"Officer A84 did not appreciate that there were potentially three people (other than McDonald) in A84`s line of fire.''
Mr Matenga also noted that the two least experienced staff members were paired together, something he questioned given the seriousness of the incident.
This, and A84`s failure to notice the Toyota van, "indicate to me a need for further training and an acknowledgement from AOS that experience matters'', Mr Matenga said.
"No thought was given to the experience of the AOS members when the decision was made to divide the attending members into sections. The only criterion used was readiness to deploy.
"The uniqueness of the situation should have, in my view, given the senior AOS officer pause to consider the relative experience of his squad and separate into sections taking experience into account.''
Mr Matenga also noted that the police communications centre inspector who was coordinating the pursuit had difficulty communicating with some units, partly because some had not logged in.
Police have begun adopting automatic vehicle locator (AVL) technology, which Mr Matenga recommended they continue with.
He also suggested AOS vehicles should have visual markings of some sort so other police could identify them in such a pursuit.
Mr Matenga also said he was concerned at the actions of one other officer, a case since handed on to the Independent Police Conduct Authority (IPCA).
"In the course of hearing the evidence I became aware that an unnamed police officer who was part of the chasing group of police stopped his vehicle when the chase came to an end, exited, drew his Glock (pistol) and fired in the direction of McDonald as he made his way on to the city bound traffic lanes.
"This was a gross infraction of the police instructions on firearms, appears to have been incredibly dangerous and is a matter that I will refer to the IPCA to deal with.''
The IPCA is also investigating the incident, and its chairwoman Justice Lowell Goddard today said its investigation was complete and it was preparing its report for an upcoming public release.
Police assistant commissioner Allan Boreham said police deeply regretted the shooting and their sympathies were with Mr Naitoko's family.
"We're an 100 percent business, we're out there to protect the public and we've got to get it right all the time,'' Mr Boreham told NZPA.
"This shooting was unprecedented and it's not why we come to work. We come to work to protect the public, so our general feeling is one of devastation, but there is some learnings for us and the best thing we can do to his memory is to take the learnings out of reports like these and make sure it never happens again.''
Increasing the minimum number of AOS officers available so more experienced members could always be called on was being done, he said.
The two officers involved were still with police and were being supported, Mr Boreham said.
"I understand they remain devastated, but they do remain operational,'' he said.
"This was a really difficult situation and what we want our police to do is go out and protect our public and we need them, in a properly trained way, to take immediate action to bring the situation to a safe conclusion. We want our officers to have that courage to act.''
Naitoko family spokesman Peter Sykes said the family wanted more time to digest Mr Matenga's report, and for the release of the IPCA report, before commenting.
McDonald was jailed for 13 years after admitting 23 charges in relation to events on January 23.
- NZPA
