alertness”.

When a colleague discovered the controller asleep, there was no traffic in the Cairns airspace they were responsible for managing, which was usual for that time of day, and there were no scheduled flights until after their shift.

“There were no negative consequences from this occurrence, but it does highlight areas for improvement in work scheduling and fatigue risk management,” said Mitchell .

The ATSB report found changes to the worker’s shifts were introduced on short notice because of rostering issues.

Since the incident, Airservices Australia has increased its overall number of air traffic controllers, including in the North Queensland group.

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The aircraft was scheduled to embark on a multi-day charter away from base with a flight crew consisting of three pilots, an engineer, a load master and six cabin crew. The first sector was a positioning flight from London Stansted Airport to Orlando International Airport, Florida. In addition to the 11 crew there were nine passengers on board who were all employees of the tour operator or aircraft operating company.

The aircraft was previously at Southend for maintenance repair after being used for VIP flights on behalf of the British government.

The passengers sat together in the middle of the aircraft just ahead of the overwing exits.The aircraft departed a few minutes ahead of schedule and took off from Runway 22. Several passengers recalled that after takeoff the aircraft cabin seemed noisier and colder than theywere used to. As the aircraft climbed through FL100 and the seatbelt signs were switched off, the loadmaster, who had been seated just in front of the other passengers, walked towards the back of the aircraft. He noticed the increased cabin noise as he approached the overwing exits and his attention was drawn to a cabin window on the left side of the aircraft. He observed that the window seal was flapping in the airflow and the windowpane appeared to have slipped down1. He described the cabin noise as ‘loud enough to damage your hearing’.

The loadmaster told the cabin crew and then went to the flight deck to inform the commander. At this stage the aircraft was climbing past FL130, there were no abnormal indications on the flight deck and the aircraft pressurisation system was operating normally. The flight crew stopped the climb at FL140 and reduced airspeed whilst the engineer and then the third pilot went to look at the window. Having inspected the window, it was agreed the aircraft should return to Stansted.

The cabin was quickly secured and the flight crew initiated a descent, first to FL100 and then to FL90. They established the aircraft in a hold whilst they completed the overweight landing checklist, confirmed landing performance and briefed for the return to Stansted.

Having parked and shut down, the crew inspected the aircraft from the outside and saw that two cabin windowpanes were missing and a third was dislodged.

The windows appear to have sustained thermal damage and distortion because of elevated temperatures while illuminated for approximately four to five and a half hours during filming activity the day before the flight. It is likely that the flood lights were positioned closer than 10 m. Whereas in this case the damage became apparent at around FL100 and the flight was concluded uneventfully, a different level of damage by the same means might have resulted in more serious consequences, especially if window integrity was lost at higher differential pressure.

You can download the full UK-AAIB report.

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The Boeing 737 MAX 8 with registration N8788L was flying from Honolulu (HNL) to Lihue, Hawaii (LIH) as flight WN2786. Due to bad weather conditions, the crew initiated a go-around maneuver at approximately 1,000 feet above ground level (AGL), as reported by the Aviation Herald.

However, the aircraft subsequently entered a rapid descent, dropping to a critically low altitude of 400 feet AGL before regaining control and climbing safely back to altitude.

According to an internal memo circulated within Southwest Airlines and data from ADS-B Exchange, the cause of the incident appears to be a pilot error. 

During the go-around maneuver, the First Officer, who was piloting the aircraft, inadvertently pushed the control column forward while monitoring engine power settings. This caused the plane to descend rapidly. 

Thankfully, the crew quickly recognized the situation and initiated a climb, successfully recovering from the descent.

The Federal Aviation Administration (FAA) is currently investigating the incident. Southwest Airlines has also addressed the issue through its internal Safety Management System (SMS).

This event highlights the importance of crew coordination and situational awareness during critical maneuvers, especially in challenging weather conditions. The quick response of the Southwest Airlines crew undoubtedly prevented a much more serious situation.

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Monday, April 15 2024, United flight UA264 departed Chicago O’Hare International Airport but returned only 1 hour later.

The A320-200 (registration N479UA) took off at 06:40 CDT when the crew contacted the tower about a bomb threat message written on the mirror of a lavatory.

The pilots requested an immediate return for the 137 passengers and crew on board.

The aircraft was vectored back to ORD where it was met by emergency services in a remote area of the airport.

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On the morning of Jan. 26, as two Alaska Airlines flights from Seattle to Hawaii departing six minutes apart experienced a tail strike.

The pilots of each flight felt a slight bump and the flight attendants at the back of the cabin heard a scraping noise. As the noses of both Boeing 737s lifted skyward on takeoff, their tails had scraped the runway.

Both planes circled back immediately and landed again at Seattle-Tacoma International Airport. The incident grounded both flights and forced a temporary shutdown of Alaska’s flight activity nationwide.

Horrifyingly, investigators have now discovered that a software glitch was responsible for the incident. According to the Seattle Times, the tailstrikes occurred largely as the result of a bug in a program sold by a Swedish firm called DynamicSource.

The program is supposed to deliver “crucial weight and balance data” that pilots enter into their flight computers to help determine stuff like “how much thrust the engines will provide and at what speed the jet will be ready to lift off.”

The data [delivered] was on the order of 20,000 to 30,000 pounds light. With the total weight of those jets at 150,000 to 170,000 pounds, the error was enough to skew the engine thrust and speed settings.

Both planes headed down the runway with less power and at lower speed than they should have. And with the jets judged lighter than they actually were, the pilots rotated too early.

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The passenger jet was nearly 10,000 feet up in the air flying over Kent when the device was spotted.

The pilot of the A321 plane said they became aware of an object slightly to the right of the nose at same level on a constant bearing with closing distance.

It passed down the right-hand side of the aircraft and over their right wing.

The reported risk of a collision was found to be high.

Details were passed immediately to London Air Traffic Control who informed the pilot of the aircraft behind them.

The UK Airprox Board investigates risks of airborne collision to enhance air safety in the UK.

They reported the incident happened at around 4.30pm on 3 January 2024 saw the rogue craft pass within just five feet of the airliner.

It’s thought the flight had been on its way to London Heathrow from Greece.

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On 25 January 2024, the Airbus A320 was being operated as scheduled passenger flight from Soekarno-Hatta International Airport (WIII), Jakarta to Halu Oleo Airport (WAWW), Kendari and return. The aircraft was operated by two pilots and four flight attendants.

As the aircraft reached the cruising altitude of 36,000 feet, both pilots took their headsets off and the cockpit loudspeaker volume was increased. The PIC then asked permission to rest from the SIC and was granted. A few seconds later, the PIC slept and the SIC then took over the PIC duty as PM.

The PIC woke up and at 0122 UTC, asked whether the SIC wanted to rest. The SIC responded that he did not want to rest. Both pilots then had a non-related-duty conversation for about 30 seconds and then the PIC continued to sleep.

Around 20 minutes later, the SIC readback a Jakarta ACC instruction. A few moments later, the SIC then inadvertently fell asleep. 12 minutes after the last recorded transmission from the SIC, the Jakarta ACC asked BTK6723 how long the aircraft need to fly on the current heading (250°). There was no reply from the pilots.

28 minutes after the last recorded transmission from the SIC, the PIC woke up and was aware that the aircraft was not in the correct flight path. The PIC then saw the SIC was sleeping and woke him up. About the same time, the PIC responded to the call from another pilot and Jakarta ACC. The PIC advised the Jakarta ACC that BTK6723 experienced radio communication problem and currently the problem has been resolved. The flight then continued and landed at Jakarta uneventfully.

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Atlas Air flight 3885, a Boeing 747-87UF sustained an inflight engine fire following departure from Miami International Airport (MIA), Miami, Florida.

The flight crew reported that, after departure and while passing through about 3,000 ft mean sea level (msl) they received an “OVHT ENG 2” followed by a “FIRE ENG 2” warning message on their engine indicating and crew alerting system (EICAS) display.

Simultaneously, the fire warning light illuminated, and the fire bell sounded. The captain declared a mayday with air traffic control (ATC) and the flight was cleared back to MIA via radar vectors for a landing on runway 9.

The electronic non-normal (NNC) checklist was completed, and the number 2 engine was shutdown by the flight crew. One fire bottle was discharged, and the fire warning light subsequently extinguished.

Following an uneventful landing, the airplane was met by firefighting personnel and the airplane was cleared to taxi under its own power to parking.

A post-incident inspection of the General Electric (GE) GEnx-2B67 engine revealed burn through of the thrust reverser fan duct fixed inner wall. The engine cases were intact and there was no evidence of an uncontained engine failure.

The combustor diffuser nozzle (CDN) case port M borescope plug was not secured in the case and was found loose in the engine cowling. That finding is potentially significant because records show a third-party vendor performed a borescope nozzle inspection four days earlier, on Jan. 14, that required the removal of a borescope plug. The technician performing the work and an inspector initialed a work card indicating the task was completed in accordance with the instructions in the maintenance manual.

A preliminary review of quick access recorder (QAR), flight data recorder (FDR), and continuous engine operating data (CEOD) showed no evidence of engine failure or surge/stall.

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On January 5, 2024, Alaska Airlines flight 1282, a Boeing 737-9, N704AL, returned to Portland International Airport (PDX), Portland, Oregon, after the left mid exit door plug departed the airplane leading to a rapid decompression. The airplane landed on runway 28L at PDX without further incident, and all occupants (2 flight crewmembers, 4 cabin crewmembers, and 171 passengers) deplaned at the gate.

In its 19-page report, the NTSB says four bolts that were supposed to hold the door plug in place were not recovered. Nevertheless, investigators say “the observed damage patterns and absence of contact damage” on the door panel and plane itself indicate the four bolts were “missing” before the door plug was ejected from the plane.

The door plug was originally installed by contractor Spirit AeroSystems in Wichita, Kan., and then shipped to Boeing’s factory in Renton, Wash., for assembly. Once it arrived in Washington, the NTSB says damaged rivets were discovered on the fuselage that required the door plug to be opened for repairs. After that work was completed by Spirit AeroSystems personnel at the Boeing plant, the bolts were not reinstalled, according to photo evidence provided to the NTSB by Boeing.

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On 5 November 2023, the Easyjet flight #U23291 from Edinburgh to Geneva was on final approach to runway 22 at Geneva Airport when the crew initiated a go around after the aircraft descended well below the glide path.

The A320-200N (registration G-UZLO) went around and landed safely on its 2nd attempt 14 min later.

There were 157 passengers on board as well as 2 pilots and 4 crew members.

An investigation is in progress by the Swiss Transportation Safety Investigation Board.

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