Civil Defence has singled out problem areas in an internal report into how the agency handled the Kaikoura Earthquake.
The Ministry of Civil Defence and Emergency Management (MCDEM) today released its event report into the 7.8-magnitude November 14 quake, acknowledging specific issues with how it issued tsunami warnings, and getting the right staff in quickly.
In the weeks following the midnight quake, MCDEM drew heavy criticism over how it responded to the disaster, while then Acting Civil Defence Minister Gerry Brownlee also conceded an "an unacceptable level of confusion" before signalling a review of the agency's entire command structure.
In its report, MCDEM acknowledged the size and complexity of the midnight quake, along with a "rapidly changing assessment" in the first hours, made it a challenging response.
MCDEM immediately activated the Wellington-based National Crisis Management Centre (NCMC) to support different Civil Defence groups' responses to the quake and tsunami.
The report listed a raft of areas where the response had gone well, including good communication between managers and agencies, and the swift activation of the NCMC, which happened within 30 minutes of the main shock near Culverden.
But it added how MCDEM and local response staff capacity was "stretched" during the response - and extra staff had to be called upon to help around the country.
"While general supplementary staff were put in place quickly, the process for requesting and matching the need for specialist support staff with available skills was ineffective."
It took time to get specified requests, while the offers of assistance from other Civil Defence groups and agencies were "not aligned" with the NCMC's own requests for assistance.
"Subsequently some support staff did not represent the skills required or were unfamiliar with processes and/or systems."
The access process for support staff entering the NCMC was double handled by Parliament Security and the NCMC, resulting in delays.
Some staff were also unclear about who to report to and where to go, while at the same time Parliamentary Security were uncertain who to send staff to.
The report further found issues with the rostering of staff, finding that shifts could not be equally staffed in terms of capacity, experience and skills across the NCMC.
It recommended five key improvements to the resourcing problems: namely creating a pool of "sufficiently trained" staff across agencies.
But the report also pointed to the fact the NCMC itself faced the risk of tsunami.
At the time it was activated, there was a potential tsunami threat to the Wellington region and it wasn't clear to some staff how to respond to call-outs if they would have had to make their way through potential tsunami hazard zones.
"In addition, staff also felt uneasy in the NCMC during the initial stages of the response due to uncertainty about building safety."
How MCDEM's issued warnings and communicated with the public was also highlighted.
A number of advisories about the earthquake and tsunami were issued, based on the information available at the time, and procedures were followed correctly in all instances.
But the information and advice received changed "significantly" during the first hours after the earthquake, leading to decisions also changing.
This created what many called a delay in issuing a tsunami warning, while an "inconsistent response" to the warning at local levels further fuelled criticism.
While it noted official warnings were unlikely to be issued rapidly enough to warn communities nearest to the tsunami source, the report pointed out how rapid and effective warnings were hampered by the sharing of responsibilities between GNS Science, which monitors and assesses tsunami risk, and MCDEM, tasked with issuing warnings.
It found the practice was "unnecessary complicated" and could cause delay - a problem compounded by the fact neither MCDEM nor GNS Science conduct their responsibilities from a dedicated, 24/7 monitoring and warning centre.
Following the disaster, a public education campaign around tsunami danger was launched, while MCDEM began work to enable better warnings for local-source tsunami.