Hard News: Republished: The CTV collapse and inquiry: my personal thoughts from being there
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Gilbert's original blog has now been published by The Press. Strong support for him from the community.
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Matthew Poole, in reply to
Quite so – which is why it’s drilled into em beforehand. The military seem to manage it.
With respect, Sacha, whatever you think you know about emergency management isn’t up to critiquing the response. If you dragged an army unit away from their daily tasks with no warning (remember that zero-notice military action is largely unheard-of), dumped them into pitched battle, and expected the commanders to immediately deliver a coherent tactical and strategic plan at the drop of a hat, it wouldn’t happen. They’d muddle through, but unless they’d had strategic warning of what was coming the higher-level officers would have been stuck. They’d also have the advantage of absolutely-certain roles and chains of command, neither of which exists in NZFS in terms of management of an incident because senior officers rotate on and off call so at no particular point is a specific office going to be represented at a call; it’s no use saying that the Chief Fire Officer of Christchurch district is the planning officer and their Deputy CFO is the logistics officer and the Assistant Area Manager is the incident controller, because it’s quite possible that not a single one of those three would be at an incident. Changing that fluid management structure would be a huge failure, because it would enforce a structure that doesn’t recognise the lack of specialisation that exists in the fire service. It would also limit the opportunities for lower-ranked officers (the operational officers who ride trucks every day, and run smaller incidents every day) to get experience as managers of larger incidents.
You speak of getting to know officers from other services, and NZFS senior officers do (inter-agency exercises happen regularly, because CD groups must run them), but the corresponding ranks from the police don’t tend to show their faces at incidents; they’re cosy in an emergency operations centre somewhere, being all strategic and shit. You’d never get a deputy commissioner showing up to anything less than the likes of CTV, and certainly they wouldn’t spend hours and hours there in a command role, but the area management from NZFS do it all the time. Show up, take up slots in the incident management team (either as controller or as a supporting role to mentor the controller), and get their boots dirty. But they don’t have relationships with the inspectors and senior sergeants who are running the police operation. Ranks get to know like ranks, so when CD runs a big table-top exercise the senior brass from both sides gather and play their parts and then promulgate the lessons down through their respective organisations. The inspectors and senior sergeants get to know the senior station officers and station officers, maybe the deputy chief fire officers and the chief fire officers. But when the shit hits big NZFS expects more-senior people to show up at the scene and run the show while the police leave lower-ranked-but-still-senior officers to handle the on-scene management. It’s partly to do with ratios of officers to crew. For a career fire appliance with a crew of four, there’s one officer and three fire fighters (with anywhere between one and three of those fire fighters being ranked as senior FFs). A station officer is equivalent to a police sergeant, a senior station officer to a senior sergeant. In a big city there will be at least one senior station officer in an area of three or four fire stations, so a ratio of roughly one SSO to three SOs to 12 FFs (three on the truck the SSO came on). The police might have one sergeant to a half-dozen (senior) constables, and a single senior sergeant to an entire policing district. The ratios just don’t give equivalence for relationships between services. Officers above SSO show up to any mid-size emergency, but for the police it has to be pretty special to get an inspector to the scene.
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Matthew Poole, in reply to
It's a hugely complex topic, and hard to explain in writing why it's wrong to presume that it ought to be easy for emergency managers to just step into running a complex, demanding incident when they haven't actually got the easy structure that exists in training exercises and smaller incidents. The normal way of things is that a defined response is sent to a call, and as required the response escalates in a defined way with higher levels of notifications bringing defined responses from on-call officers but those officers also being free to respond themselves at any point earlier on. And as the response escalates and more resources arrive, there's always one person who's in charge. Always. But CTV wasn't like that because the appliances that arrived first self-tasked and none of the officers set up the management structure into which senior officers would ordinarily step. There were multiple incidents, effectively, and they needed to be run both individually and collectively. Taking the step back and doing the coalescence of management that's required requires knowing that that's required, and you can talk and talk and talk about how those officers should have known to do that, but an intellectual appreciation isn't the same thing as it being an instinct that will kick in at a time when all you have is adrenaline and muscle memory.
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Sacha, in reply to
none of the officers set up the management structure into which senior officers would ordinarily step
how come?
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Sacha, in reply to
muscle memory
hence training, yes
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Matthew Poole, in reply to
none of the officers set up the management structure into which senior officers would ordinarily step
how come?
I can only speculate, but it’s educated speculation: the initial arriving appliances were confronted with an event of a scale not seen in modern NZ. The SO/SSO-level officers, arriving disjointedly (rather than as an organised response) at a complex operation requiring many strands of work that were related but independent, took charge of their crew and maybe one other and went to work on the immediate need: surface and lightly-trapped casualties. With so much to be done, and too few hands, it would become a bunch of parts working individually with no coordination amongst the officers to set up a proper incident management structure. A job the size of CTV requires an IMT of at least four (would have ultimately been more than double that), and the individual component groups working on the pile also need supervision. Breaking out first-arriving station-level officers to establish an incident management framework wasn’t going to happen because those officers were needed as boots on the ground.
See Mark Montgomery’s earlier comment, and he’s speaking as a senior-ranked officer in a volunteer rural fire brigade. He describes an event where there was no overall command, no larger CIMS structure, just a bunch of groups doing their thing. That’s not unexpected when the response is not coherent (and could never have been coherent) so does not have the structure that normally applies to an NZFS response. The normal pattern of a response is that a first alarm is dispatched composed of a predetermined group of appliances, and the officer on the first-arriving appliance is the Incident Controller until relieved. That appliance is the Incident Control Point unless and until another one is established. Subsequent-arriving appliances report to that ICP, incoming senior officers report to that ICP, and as an incident grows the role of IC (or at least OIC Fire if the Police are the agency in overall charge) changes hands in an orderly fashion. At all times in the normal scheme of things there is clearly one fire officer in charge at a single ICP, that officer knows what the overall mission is, and everyone arriving knows who they report to. 22/2 was an event where there is no certainty of additional appliances arriving, or when they will arrive, because there were so many competing demands on NZFS resources. If the first officer on scene decided that they were going to take up an overall management role, that would have meant they might be putting their three fire fighters onto a rubble pile with no direct supervision, breaking the buddy system (always work in pairs), and possibly to no greater use because it could have been a very long time before any other NZFS resources arrived. A common theme from people who were involved in response on the day is that they knew how bad it was where they were but they had no idea what it looked like elsewhere in Christchurch. An officer looking at the ruins of CTV and feeling the aftershocks would have been rightly entitled to think that they were on their own because the rest of Christchurch was going to be, to use the vernacular, very munted. Without that first OIC/ICP established, trying to get any SO/SSO-level officer to pull back and take overall command was unlikely to ever happen. They were actively involved in rescues and fire suppression activity, and those things had to keep on happening.
The failing of the senior officers was in seeing the command vacuum for what it was and establishing the necessary IMT structure. Doing it from scratch is not something they regularly do, or train for; they train to step into an orderly structure in an orderly way with an orderly hand-over from the existing incident controller. Knowing how to do that and run an incident, it turns out, doesn’t translate to being able to recognise a lack of order and then take the necessary steps to create that order.
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Lilith __, in reply to
The failing of the senior officers was in seeing the command vacuum for what it was and establishing the necessary IMT structure. Doing it from scratch is not something they regularly do, or train for; they train to step into an orderly structure in an orderly way with an orderly hand-over from the existing incident controller. Knowing how to do that and run an incident, it turns out, doesn’t translate to being able to recognise a lack of order and then take the necessary steps to create that order.
Interesting Matthew, thanks.
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Liz Scott-Wilson, in reply to
Matthew - alas all of us not directly involved can only ever be armchair generals - and you're right I'm not an emergency responder so am woefully underqualified for many things.
One thing I can opine on - sunshine is the best antiseptic especially when it comes to public affairs. Keeping things quiet and hidden away, when there is a public interest, just leads to whispers of cover-ups and looking after our mates.
I think the coroner got the right balance - they should have done things better. The coroner specified where things should have been better. And it is his call that poor performance didn't result in unnecessary deaths.
Do I feel reassured by the NZFS CEO saying learnings had been learned - somewhat - as experience IS the best teacher. And you (and others) are right - these things don't happen all that often.
But experience can't be our only teacher.
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Hebe, in reply to
officers, arriving disjointedly (rather than as an organised response) at a complex operation ... went to work on the immediate need
That is the difference between a call-out and a citywide emergency. There was no way of knowing if any of the usual resources -- people and equipment -- would be available.
Was the coroner's call that things should have been done better or that they could have been done better?
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Matthew Poole, in reply to
Was the coroner’s call that things should have been done better or that they could have been done better?
He uses the word "could" (Para 139), but some of the criticism does appear to be more of the "should" variety.
Having now read his findings (I hadn't read beyond the summaries), my speculation appears to have been pretty accurate. NZFS personnel on the ground, who included USAR TF2 technicians and the TF2 team leader, did not establish an incident management structure because they were occupied with doing those things that were immediately necessary on their arrival as NZFS personnel. None of the senior officers present in Christchurch by midnight of 22/2-23/2 did anything more than show up at CTV as part of city-wide reconnaissance, but even if they had assumed command they would have been trying to assemble an IMT to manage an incident that had organically separated into two sectors with sector commanders but had no overall management and no established ICP.The failure to set up an ICP/IMT actually fell down in the first hour, when the initial-responding police officers who commenced rescue operations failed to hand over management of the incident to the first-arriving fire appliance (which didn't manage to arrive until 42 minutes post quake), since the presence of fire made the incident the responsibility of NZFS. It was all down-hill from there.
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Hebe, in reply to
the first-arriving fire appliance (which didn't manage to arrive until 42 minutes post quake
Hell, the CTV site is less than 10 minutes' walk to the Central Fire Station. That is even longer than I thought it would have taken -- and I'm implying no fault whatsoever on the Fire Service's part. That is how it was that day all over the city.
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Matthew Poole, in reply to
Hell, the CTV site is less than 10 minutes’ walk to the Central Fire Station.
First appliance on scene was from Addington. There was no directed dispatch to CTV, just self-responded appliances crawling through grid-locked traffic looking for requirements for assistance and informed by the radio traffic from other appliances. See paragraphs starting at 36 in the Coroner's report.
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Lilith __, in reply to
the CTV site is less than 10 minutes’ walk to the Central Fire Station. That is even longer than I thought it would have taken – and I’m implying no fault whatsoever on the Fire Service’s part. That is how it was that day all over the city.
A man died in City Mall, barely 3 blocks from the Hospital, who might have been saved if he could have been got there. So much going on, so many difficulties, a limited number of emergency service personnel.
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The irony of the whole NZFS and the aftermath of the CTV and where it all happened......
The NZFS rose out of NZs biggest shop fire. 18 November 1947. Ballantynes. Christchurch.
From the Royal Commission the NZ "The inquiry’s recommendations brought about the Fire Services Act 1949 which was the first attempt to standardise the Fire Service organisation, its administration, and financing. The Act established the Fire Service Council which represented the Government, insurance companies, local authorities, the United Fire Brigades’ Association, and the firefighters."
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Matthew Poole, in reply to
However, Ross, NZFS has no statutory duty to do anything other than fight fires. Road crash rescue, USAR, and all the other non-fire emergency services provided by NZFS are done under the general competence to respond granted to a district’s Chief Fire Officer by section 28(2) of the Fire Service Act 1975. Even hazardous substances response is a "if the CFO thinks the brigade can be useful" situation, whereas responding to fires is a "the brigade shall respond to an alarm of fire" situation.
Which is something that a lot of people don’t realise. NZFS does a huge amount of stuff for which they are not explicitly funded and, because it’s not the Service’s explicit duty there are gaps in supporting structures. NZFS is the lead agency for USAR, for example, but 22/2 demonstrated that there are some conflicts between providing USAR response and providing fire suppression response, and in how USAR response is managed.
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Funny you should say that about what they can or do. My impression over recent decades was that they get called out to accidents, heart attacks "because they are there". That is, they seem to be more fire stations with volunteers who hang around waiting for some action. Did they then decide if we got involved with things-other-than-fires then we can do more. ( eg. My Mum had a turn and we ended up having the local fire brigade and paramedics tune up before the ambulance arrived. My wife had an asthma attack and the same thing happened).
This now seems to have become "the norm". I can understand how this was taken up because there is basically no cost when volunteers are involved.
Is it coming home to roost because they are expected to be the jack of all trades?
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Lilith __, in reply to
there is basically no cost when volunteers are involved.
Also, professional firefighters have a lot of time between callouts, since fires happen at unpredictable intervals. It's great that they can assist with other emergencies.
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