The death of Tamara Cvetanova, who was speaking by cellphone to her husband as she lay crushed in the Canterbury Television building after the Christchurch earthquake, will haunt the Fire Service for a long time. Coroner Gordon Matenga's report on her death and those of seven others who were waiting to be rescued does not provide much comfort.
He concludes that it was never possible to rescue the eight, who survived the building's collapse, and finds the rescue teams, led by the "outstanding, courageous and selfless" Fire Service, were not to blame.
But he also reports that Fire Service executives "went missing in action". He could not understand why they did not take charge of the disaster area, set up an incident control room and see that resources and manpower went where they were needed.
Voice detectors and cutting equipment were in use on one side of the CTV building but not on the side where eight people were still alive.
Alec Cvetanov, who spoke to his trapped wife six times and told searchers where she was, believes the equipment could have saved her life.
The coroner does not go that far. "More people, more resources, better communication and a better structure," he says, "may have improved the chances of saving more lives."
Hindsight is an obvious problem. Three years on, it is easy to forget the scenes that search and rescue teams faced that day. In the noise of sirens and the dust, fires, haze and debris of the city centre that afternoon and evening, it may be unreasonable to expect the Fire Service to know that almost the only people trapped were in the collapsed CTV and Pyne Gould Corporation buildings. Of the 185 people killed by the February 22 earthquake, 133 were in those two buildings.
But hindsight does not prevent lessons being drawn. In the hours after the earthquake at 12.51pm, a control centre should have been set up. Lines of command ought to have been clear to firefighters and Urban Search and Rescue volunteers.
The CTV building contained a language school for foreign students, and Dr Cvetanova was not the only student in contact with loved ones. Texts went as far as China and the Philippines. Fire had broken out. Those who had not been crushed would be choked or burned to death. There was clearly no time to lose and, equally clearly, with flames coming from the ruins, the Fire Service was in charge.
It is dismaying that the coroner finds senior fire officers at the scene were "clearly overwhelmed" by the disaster. A senior station officer arrived late at the scene and believed he was not in command, while others thought he was, causing confusion.
Surprisingly, the coroner has found no evidence the rescue was delayed by the Fire Service giving attention to other reports or calls for help, as Mr Cvetanov believes. If there were no reports coming in of other possible endangered people, the Fire Service should have concentrated its attention and resources on Canterbury Television and the Pyne Gould Corporation sites.
The Fire Service national commander, Paul Baxter, says it is carrying out the coroner's recommendations, which include giving Urban Search and Rescue technicians specialist training in the use of heavy machinery, including cranes. He also urges the police and the Fire Service to do more training in incident management, emphasising the need to co-operate to establish a control point and an incident controller.
The scale of the Christchurch disaster exceeded anything the Fire Service has dealt with in the lifetime of its leaders but they could have performed better. If they are to be a controlling agency in civil emergencies, they must take these deaths to heart.