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The following is the detailed summary of the report compiled by the Commission of Inquiry on the New Airport:
DECISION TO OPEN THE NEW AIRPORT
1. The decision to open the new airport on 6 July 1998 for operation was made by the Airport Development Steering Committee ("ADSCOM") in January 1998 after carefully taking into consideration the state of the construction and the development works for the systems and facilities in the Passenger Terminal Building ("PTB") and in the major franchisees' premises and the assurances of Airport Authority ("AA") since about mid-1997 that the new airport would be ready for operation in April 1998.
2. AA was established as a statutory corporation by the Airport Authority Ordinance ("the Ordinance") that came into force on 1 December 1995. Under the Ordinance, AA has the functions and duties to provide, operate, develop and maintain an airport for civil aviation. While AA shall conduct its business according to prudent commercial principles, the Ordinance provides that it shall have regard to safety, security, economy and operational efficiency and the safe and efficient movement of aircraft, air passengers and air cargo. AA had to examine and evaluate when the new airport and all the structures, facilities and systems that were required for airport operation would be ready for opening the new airport for operation, in other words, it had to examine and evaluate airport operational readiness ("AOR").
3. Prior to January 1998, the target date for the opening of the new airport had always been scheduled for April 1998, and the works regarding the construction of buildings, the installation of facilities and the commissioning of various systems for the operation of the new airport had been awarded by AA or its predecessor, the Provisional Airport Authority, to contractors with completion dates corresponding to or compatible with April 1998. Similarly, those works regarding the premises of AA's franchisees and business partners whose services were required for the operation of the new airport would also be completed at such time as to meet the April 1998 target.
4. Under AA's franchise agreements with its franchisees, AA was obliged to give a three-month advance notice to the franchisees of the date of opening of the new airport. ADSCOM was mindful of the importance of fixing an airport opening date well in advance so that the public as well as all concerned parties would know this date for their own planning purposes. It was therefore necessary for ADSCOM to take a decision on a firm airport opening date at least three months ahead of April 1998.
5. As early as October 1995, ADSCOM considered that since the smooth opening of the new airport is essential to Hong Kong, ADSCOM was best placed to be the overall monitor of AOR. ADSCOM's executive arm is the New Airport Projects Co-ordination Office ("NAPCO"). NAPCO's primary duty was to co-ordinate between Government departments which were responsible for the development of seven of the 10 Airport Core Programme ("ACP") projects and the three bodies that were responsible for the development of the remaining three ACP projects, ie, AA in respect of the new airport, Mass Transit Railway Corporation ("MTRC") in respect of the Airport Railway ("AR") and Western Harbour Tunnel Co Ltd in respect of the West Harbour Crossing. ADSCOM also directed NAPCO as its executive arm to monitor the progress of AOR.
6. Towards the end of 1997, ADSCOM asked AA to recommend a date for airport opening. NAPCO assisted ADSCOM by critically examining the progress of AOR critical items, and ADSCOM put details of matters of concern to AA to obtain its comments. ADSCOM was particularly concerned with three matters: (a) when AR would be ready for operation to provide ground transportation to complement the operation of the new airport; (b) the delays in the completion of the construction and system works in PTB; and (c) the slippages in the construction of SuperTerminal 1 ("ST1") to be operated by Hong Kong Air Cargo Terminals Ltd ("HACTL"), the major cargo handling operator at the new airport. AA advised that PTB would be ready to open for operation in early April 1998. HACTL had given an assurance that it would be ready with 50% of its throughput capacity (which was the required amount in April 1998) by early April 1998. However, considering the delay in ST1's construction works, AA was confident that the new airport would be ready at the end of April 1998, which date it recommended to ADSCOM. On the other hand, MTRC was adamant that AR would only be ready by 21 June 1998, the contractual date of completion, with little hope to advance the date. ADSCOM considered that it was essential for the new airport, as a world-class airport, to be complemented by an efficient ground mass transportation system, as opposed to ground transportation consisting of makeshift arrangements. It decided that 1 July 1998 to be the ceremonial opening day and 6 July 1998 to be the operational opening date ("AOD"). The ceremonial opening day was subsequently altered to 2 July 1998. 6 July 1998 was chosen because it was a Monday, when air traffic would be lighter than other days of the week and road traffic would be lighter the night before. The lighter air traffic would hopefully reduce the duties of operators of the new airport and the light ground traffic would facilitate the execution of the enormous relocation exercise to move the equipment, facilities and staff from the Kai Tak airport to the new airport on the Sunday night before AOD. The two months between the original target of April 1998 and AOD would also provide a comfortable float for the completion of necessary AOR works in PTB, and HACTL in particular. HACTL was happy with the added time, and subsequently gave assurances to AA and Government that it would be ready on AOD with 75% of its cargo handling throughput capacity, instead of the 50% throughput by April 1998. On the evidence, the Commissioners conclude that the decision on AOD was proper and wise.
7. The decision was approved by the Chief Executive in Council, accepting ADSCOM's views without comment. There is no evidence before the Commission to indicate that the decision was made with any political or ulterior consideration.
PROBLEMS ON AND SINCE AOD
8. On AOD, numerous problems were encountered, and confusion and chaos ensued. The problems affected man, cargo and machine: there was no efficient movement of air passengers, air cargo or aircraft. Even after AOD, problems continued to occur. The Commission has investigated all the problems that it has been able to identify and made findings as to their causes and where responsibility lies. The problems, which were classified as teething or minor, moderate and major, in accordance with their seriousness and scope, are set out below. The findings of the Commission as to the causes of the problems and the responsibility for them can be found in the appropriate chapters of this report, while Chapter 18 contains a summarised account of all the problems.
Teething or Minor Problems:
[1] Mobile phone service not satisfactory
[2] Trunk Mobile Radio ("TMR") service not satisfactory
[3] Public telephones not working
[4] Escalators breaking down repeatedly
[5] Insufficient or ineffective signage
[6] Slippery and reflective floor
[7] Problems with cleanliness and refuse collection
[8] Automated People Mover ("APM") stoppages
[9] Airport Express ticketing machine malfunctioning
[10] Airport Express delays
[11] Late arrival of tarmac buses
[12] Aircraft parking confusion
[13] Insufficient ramp handling services
[14] Airbridges malfunctioning
[15] No tap water in toilet rooms and tenant areas
[16] No flushing water in toilets
[17] Urinal flushing problems
[18] Toilets too small
[19] Insufficient water, electricity and staff at restaurants
[20] Rats found in the new airport
[21] Emergency services failing to attend to a worker nearly falling into a manhole while working in PTB on 12 August 1998
[22] Traffic accident on 28 August 1998 involving a fire engine, resulting in five firemen being injured
[23] A maintenance worker of Hong Kong Aircraft Engineering Company Limited slipped on the stairs inside the cabin of a Cathay Pacific Airways Limited ("Cathay Pacific") aircraft on 3 September 1998
[24] A power cut occurring on 8 September 1998, trapping passengers in lifts and on the APM as well as delaying two flights
[25] Missed approach by China Eastern Airlines flight MU503 on 1 October 1998
Moderate Problems:
[26] Delay in flight arrival and departure
[27] Malfunctioning of the Access Control System ("ACS")
[28] Airside security risks
[29] Congestion of vehicular traffic and passenger traffic
[30] Insufficient air-conditioning in PTB
[31] Public Address System malfunctioning
[32] Insufficient staff canteens
[33] Radio frequency interference on air traffic control frequency
[34] Aircraft Parking Aid malfunctioning: a Cathay Pacific aircraft was damaged when hitting a passenger jetway during parking on 15 July 1998
[35] An arriving passenger suffering from heart attack not being sent to hospital expeditiously on 11 August 1998
[36] Fire engines driving on the tarmac crossed the path of an arriving aircraft on 25 August 1998
[37] A Hong Kong Airport Services Ltd. tractor crashed into a light goods vehicle, injuring five persons on 6 September 1998
[38] Tyre burst of United Arab Emirates cargo flight EK9881 and runway closures on 12 October 1998
[39] Power outage of ST1 due to the collapse of ceiling suspended bus-bars on 15 October 1998
Major Problems:
[40] Flight Information Display System ("FIDS") malfunctioning
[41] Cargo Handling System ("CHS") malfunctioning
[42] Baggage handling chaos
9. The two main culprits for the chaos on AOD were the deficiency of FIDS and the breakdown of CHS of HACTL.
10. Due to FIDS' difficulties, incorrect and incomplete flight information was provided to all airport users, passengers and airport operators alike. All had difficulty in knowing when a flight would arrive and where it was going to park. This affected and delayed the operations of the ramp handling operators ("RHOs") in serving aircraft and passengers and in unloading baggage and cargo. Passengers and airlines did not know which departure gates were assigned to the flights, especially when such gates were subjected to many changes. Planes were late in both arrival and departure. Passengers were delayed by the flight movements and also by the late arrival of baggage. The means of communication such as TMR and mobile phones which could be and were relied on by airport operators as alternative means of obtaining the necessary flight information were overloaded. Only about one third of the public telephones were operational. The airbridges linking aircraft and PTB were not always working, and the doors that were supposed to be operated through ACS from the airbridges to PTB occasionally malfunctioned, causing further delay to both aircraft and passenger movements. A full apron resulted as early as about noon and lasted till about 5 pm, and another one was experienced between 8 and 11 pm. Aircraft had to wait to be provided with a parking stand. Passengers were greatly inconvenienced and anxious while service providers were sweating to cope. All kinds of operators of the new airport were generally unfamiliar with the environment and experienced difficulties in the operation of FIDS, and despite their tremendous efforts, the chaos could not be avoided.
11. HACTL's CHS was operating slowly and inefficiently. The slowness compelled operators to use the manual mode, which could not cope with the workload that the automatic mode would. Operators were not familiar with the manual mode either. The unpreparedness of the operation of CHS was precipitated by the long delays experienced in the construction of ST1, which also cascaded down to delaying the installation, testing and commissioning of CHS equipment and systems as well as the training and familiarisation of HACTL's staff. There was a breakdown of the hand-over procedure that had been agreed between HACTL and RHOs, resulting in a large backlog of inbound cargo being left on the ramp interfacing with HACTL's premises. Not only the customers of HACTL suffered, but Hong Kong's airfreight-forwarding trade also sustained severe losses.
12. The baggage handling problem is also a major one, because of its impact on numerous passengers on AOD and the days following. However, had FIDS been operating properly, RHOs' resources and energy could have been focussed on alleviating the baggage problem. The other 39 problems are classified as teething or minor and moderate. Some of them were isolated incidents, and did not contribute to the chaos on AOD. The others would by themselves have only caused minor inconvenience to passengers, freight forwarders and other airport users had FIDS and ST1 been running smoothly. However, the effects of each of the small problems were enhanced, snowballed and spiralled when they interacted with each other and the trouble caused by FIDS and CHS, to the extent that nobody could have reasonably anticipated.
THE KEY RESPONSIBLE PARTIES
13. The main cause of the inefficient operation of FIDS was the problems with the FIDS software, giving rise to slow response time and causing great difficulty to the operators of FIDS on AOD. The lack of training on the part of the operators was also a major contributing factor. The root cause of all these was the lack of time. Due to delays in the development of FIDS, software development time, testing time as well as training time had all been compressed. There is insufficient evidence for the Commission to decide whether it was AA or its contractor and subcontractors for FIDS that should be responsible for the delays. For the software problems, Electronic Data Systems Ltd., the subcontractor providing the software, should be responsible. AA should mainly be responsible for the failure to have its operators properly trained.
14. The delays in development of the software at the early stage was mainly caused by the lack of co-ordination between AA's Project Division ("PD") led by W43 Mr Douglas Edwin Oakervee and Airport Management Division ("AMD") of which W44 Mr Chern Heed is the director. There were also other instances of lack of co-ordination, the most important of all was AMD and the Information Technology ("IT") Department headed by W45 Mr Kironmoy Chatterjee failing to effectively arrange the staff of the subcontractors for the software of FIDS (inclusive of the Terminal Management System) and IT Department to timely attend the Apron Control Centre to assist the operators there when help was most needed, although such staff were present in other parts of PTB. For this lack of co-ordination, W44 Heed and W45 Chatterjee should be responsible. W45 Chatterjee also failed to advise AMD of the risk of deferring the stress and load tests of FIDS.
15. Though there were risks involved in using FIDS on AOD, W44 Heed did not make any global contingency plan or have an overall risk assessment. W44 Heed should be responsible on this account.
16. For the chaos in PTB on AOD and the days after, W44 Heed as AMD Director must be primarily responsible. W3 Dr Henry Duane Townsend, as the Chief Executive Officer ("CEO"), should also be responsible. He is further found to be responsible for not co-ordinating AMD and PD as the CEO.
17. The Commission also finds that the lack of co-ordination between AMD and PD was probably caused by the personalities and characters of those occupying the posts as directors of these two divisions as well as the CEO. W3 Townsend did not give sufficient priority to the operational requirements of AMD, and did not give adequate support to W44 Heed.
18. AA as a whole failed in the duty imposed on it by the Ordinance to have sufficiently regard to the efficient movement of air passengers, air cargo and aircraft in operating the new airport. As to the chaos in PTB, despite the responsibility of W44 Heed and W3 Townsend for the same matter, the AA Board must bear the ultimate responsibility, because the Ordinance has imposed the duty on it, although it has power to and did delegate that duty to the CEO and the AA management.
19. The evidence shows that W3 Townsend had made two misstatements to ADSCOM, one on paper and the other orally. The written misrepresentation was that FIDS was, as a whole, 98.7% reliable, and the oral one was that ACS had been successfully tested. The Commissioners do not have sufficient evidence to conclude that the misstatements were uttered with intent to mislead, but ADSCOM was in fact misled. For these misstatements, W3 Townsend must be responsible. W45 Chatterjee is found to be grossly negligent in not disabusing ADSCOM of the misstatement on FIDS, but is not found responsible regarding ACS. W44 Heed's attitude that he would not bother if ADSCOM was misled betrayed the trust that ADSCOM reposed in him, and exposed a weakness in his integrity.
20. The top management of AA was over-confident in what they could achieve, and were too busy to step aside to look at the risks involved. As a result they assured ADSCOM that the new airport would be ready.
21. The root cause of ST1's paralysis, similar to the cause of FIDS' deficiency, is also the lack of time. There were progressive delays in the construction and commissioning works in ST1, compressing the time for testing and for training of operators. There is insufficient evidence as to whether HACTL or its main contractor and subcontractors were responsible for the delays.
22. The Commission finds that probably the main cause of the breakdown of HACTL's CHS was the problems with the integration between the Logistic Control System and the mechatronics of the Container Storage System and the Box Storage System. The operators were also not trained well enough to operate CHS in manual mode.
23. HACTL is primarily responsible for not being able to provide a cargo handling terminal ready with 75% of its full throughput capacity that it had assured AA and Government. HACTL was also over-confident in CHS that they had developed.
24. AA should also have monitored the readiness of HACTL. While AA had professionals to check on the physical construction side of the works carried on in ST1, it did not have any expertise to effectively monitor CHS. AA therefore did not have sufficient regard to the efficient movement of air cargo in preparing the new airport for operation and should be responsible.
25. NAPCO was the overall monitor of AOR. It should have critically examined and evaluated AOR critical issues, including the readiness of PTB and ST1 in effecting the efficient movement of air passengers, aircraft and air cargo. In discharging these functions, NAPCO committed two errors: (a) assuming that AA had the necessary expertise to monitor HACTL's CHS, without even asking AA if it actually had the expertise; and (b) failing to critically examine the contingency plans of AA and to query if it had made an overall risk assessment.
26. NAPCO therefore failed to discharge its duties as the overall monitor of AOR in its position as the executive arm of ADSCOM and as directed by ADSCOM. However, as ADSCOM itself was the overall monitor of AOR, it is ultimately responsible for the duties of such an overall monitor not having been satisfactorily discharged by NAPCO.
27. Both AA and HACTL were too confident to appreciate the risks involved in the compression of their testing and training time. They never sought any postponement of AOD. Had a deferment been suggested by either AA or HACTL, the chaos could have been avoided by a postponement of AOD by about two months. Unfortunately, no one ever made any such suggestion, and everyone was working diligently but blindly towards the common goal of AOD.
28. FIDS was operating reasonably efficiently about a week after AOD, and the other less serious problems also subsided within a short time. On the other hand, it had taken HACTL about six weeks to recover. Although there may still be glitches and hitches, the new airport is now running as a pride of Hong Kong.
End/Friday, January 22, 1999
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