Fire and Emergency NZ has been urged to review its firefighting strategies for buildings under construction after last year's catastrophic blaze of the Sky City Convention Centre.
An independent review of the blaze also discovered "almost all" attending personnel underestimated how long it would take battle the fire, estimating 24 hours at the most, when in fact it took 10 days to fully extinguish.
That meant Fenz focused entirely on extinguishing the fire and taking into account the impact it would have on the rest of the CBD.
At its peak, 130 firefighters, 30 appliances and 16 operational support vehicles descended on the central Auckland building after a fire began in the roof just after 1pm on October 22, 2019.
Categorised by a review team as one of the most complex and dangerous fires Fenz has ever had to deal with, the blaze saw toxic smoke waft across the city, seeping into air conditioning systems in apartment blocks and bringing the city to a halt to allow crews to safely battle the blaze.
An independent operational review was commissioned by Fenz earlier this year which saw two Australian experts spend a week in February, together with a senior Fenz firefighter to provide context, and their report released today.
Eleven recommendations were made the first of which was for Fenz to review its strategies to understand and manage high-risk buildings, .
While the convention centre had all of its necessary consents and there was "extensive" consulting of the non-mandatory Fire Engineering Brief between 2014 and 2017, Fenz only had a detailed plan of the building's final design.
In April the fire was found to be accidental.
However, Fenz had been guided by Fletcher's management that any planning of the building as it was being constructed would be out-of-date after three months.
"It was clear to us, however, that risk management both for the NZICC and for other major construction projects in Auckland poses a major challenge for Fire and Emergency New Zealand," the report stated.
"There are issues both with simply keeping up with the size and pace of development in terms of understanding from an operational point of view, what new risks are arising and how they can best be managed; and also from a practical point of view, of having available materials such as drawings and plans to allow for most effective response."
Fire and Emergency NZ National Commander Kerry Gregory said the fire was "particularly complex and dangerous".
"It was of a scale rarely experienced in this country."
He said crews made decisions "based on protecting the lives of the public and our people first and protecting property where we can".
"We are always ready to do better and we'll be working with our own people and partners across the emergency sector to implement the review's recommendations."
Fenz was still working on its "Mobility" project which would see tablets put on all appliances to allow quick access to plans relevant information.
In compiling its report, officers met with not only Fenz personnel but also staff from other agencies and reviewed footage of the fire and the firefighting operations.
More than 20 submissions were also given to the review team from firefighters who responded to the request for input.
The complexity of the roof construction "made it impossible" for firefighters to cut through its construction to create a fire break.
And even if it did, the vast fuel comprised in the high-grade timber roof - which included a compressed "straw-like product", absorption blankets, thermal insulation, wire netting, rubber membrane and plywood substrate - meant it was "doubtful that it would get through each layer.
The roof's "unique" construction imposed limits on the firefighting capabilities which meant it wouldn't have been able to reduce the loss anymore significantly than what it did.
The roof was ultimately "compromised" and firefighters battling the fire from there were unaware of its instability and were immediately ordered off after advice from Fletchers and Beca staff.
The review found both Fenz and Fletchers staff tried to salvage some vehicles from the basement car park early on, including bringing in a large portable pump to help drain it.
However it was decided that it would be logistically too difficult and also what to do with the water which had been contaminated with oil and water from vehicles and toxins from the fire.
"Auckland Watercare did not want it going into the storm water system, nor was it appropriate to pump it into the harbour," the report stated.
The report was largely supportive of how Fenz handled the fire and in particular the initiative of a senior station officer who had been called to a central fire just prior to the SkyCity blaze, and saw the smoke billowing from the centre, called comms and went to the scene, up scaling it to a third alarm on the way. It was escalated to a sixth alarm once executive officers arrived at the scene.
"All attending personnel recognised the incident's scale and significance from a very early stage, and resourced the incident appropriately."
Battling the fire was also made harder as there was no hydrant supply of water to the upper floors of the building due to construction not having been completed.
Instead, firefighters had to run more than 20 lengths of hose up stairways, reducing water pressure.
The availability of aerial appliances was also a key issue. Despite there being five in the Auckland, only one was available while two others only had a 17m high reach.
Fortunately NorthComms called one up from Hamilton early on, a move which was highly praised by the review team.
However, not only was there a shortage of aerial appliances not only Auckland but nationally, but also those tasked with operating them.
"The fact is Auckland effectively ran out of aerial operators and individual operators had to work unacceptably long periods of time without relief.
"It is not for the Review to specify a number of operators that need to be trained, but we think that Fenz should train more aerial operators and put them on the run in the next 12 months."
• The report's recommendations for Fenz also included for it to; review its operational doctrine to help identify incidents that are likely to develop into long-duration events, reinforce individuals should only be given sector command responsibility if they have the appropriate training and competency assessment and engage with Government to allow for air quality monitoring capability could exist for large-scale fires.
The woman was shaken by the incident.