Aviation occurrence briefs

Foreign object damage involving Boeing 787-8, Bali International Airport, Indonesia, on 28 March 2018

Number:
AB-2018-053
Status: Completed
Investigation completed

Brief

Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.

What happened

On 28 March 2018, a Boeing 787-8 departed Bali, Indonesia on a scheduled passenger flight to Melbourne, Victoria (Vic.). After arrival in Melbourne, at about 0230 Eastern Standard Time, maintenance engineers were investigating a right engine anti-ice fault indication, when they discovered a cabin passenger blanket within the engine cowling (Figure 1).

Investigation by the operator found that maintenance had been performed in Bali prior to the aircraft returning to Australia, and five blankets from the passenger cabin had been used in place of correct personal protective equipment to prevent burn injuries to the engineers while maintenance was conducted. One of these blankets was inadvertently left on the engine after maintenance. The area in which the blanket was discovered was protected by fire suppressant, should it have been required.

Figure 1: Passenger blanket as found on engine
A towel wrapped around part of an aircraft engineSource: Aircraft operator

Safety message

This incident highlights the importance of maintenance personnel remaining vigilant in the conduct of their duties. There are a number of factors that can lead to errors occurring. The ATSB research report AR-2008-055, An Overview of Human Factors in Aviation Maintenance is available from the ATSB website.

Utilising an independent inspector may also minimise the possibility of items being missed upon the completion of maintenance.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

 

 

General details
Date: 28 March 2018   Investigation status: Completed  
Time: 08:20 UTC    
Location   (show map): Bali International Airport, Indonesia    
State: International    
Release Date: 06 July 2018   Occurrence category: Incident  
Report status: Final    

Aircraft details

Aircraft details
Aircraft manufacturer The Boeing Company  
Aircraft model 787-8  
Type of operation Air Transport High Capacity  
Sector Jet  
Damage to aircraft Nil  
Last update 12 December 2018