Hard News by Russell Brown

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Hard News: Republished: The CTV collapse and inquiry: my personal thoughts from being there

42 Responses

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  • Liz Scott-Wilson,

    Jarrod's account is certainly heartfelt and moving. I listened with interest to the National Radio interview with the Fire Service CEO this morning.

    One thought that keeps being expressed by the Fire Service CEO is that ...

    “The fire officers in command of NZFS resources at the CTV site were faced with a situation that no other officer in the history of NZFS has had to face. It is widely accepted that a natural disaster of this scale presented challenges beyond the training, experience and resources of the service particularly given the multiple sites.”

    This is not good enough.

    Many of the type of events the emergency services train for have NEVER been experienced by the people responding to the event - especially the big civil defence type events.

    That's why organisations send their people to training exercises. And to visit overseas sites of such disasters. And bring people with that experience to train and educate our people here in NZ.

    The great unspoken (it seems to me) is that senior staff at the site of the CTV building did not do what they should have been trained and educated to do.

    In the words of the Pilling report...

    "However, it does not appear that there was at any time a strategic plan in place driving the sum of the parts. Both strategic leadership and direction together with tactical structure and organisation could have been more effective during the first 12 hours of the incident. Preparedness and resilience require fresh focus and investment."

    http://www.scoop.co.nz/stories/AK1403/S00730/nz-fire-service-and-ctv-coronial-findings.htm


    Actual people at the CTV site failed to do these things. The thought that they were not trained to do so is almost unbearable. If they were trained and failed to do so, well that's what accountability is for.

    And the sentiment from the CE is laudable - the sound of staff being protected from public censure is not so laudable.

    If staff are being counselled internally and accountability is being assigned and responsibility accepted away from the public gaze - well I understand that but honestly it's not good enough.

    Wellington • Since Sep 2013 • 2 posts Report Reply

  • llew40,

    Hmm you may well be right Liz, but some of those criticisms do feel quite strong , particularly in relation to the lack of resources. I honestly doubt that many entities preparing for future disaster responses can realistically and adequately resource for all possible yet hitherto unrealised scenarios.

    Since Nov 2012 • 140 posts Report Reply

  • Lilith __,

    I'm glad to read this blog. The earthquake death-toll would have been much higher if so many police, firefighters, medics, and members of the public hadn't worked tirelessly and selflessly to rescue survivors.

    Dunedin • Since Jul 2010 • 3887 posts Report Reply

  • Sue,

    Is there a legal reason why the fire service won't or can't just say 'we are sorry'

    Wellington • Since Nov 2006 • 527 posts Report Reply

  • Matthew Poole,

    on the basis that it was a breach of the service’s media policy.

    Not defending the policy, which I consider to be an over-reach by an agency that is bound by the Bill of Rights Act’s provisions on freedom of expression, but it is quite clear that this posting is a breach since it’s so very definitely "incident related information".
    Given that NZFS brass in Christchurch came out of the inquest with very muddy faces, one would have thought they’d have been exercising some valorous discretion.

    Auckland • Since Mar 2007 • 4097 posts Report Reply

  • Matthew Poole, in reply to Sue,

    Is there a legal reason why the fire service won’t or can’t just say ‘we are sorry’

    In this litigious age, while the Coroner still hasn't reported on whether or not the (in)actions of NZFS contributed to the deaths of people in the CTV building, it would be a very risky thing to say. "Ah, that's an admission of fault" would say the lawyers.
    Now that the Coroner has reported, however, I would hope something will be forthcoming.

    Auckland • Since Mar 2007 • 4097 posts Report Reply

  • Matthew Poole,

    Liz, it’s great that you feel able to be all “armchair general” about this, and far be it from me to suggest that you’re actually woefully under-qualified to hold such opinions, but emergency services very, very rarely come away from such massive events to showers of glory.
    FDNY fucked-up royally in their command of the WTC response, and in the years leading up thereto, and lost many more fire fighters than necessary in the collapse. The accolades and hero-worship occlude the reality that although many of the FDNY deaths in Tower 2 were pretty much inevitable (command functions should not have been located in the lobby of the burning building and immediate vicinity) the deaths in Tower 1 were mostly very avoidable if repeated requests over many years to deal with radio reception problems had been paid heed.

    Consider this: in all of NZ there are somewhere around 10k fire fighters. Somewhere around 1400 are paid (aka career) staff, the rest are volunteers. NZ Fire Service has roughly 150 staff, all career, who are attached (as a secondary duty, they're primarily just fire fighters) to the three Urban Search and Rescue task forces based in Palmerston North (TF1), Christchurch (TF2), and Auckland (TF3). That number are mostly operational staff, not senior officers. It is those small number of men (pretty sure they’re all male, the number of career females in bunker gear in NZFS is tiny) who have the training in dealing with mind-blowingly-enormous incidents of the scale of 22/2. The officers attached to the TF’s have training too, but they’re a smaller number again.
    Managing a massive, whole-of-region multiple-site collapse incident is decidedly non-trivial. Doing it with mere dozens of paid fire fighters and not all that many more volunteers in the initial period, across agencies, is a different set of skills to what fire officers here normally deal with. Even a large fire that encompasses a few buildings in a block is different. It’s contained, you can visualise the scope, you can marshal resources to one location and put them all to work on one task. Hell, a single collapsed city block is a pretty easy management task. Demanding, but straightforward for the same reasons that a whole city block ablaze is straightforward: one location onto which you can focus all your resources. Consider this, too: a USAR heavy task force – and ours are not yet equipped to the international “heavy” standard – is only meant to be dealing with one collapsed multi-storey building; so NZ only has the internal capacity to cope with three collapsed buildings simultaneously, and in reality CTV alone could have used two TFs.

    Should the NZFS senior officers in Christchurch on the day have responded more efficiently and expeditiously? Absolutely. Is it completely inexcusable and inexplicable that they did not? No, I don’t think it is. The further back you are from a true disaster, the easier it is to be overwhelmed by the scale. The peons on the rubble pile don’t have that luxury, they’re staring at bricks and beams and bodies and that’s got all their focus. All the finest training in the world is only as good as the regularity of its exercise and the quality of the structure into which it is deployed. It was obvious after Pike River that there are holes in how complex multi-agency incidents are handled, and that structure (Coordinated Incident Management System, or CIMS) had not, and has not yet, had the review that it needs to really scale well for a big incident with lots of people joining the party. Most fire officers will never deal with a collapse more serious or complex than a house that’s been knocked off its pilings. Many will never even deal with that. Without regular exercising to maintain mental currency in dealing with not just one big building that’s come down but a whole city littered with collapsed buildings, no level of training is sufficient. Exercising to that scale when it’s a once-in-a-lifetime event is hard to justify, especially when smaller, less-complex incidents happen regularly and, in theory, “the system” scales to any size and complexity of incident.

    Auckland • Since Mar 2007 • 4097 posts Report Reply

  • WaterDragon,

    I wouldn't hold your breath about an apology Matthew. Actually a good sincere "sorry" ceremony (yes I did say ceremony, which is not the same as a bunfight) could be quite good. I listened to all of today's (RNZ) offerings about the coroner's report and can't quite rid my head of the echoes of the loss, pain and unrealised hopes for "something" that hasn't happened yet in some of the voices.

    Behind you • Since Jul 2011 • 74 posts Report Reply

  • Matthew Poole, in reply to WaterDragon,

    Certainly not holding my breath. There’s no being less likely to say "sorry" than a government department that’s been found to have buggered up royally.

    Auckland • Since Mar 2007 • 4097 posts Report Reply

  • Andre,

    In 1989 I worked for the company publishing The magazine for Canterbury Civil Defence - a much larger body than the Fire Service and the one responsible for the wider management of the crisis. They wouldn't have known immediately how many people were trapped in the wider city - CTV may have been seen differently on the day. As a volunteer fireman I was at an incident where the local civil defence chief was stuck in traffic on the wrong side of an incident he was meant to be controlling and the local service personnel knew each other well enough to get by anyway but it would be hard in a bigger disaster. The Fire Service is a political and hierarchical organisation but the biggest failure seems to have been the inability of the 13 similarly-ranked officers at CTV to pick a leader.

    New Zealand • Since May 2009 • 350 posts Report Reply

  • Mark Montgomery,

    What I cannot fathom is why none of the various NZ Fire Service executive officers who turned up at the CTV collapse took charge. I understand that they may have never faced a situation like this but as a volunteer fire officer I have routinely been faced with situations I have never faced before, but my logic and training tell me that I must take charge, direct resources, and ensure the safety of the firefighters under my command as well as others at the scene.

    That none of the executive officers sought advice from the on-scene fire officers or the Police beggars belief.

    Northland • Since Mar 2014 • 1 posts Report Reply

  • Matthew Poole, in reply to Mark Montgomery,

    What I cannot fathom is why none of the various NZ Fire Service executive officers who turned up at the CTV collapse took charge. I

    Probably assumed (hoped might be a better word) that someone else had done it already, because someone else had to have done it already. Wouldn't be the first time.
    Is anything being done around having the Comms Centres take a more assertive role with getting senior officers to establish a proper ICP?

    A key difference I can see between this and a smaller incident is that a smaller incident has a defined response, defined OICs, defined perimeter, etc etc. You know, with certainty, who's responded, who's in charge now, who to talk to to determine if a change of incident controller is required. Unless the first-arriving appliances at CTV set up a clear command structure, and it sounds like they didn't really, the incoming chiefs would have been left wondering which indian they needed to take control from. Which is not an excuse for not figuring it out, but it's easy to see how a significant deviation from "the norm" would throw officers used to things being done "this way" because they're always done "this way".

    Auckland • Since Mar 2007 • 4097 posts Report Reply

  • Ross Mason, in reply to Andre,

    The Fire Service is a political and hierarchical organisation but the biggest failure seems to have been the inability of the 13 similarly-ranked officers at CTV to pick a leader.

    That is the staggering bit isn't it. If my understanding about the Fire Service is right, then as any situation develops and as each next highest brass arrives they get to be the one to say "Go". Having 13 (!!!) arrive at once would put the shits up all 13. Each was probably scared shitless to say "Go" to the other 12. Sad. but Superman was on the other side of the world that day.

    But lets go back to square one. A building fell down when by all rights it shouldn't have. Once six or seven floors collapse on one another all bets are off to carefully dissect it within 48 hours and rescue everyone who is alive.

    Those poor bloody firemen never had a show. Just like the dead. 30 years ago no one would have known about those people alive in the midst of such a hell hole. Cell phones weren't invented. Can anyone in their wildest dreams have imagined being able to call their family - in China - from under such rubble? That is mind blowing in any world order.

    It is sad but with such instant communication we now expect heaven and earth to move at the drop of a hat.

    Nature doesn't work like that. Sorry.

    Upper Hutt • Since Jun 2007 • 1588 posts Report Reply

  • Lara,

    I am thankful for all that was done by emergency services & members of the public over those days of hell.

    Christchurch • Since Jul 2009 • 82 posts Report Reply

  • Matthew Poole, in reply to Ross Mason,

    If my understanding about the Fire Service is right, then as any situation develops and as each next highest brass arrives they get to be the one to say “Go”.

    Kinda. There is no obligation on any particular senior officer to take over just because they're the highest-ranked officer on the scene. Junior officers don't get experience and mentoring if they get flicked as soon as someone senior arrives; even in an event like this, there are considerations beyond seniority as to who's going to be Incident Controller. In the case of these 13, as Andre said they're all of similar rank, all long-term career fire fighters with vaguely similar levels of experience and training. They needed to decide who should take charge at a scene (and there were multiple scenes, don't forget), who should represent NZFS at the regional emergency management level, who should be getting on a plane to Wellington, and who should be getting some rest so they can step in effectively in 12 hours' time when the current bosses need relief; all on top of being residents in a city that's now heavily damaged with hundreds dead. We pay them to be good emergency managers, but they're still humans.

    Auckland • Since Mar 2007 • 4097 posts Report Reply

  • Matthew Poole, in reply to Matthew Poole,

    There is no obligation on any particular senior officer to take over just because they’re the highest-ranked officer on the scene.

    Just to be clear, if the officer who is in charge is both junior and not coping, the senior officer is expected to take over. And the senior officer is just as much in the gun as the junior, coping or not, if something goes wrong. But seniority does not automatically confer command/control responsibilities.

    Auckland • Since Mar 2007 • 4097 posts Report Reply

  • Sacha, in reply to Andre,

    the biggest failure seems to have been the inability of the 13 similarly-ranked officers at CTV to pick a leader.

    And that's what they needed to know how to do, both inside their service and with other agencies. If any emergency organisation isn't regularly practising collaboration that scales up, they really can't claim to be prepared. Note EQC's similar failings.

    Collaboration doesn't just happen. Scalable system design isn't rocket surgery either.

    Ak • Since May 2008 • 19686 posts Report Reply

  • Sacha, in reply to Matthew Poole,

    All the finest training in the world is only as good as the regularity of its exercise and the quality of the structure into which it is deployed.

    Quite.

    Ak • Since May 2008 • 19686 posts Report Reply

  • Matthew Poole, in reply to Sacha,

    If any emergency organisation isn’t regularly practising collaboration that scales up, they really can’t claim to be prepared.

    In theory (and practice for routine events like major fires, even really big ones that have a hundred or more NZFS personnel plus other agencies) the Coordinated Incident Management System does scale up. And NZFS utilises CIMS at varying scales for every single job, every single day, and works with other agencies every single day. Exercises are a regular thing, too, both within agencies and at the local and regional CD level.

    CIMS is derived from the United States’ Incident Command System, which scales all the way up to management of California wildfires (its genesis was California in the 1970s, in fact) that cost 10s-of-millions of dollars and utilise thousands of personnel. CIMS is scalable in design, but it’s got some weaknesses in application to the very largest incidents that, unfortunately, only show up when it’s used in anger. An exercise is always artificial unless it’s incredibly well designed, and designing an exercise to test events of the scale of 22/2 is really, really, really difficult. Incredibly difficult. Did I mention it’s difficult? It can be done in a computer simulator, sure, but that’s extremely artificial and the officers involved know it’s a simulation so it lacks a lot of the chaos and adrenaline that come into play in a real event.

    Auckland • Since Mar 2007 • 4097 posts Report Reply

  • Sacha, in reply to Matthew Poole,

    chaos and adrenaline that come into play in a real event

    which can be mitigated by system design and constantly staying in touch with who your collaborators are likely to be. Making sure senior managers across agencies regularly meet one another helps.

    Ak • Since May 2008 • 19686 posts Report Reply

  • Hebe, in reply to Sacha,

    "chaos and adrenaline that come into play in a real event"

    ...which can be mitigated by system design and constantly staying in touch with who your collaborators are likely to be.

    No system could have been designed to cope with the conditions people were working under that day. The threat to rescuers' lives was unrelenting and unpredictable; communications and the usual avenues of recourse were totally disrupted and often not working.

    The rescue chain of command, like all of us, would have constantly been assaulted by the huge aftershocks --by my count 51 quakes of a mag 4 or more in the first 24 hours -- meaning the adrenaline response kept piling on and on. Time to think through process was not possible for anyone on the ground.

    Christchurch • Since May 2011 • 2895 posts Report Reply

  • Sacha, in reply to Hebe,

    Time to think through process was not possible for anyone on the ground.

    Quite so - which is why it's drilled into em beforehand. The military seem to manage it.

    Ak • Since May 2008 • 19686 posts Report Reply

  • Lilith __,

    I think it’s important for non-Chch folks to remember that immediately post-quake our power, water, phone, and cellphone services were all knocked out. Our many bridges became unusable or dangerous, many roads were impassable and the rest rapidly became gridlocked.

    Nobody had the big picture. Not only were almost 200 dead at multiple sites, but thousands were seriously injured. Aftershocks continued, as Hebe says, and nobody knew how safe the buildings were that still stood, or whether there were people trapped inside. Brave folks systematically checked THEM ALL.

    I don’t doubt mistakes were made, but don’t forget the level of chaos and uncertainty our emergency services had to deal with.

    Dunedin • Since Jul 2010 • 3887 posts Report Reply

  • Hebe, in reply to Sacha,

    Quite so - which is why it's drilled into em beforehand. The military seem to manage it.

    It's easy to practice shooting and bombs and fighting-type stuff. But there's no way of practising for the earth exploding on you. And there's no way of knowing how you will react until it happens. I heard tell of a battle-hardened ex-military Aussie, working as an insurance assessor who just flipped and ran on Feb 22, leaving someone alone who really needed help. Other people turn out to be tungsten: I know a kindly person who went through town slapping complete strangers to stop them going back into dangerous buildings.

    I am amazed by how well the services did: it is difficult to convey the destruction of the CBD, the number of serious "incidents" that happened within 20 seconds.The scale was beyond anything imaginable. I know it's important to review, learn from, analyse mistakes, but I really deeply believe that 99.99% of people did their absolute best that day.

    Christchurch • Since May 2011 • 2895 posts Report Reply

  • Hebe, in reply to Lilith __,

    Nobody had the big picture. Not only were almost 200 dead at multiple sites, but thousands were seriously injured.

    Good point Lilith. I had the car radio on for a short trip, but nothing was clear. There was no way of knowing what was happening a block away -- the only reports were anecdotal phone-ins, often by distressed people.
    And the thousands injured as well as the deaths.

    Christchurch • Since May 2011 • 2895 posts Report Reply

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