Fire chiefs failed to cope with the February 22 earthquake response, according to a report out today which criticised them for being disorganised, out of the loop, and failing to support their firefighters who were battling to save lives.
Firefighters battling the blaze at the collapsed CTV Building site, where 115 people alone died, were left to their own devices.
For six hours after the quake, no frontline operations staff heard from either of the three executive officers on duty that day.
The management failures meant key heavy equipment wasn't mobilised, communications broke down, firefighters weren't fed or watered, and operations officers on site were left to organise everything.
"They (executive officers) didn't do the job that we needed them to do," said firefighters union rep Dennis Fitzmaurice today.
The New Zealand Fire Service has released an independent review of its management's response in the first 12 hours of the Christchurch disaster, which claimed 185 lives.
The review, carried out by English fire chief Simon Pilling, found the scale of event would have "stretched any fire service in the world".
But while frontline firefighters are praised for heroic and brave actions in the chaotic hours after the deadly jolt at 12.51pm, the executive officers should have been "better organised, integrated and supportive" of operational crews and incident commanders.
A decision to withdraw and "largely prevent" some local Christchurch crews from carrying out life-saving operations within the city less than 24 hours into the incident provided the "blue-touch paper" for operational crews to "react adversely towards management".
Incident support arrangements during the first 12 hours were provided in an "ad hoc fashion" and with a "piecemeal approach" and were carried out in the main by operational staff during the initial throes of the event.
Management failed to take advantage of a number of opportunities to review command structures and options on the day, the report concludes, with executive officers failing to have meetings, including a crucial re-grouping at 5pm - four hours after the quake hit.
Mr Pilling said the fire service also failed to learn lessons from the magnitude-7.1 earthquake of September 4, 2010, which sparked the earthquake sequence and triggered thousands of aftershocks.
And despite the magnitude of the February event, it was still reasonable to expect "at least a single officer" to take charge of setting up the Fire Emergency Operations Centre and to become responsible for a single incident management team supporting the key sites each run by operations commanders, and to work with other emergency services and agencies.
Families of earthquake victims, including six victims whose deaths will be investigated at a Coroner's inquest later this month, say these delays meant their loved ones who survived for hours beneath rubble and debris weren't pulled out alive.
But while chief executive and National Commander Paul Baxter accepted the findings "in general", he denied the failings cost lives.
"I don't believe that operations on any one of those major sites (including the CTV Building which caught fire after its collapse) was hampered by the arrangements that were in place.
"But having said that, I would add that is the purpose of the coroner's court, to look at all of that information objectively, and once again with hindsight."
The review made a number of key recommendations and Mr Baxter today said action has been taken to address them.
He vowed that lessons would be learnt, adding that several managers have moved on or changed roles.
A lawyer representing Srecko 'Alec' Cvetanov, who spoke to his wife Tamara on a cellphone as she lay trapped in rubble beneath the CTV Building before she died, says his client doesn't think the report goes far enough.
Vaughan Taylor, who with Nigel Hampton QC is acting for Mr Cvetanov at the Coronial inquest into his wife's death, said the Fire Service had conducted a "reasonably robust" inquiry" but it was "really disappointing" to hear of some of the problems it had uncovered.
"It certainly highlights what appears to be some fairly significant cultural concerns at the New Zealand Fire Service.
"But Alec remains concerned that it doesn't answer the questions he's got. From Alec's perspective, the report itself doesn't look into some of the concerns he holds anywhere near as closely as he would hope the Fire Service would've looked, and that includes, for example, some of the decision making processes, command structures and equipment on the day at the CTV site."
The lawyers are pushing for a royal commission of inquiry to investigate the emergency services' response to the disaster.