Coroner clears of blame officers 'missing in action' on quake day but wants more change in service shaken to the core.
No one ever doubted their bravery that day. Firefighters, police officers, Urban Search and Rescue experts, and courageous passersby risked life and limb to drag several stunned survivors from the rubble and chaos of the collapsed CTV Building. While the ground still rumbled and rocked threateningly, they choked on the caustic dust and smoke as they dug through mangled steel and crushed concrete to find signs of life. They clawed with their hands, commandeered diggers, shouted for help, fought fatigue and tried to make sense of it all; wondering all the time if their own loved ones had survived the vicious February 2011 event. But while they were on the frontline, drawing on years of training and experience, desperately seeking the people they knew had somehow survived the collapse, they were being badly let down. Their bosses were "missing in action". And the results were monumental, even fatal, some families of victims say. A failure by 13 New Zealand Fire Service executive officers in the city that day to set up a proper chain of command and incident control point meant a total breakdown in communication. Rescuers weren't told about critical searching gear, like Delsar listening devices or concrete-cutting tools. Some teams were diverted to other jobs. Key heavy equipment wasn't mobilised, firefighters weren't fed or watered. Emergency services search the rumble for survivors of the collapsed CTV building. Photo / Brett Phibbs The Fire Service, the lead agency given a fire broke out in the lift shaft after the collapse, has today been cleared of causing any of the deaths of the eight people who survived the collapse but died before they could be rescued: Tamara Cvetanova of Serbia, Cheng Mai of China, Japan's Rika Hyuga, and Jessie Redouble, Emmabelle Anoba, Ezra Medalle, Reah Sumalpong and Mary Amantillo, all from the Philippines. But the CTV collapse, in which 115 people died, has resulted in the biggest shake-up in the New Zealand Fire Service since the Royal Commission of Inquiry into the Ballantynes department store fire, also in Christchurch, in 1947. Coroner Gordon Matenga made eight recommendations to improve New Zealand's response to any future search and rescue operations. Fire Service chief executive and national commander Paul Baxter says all the recommendations have either been addressed already, or are in the process of being implemented. And he points out that after the disaster, the Fire Service took a proactive approach and commissioned two independent reviews of its performance of the CTV rescue, and contributed to a wider Civil Defence and Emergency Management review. "We're really hard on ourselves as an organisation," Mr Baxter said. "We knew what a lot of the areas for improvement were, and have already been working towards those. So the coroner's recommendations are another set, and we take those on board and make sure they're covered. He acknowledges quite clearly the progress we've made on those, and that's what the families want to know, that the people they lost were not in vain." Emergency services search for survivors amongst the rubble of the CTV building. Photo / Brett Phibbs Mr Baxter was pleased for his staff that their actions didn't contribute to the deaths of people who survived the collapse, as the coroner ruled. He also welcomed the coroner's conclusions that a decision, about three hours after the collapse, to start lifting rubble with diggers to find survivors on the eastern side of the collapse was the right one. They were in a difficult situation, Coroner Matenga said, as delayering raised risks to people trapped underneath - it could have caused concrete slabs to fall on them, or spread the fire with more oxygen. "There was also significant risk in sitting by and doing nothing," he said. "In the end, the correct decision was made. Time was of the essence. It was necessary to commence the delayering process at that early stage and make use of the heavy machinery available. This decision was made based on the experience and judgment of these men who were risking their lives and the lives of others, to save lives. The delayering process proceeded with care and caution." That decision was immediately vindicated, the coroner said, with two people being pulled out alive. But they were the last to be found alive on that side of the pancaked building. A 2012 review into the Fire Service response by English fire chief Simon Pilling found the scale of the disaster would have "stretched any fire service in the world". It was the first time any New Zealander firefighter had faced such a daunting task. The lessons to be taken out of the event are considerable, Mr Baxter says. The Pilling report made 15 recommendations, which were referenced by the coroner in his report. Already, senior fire officials have been sent on strategic training courses at the Australasian Fire Authorities Council in Sydney. Executive officers are going through a new tactical command course designed from lessons emerging out of the Christchurch earthquakes. They're working more closely with other agencies and going on joint exercises. The Queensland Fire and Rescue Service has been brought in to mentor their New Zealand urban search and rescue colleagues as they try to become internationally accredited by the United Nations. As part of that, Usar officers will go through major training and development. It also means New Zealand Usar teams will have an international-standard equipment cache. Brand new, high-tech gear, including core drills and listening devices, has already been purchased. The moves go well beyond what Coroner Matenga has recommended. But Mr Baxter says he wants the public and the CTV families to "be assured that I take it seriously and I'm making sure the organisation is taking it seriously in terms of positive change". "All of our people, every single one of them, I believe did all they possibly could [on February 22, 2011], often putting their own situations and families to one side - and many risked their own lives to try and save others. "The concession made to the coroner was that we needed to do more to prepare those people for that type of crisis where all of your normal day-to-day systems are stripped away from you. We said, hands up: we've got to do better. Police and volunteers work to rescue people trapped in the collapsed CTV building. Photo / Geoff Sloan "But I didn't want to just set about ticking boxes. I wanted to ensure the change is long-lasting. It's really about changing the organisation and developing it for the future." Dr Cvetanova's husband and father of their two children, Alec Cvetanov, has welcomed the coroner's recommendations but also wants some accountability. Senior staff should pay for their failures in the future, he said, whether by demotion or salary cuts. For, as the Macedonian-born engineer said, "If I'm an engineer and I burn a machine in the factory, I will be held responsible." The coronial inquest into the eight people who survived the CTV Building collapse but died before they could be rescued was not conducted to determine civil, criminal, or disciplinary liability. It was carried out to find out how they died, and for the coroner to see if he could make any recommendations that would make New Zealand better equipped to respond to any future disaster. Coroner Gordon Matenga's report was expected back much earlier than today, but it was delayed after he underwent major heart surgery. He makes eight recommendations. The coroner recommended the Fire Service, Defence Force, Air New Zealand and DHL establish a memorandum of understanding to ensure the "expeditious deployment" of Usar teams and for joint training exercises. That has already happened, says Fire Service chief executive and national commander Paul Baxter. Recommendations that Usar technicians undertake specialist heavy machinery training and become International Air Transport Association certified have also been acted upon. For all major disasters where international assistance is sought or accepted, it is now the default position that a request be made for help from a United Nations Disaster Assessment and Co-ordination team. Coroner Matenga recommended the Fire Service, in conjunction with the Civil Defence Emergency Management Group, develop and undertake joint exercises with Light Response Teams established by local authorities. Joint exercises recently took place in Rotorua and Christchurch. The coroner also recommended that the Fire Service develop a standard operating procedure following an earthquake. A National Response Plan was developed before the inquest began, Mr Baxter says. It now needs to be practised before it's "used in anger". Another critical point was for fire and police services to develop and undertake further training in incident management, and to emphasise the need to co-operate to establish an Incident Control Point and an Incident Controller in the Usar environment. The final recommendation suggests the Ministry of Civil Defence and Emergency Management updates its Co-ordinated Incident Management System model.