In accordance with the applicable regulations, in September 2019 a group was appointed to draw up an occurrence report on the whole case and issue a number of recommendations. The report was quality-assured by an external and professionally recognised safety expert.
The final report was approved and signed by the two employees who have now come forward with criticism and concerns. A task force of specialists and experts, including the Safety Manager, was appointed to assess and conclude which mitigations were needed to control the risk. The two former employees were not part of this specific task force, which, according to procedures, had all the necessary qualifications and competences covered. The Task Force concluded, that the risk was managed to an acceptable level, and hence, that continued operation was safe.
It emerges from the report that the individual episodes with the runway lights were all handled operationally correct and according to procedure. The episodes resulted in runway closures and extraordinary runway inspections, and in a number of cases, as a mitigation, special individual checks of all bolts for securing the runway lights in the affected areas were initiated. In this way, it was ensured that the affected area was only used for air traffic operations when the area had been inspected and confirmed to be operationally safe.
At the same time, however, the case showed that the processes in the safety organisation had some faults. In particular, in the first days after the occurrences on 14-15 September 2019, it was not sufficiently documented in writing that the risk was under control. In that light, the occurrence report stated that CPH had not adequately ensured that, at the time of the occurrence, there were established routines among the employees that could guarantee that the case was documented and escalated up through CPH’s safety organisation.
This meant that for around 24 hours, between the occurrences of 14-15 September and the task force’s decision of 17 September, CPH operated with a potential “risk A” without having identified whether adequate risk-mitigating measures had been introduced. Although the runways are inspected five times daily, continued operation with a potentially critical risk was, according to CPH’s Safety Management System, not acceptable. According to CPH’s risk classification scheme, Risk-level A is the definition of a risk with high severity and the probability of an occurrence within 10 years.
Since the occurrence report was completed, CPH has been in the process of implementing the occurrence report’s action plan of 33 initiatives that are intended to improve safety further. The plan focuses on the work with aviation safety, runway lights, organisation, processes, documentation and training. Execution of the action plan is progressing as planned. 25 initiatives have been fully implemented, while eight are under implementation as planned.
In January 2020, the full occurrence report on runway lights was sent to the Danish Transport, Construction and Housing Authority (TBST), which has authority for CPH. It was drawn up with a view to learning and improvement in accordance with best practice within the work of flight safety. This means i.e. that the report contains personally sensitive data and is therefore subject to confidentiality because employees must be able to freely contribute information and raise concerns without fear of being personally blamed.
If all details in an occurrence report are subject to public debate, individuals may choose not to come forward with concerns and observations – rather than focusing on sharing information openly to enhance learning and thereof improve safety. The two former employees who have now come forward publicly with criticism of the airport were tasked with drawing up the occurrence report aimed at identifying how the airport could end up in a situation where the runway lights shook themselves loose – one as occurrence reporter, the other as assistant.
During the process of preparing the report, there were areas where individuals had completely different opinions and judgements – as can occur in difficult cases involving multiple experts. There has to be room for that; and there was. Everyone had their say. In the concluding phase, an external and professionally recognised expert helped to validate the conclusions in the final occurrence report, which was drawn up and signed by the two former employees..
CPH has a number of safeguards to ensure that employees can, anonymously and without risk of losing their jobs or suffering other sanctions, voice their concerns about the company and the airport’s safety. There is an internal whistleblower scheme that the employees can use. Also, they have the option to completely bypass the airport and go directly to the Danish Transport, Construction and Housing Authority (TBST), which is the authority that supervises the airport. This is widely known, especially to employees working with safety at the airport.
However, there have been no reports – whether during the occurrences, amid the work on the report or subsequently – to either TBST or CPH’s whistleblower scheme concerning the circumstances of the case.
As a result of the case, the organisation has been revised and the processes have been tightened up. An investment of DKK 19 million has been made in replacing the bottom parts of approx. 2,400 runway lights. Since September 2019, no finds of dislodged runway lights have been reported.
All occurrences were reported to the authorities by CPH. In September 2019, the drawing up of the occurrence report was initiated. On 2 December 2019, the Danish Ministry of Transport was informed of the progress of the work. The report and its recommendations were delivered in January and an anonymised extract of the report was published on CPH’s website and sent to interested parties in March 2020.
Facts about aircraft safety and runway lights at CPH
We work at Copenhagen Airport on the basis of a very high level of safety. We therefore have – and must have – a very low tolerance threshold when it comes to safety at the airport generally and the manoeuvring area in particular.
The occurrences with the dislodged runway lights in 2018 and 2019 were all handled in an operationally correct manner; in each case the runway in question was instantly closed, thoroughly inspected and not released until deemed operationally safe. With regards to the potential latent risk A, the organisation did not respond and react as quickly and professionally as it should have. For that we have apologisedand made changes accordingly.
- Of 33 recommendations from the detailed occurrence report that CPH drew up after the occurrences, 25 have been implemented and 8 are in the process of being implemented
- Among other things, the processes and training have been tightened up and the organisation has been revised.
- Furthermore, DKK 19 million has been invested in replacing the bottom parts of 2,400 runway lights.
- Since the last two occurrences in September 2019, no finds of dislodged runway lights have been reported.
In January 2020, the actual report on runway lights was sent to the Danish Transport, Construction and Housing Authority (TBST), which has authority for the airport. It was drawn up with a view to learning and improvement within the framework of the “just culture” principles and the legislation, which i.e. ensure that employees are able to freely contribute information and expertise without the risk of reprisals. The occurrence report from January 2020 thus includes personally sensitive data and is therefore subject to confidentiality. It is CPH’s responsibility to ensure that we do not compromise the confidentiality and release personal or sensitive and protected data.[DN1]
As we did back then, we carry out five inspections of the runway area every day. Furthermore, across the whole airport, from pilots to our technicians, there is great awareness of the need to maintain as high a level of safety as possible and report anything that deviates from the norm.
We take every single find of FOD (foreign object debris) seriously. No airport in the world can prevent the presence of FOD completely, however it is immediately removed when found. All employees in all parts of the airport are asked to report all finds of FOD. This creates the best possibility of analysing and identifying systematics and routinely learning – so that we can continuously improve safety.
It is therefore very important to have an open and trusting culture for everyone who works at the airport. Where everyone dares to admit failings and talks openly about safety issues that they see – without fear, so that we can create the highest possible level of safety for passengers.
There are powerful forces associated with flying – so zero risk is not possible. But, as is popularly said, it is safer flying to and from Copenhagen Airport than it is driving a car to and from work. This is due in part to the fact that we work targetedly on aircraft safety and treat all finds and occurrences very thoroughly.