Wrench Found After a King Air Release
During a 50-hour inspection on a Beechcraft King Air 350 at Lae, an AME finds a small wrench inside the left engine nacelle. The aircraft was released to service two days earlier after a fuel nozzle replacement. The wrench is not listed on the tool inventory. The tool is stamped with the company's initials. The engineer who signed the release is a senior colleague. The aircraft has flown six sectors since the release. The company has an SMS but no confidential reporting channel. The maintenance manager wants to handle the matter internally and not notify CASA PNG because no damage was found. The AME is uncertain whether this is a mandatory occurrence and fears blame. The wrench was found during a borescope inspection; it was resting near the fuel control unit. The AME has photographs.
1. Is this a reportable occurrence under PNG rules and ICAO Annex 13? Explain.
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Yes, this is a reportable occurrence. A tool left in an engine nacelle after maintenance is a maintenance error that could have caused engine damage, fire, or loss of control. Under PNG CAR Part 12 and ICAO Annex 13, accidents and serious incidents must be reported to the Accident Investigation Commission and CASA PNG. Many occurrences that are not serious incidents are still mandatory reportable occurrences under the rules. The fact that no damage was found does not remove the reporting duty; the purpose is to learn and prevent recurrence. The organisation's SMS should also record it as a hazard.
2. What should the AME do, and what protections exist?
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The AME should make a written report to the maintenance manager and the safety manager, with photographs and the tool's location. If the organisation does not report to CASA PNG, the AME should ask for confirmation that the report has been made. The AME should not remove the wrench before documenting it. The AME should use the SMS reporting channel and, if there is no confidential channel, report directly to CASA PNG. Whistleblower protections may apply, but the AME should keep personal records. Concealment would be worse than the original error.
3. What should the organisation's SMS do with the finding?
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The SMS should investigate why the tool was left, why the tool inventory did not catch it, and why the release was signed. It should review tool control, independent inspection, and shift handover. The senior engineer should be treated fairly but held accountable. The organisation should consider a just culture approach: report openly, fix the system, and only discipline for recklessness or concealment. CASA PNG may inspect. The investigation findings should be shared with the operator and, if required, through the safety data system.