Was there clear command?

The IPCA found the operation lacked effective command and control. During the chase, the shift commander at the Northern Communications Centre (NorthComms) did not make clear that they were in control and not the police Eagle helicopter which was following McDonald. There was confusion among staff as to who was in command, on top of a lack of information available to NorthComms - which units were responding, which were in direct pursuit and which were armed. The AOS commander also made decisions without the shift commander's knowledge. The lack of tactical control was shown when a chance to contain McDonald in Pine St, New Lynn, was missed. The shift commander was unaware that 19 armed staff, three dog handlers and three vehicles with road spikes were nearby.

Were there enough AOS officers?

Six members were rostered on duty. Five officers and an AOS dog handler responded to the call-out. None was ranked sergeant or senior sergeant. Under normal circumstances, at least 15 members would be expected to respond. Two police cars collided in the pursuit on the motorway and stopped three AOS officers from engaging McDonald just 35m away. The IPCA said those numbers were insufficient to cover a metropolitan area.


Did the AOS radio cause problems?

AOS members use encrypted portable radios and monitor other police communications on car radios. The AOS channel cannot be heard by NorthComms or field units. They also had limited range and the AOS had trouble communicating with each other. The two AOS teams were not aware of each other's locations and NorthComms did not know the intentions or strength of the AOS response. The AOS commander could not hear his two teams but knew from experience they could hear him. The IPCA found the tactical response was compromised by the radios and it was a "high risk" assumption by the AOS commander that his staff could listen to his instructions.

Why did the AOS officers fail to shoot Stephen McDonald?

Coroner Gordon Matenga has previously voiced concerns that AOS officers A81 and A84 missed McDonald from 7m to 9m. The pair fired four shots, with one from A84 killing Halatau Naitoko. The IPCA said McDonald was moving around on the road and the back of a truck, the officers were moving across the motorway, and the vehicles were also moving. The shooting happened in a matter of seconds and A81 and A84 were not under the command of a more experienced officer. Each had limited experience of shooting at moving targets. "The inaccurate marksmanship occurred because the officers were operating in a highly stressful and challenging shooting environment for which their level of training and experience had not equipped them," said the IPCA. "The shots fired ... were not accurate or safe."

Why did Officer A84 fail to identify Halatau Naitoko's van in the line of fire?

The IPCA acknowledged the four shots were fired in an environment that was "complex and far from static". Officer A84 said he did not recall "vehicles being in the immediate background" except for a van driven by Richard Neville. Evidence given at the Coroner's Inquest suggested A84's view of Mr Naitoko's van may have been obscured by Mr Neville's van and the officer was distracted by McDonald's movements. However, the IPCA said training should ensure officers are alert to objects in the line of fire and highly tuned in making "shoot, don't shoot" decisions. "The degree of weapons training undertaken by Officer A81 and A84 had not prepared them to deal effectively and safely with the particularly challenging environment they faced."

Were police actions after the shooting appropriate?

On returning to the squad room, A81 and A84 placed their Bushmaster rifles on a bench with safety catches on. The commander then cleared the weapons and removed the magazine, sling, optical sights, pop sight and torch. An internal investigation concluded this breached procedures and instructions to be followed when someone had been shot. The IPCA also noted that four days passed before A81 and A84 were formally interviewed for the internal investigation, which may have led to valuable information being lost. Officer A84 attended an armed call-out within 11 days of the Naitoko shooting - while the officers were still under investigation and before passing a qualification test. At that point, it was not known who fired the fatal shot.

"Sound and prudent advice would have been for the officers to be stood down from AOS duties until they were certified by a psychologist, undergone retraining, it was known who fired the fatal shot and the officers had been cleared of criminal liability."