31 Mar 2014

Coroner criticises CTV rescue effort

6:11 pm on 31 March 2014

A Coroner has criticised nearly every aspect of the Fire Service's response to the tragedy that claimed 115 lives when the CTV building in Christchurch collapsed in February 2011.

Gordon Matenga says more people, more resources, better communication and a better structure might have improved the chances of saving more lives that day after the 6.3-magnitude quake hit at 12.51pm on 22 February.

However, he says he is not satisfied that such improvements would have resulted in actually locating and saving the lives of the eight people who initially survived the collapse.

See the full report here

In his findings on the tragedy, Mr Matenga starts off by acknowledging the bravery of the emergency service personnel and ordinary members of the public who ignored the strong aftershocks and risked their lives to crawl under the rubble and pull people out alive. Many used their bare hands to remove rubble in the search for survivors.

The CTV building in March 2011.

The CTV building in March 2011. Photo: AFP / USAR

Fire Service leadership found to be lacking

The Coroner finds that the leadership of the Fire Service to have been lacking.

Gordon Matenga notes that by 11pm on the night of the quake, which had struck 10 hours before, not one of the 13 Fire Service executives in the city had deigned it necessary to base themselves at the CTV building - the place where by far the greatest number of people were trapped of any of the sites around Christchurch.

Mr Matenga says this was a lost opportunity, as it was a chance for these senior managers to show leadership and provide the co-ordination the CTV rescue effort so badly needed.

The national head of the Urban Search and Rescue Unit, Jim Stuart-Black, is criticised for turning down help from a United Nations emergency response team that is always on stand-by to help anywhere in the world. Given how stretched the Fire Service was, Mr Matenga says, this help should have been gratefully received.

He says there was a failure to establish an incident control point with one person in overall charge standing back from the hands-on work, co-ordinating it and supporting rescuers with more resources.

This led to a failure by rescuers on the west side to tell those on the east side they had a listening device and a concrete cutter on site. Such tools, the coroner says, would have made a huge difference to the chances of finding people alive before they were killed by the fire burning deep under the rubble.

Response protocol 'haphazard'

The Coroner describes the Fire Service's protocol for responding to disasters as haphazard.

Christchurch firefighters couldn't get through on their radios due to the large number of calls coming in to the communications centre all at once and so ended up self-deploying and heading wherever the stationmaster thought was appropriate.

The first crew to arrive at the CTV building, 42 minutes after the collapse, only went there by chance.

Paul Baxter: personal assurance to families.

Paul Baxter: personal assurance to families. Photo: FIRE SERVICE

An expert witness Captain Ernesto Ojeda, from the Los Angeles Fire Department, told the inquest there was nothing more rescuers could have done to save people and he would have abandoned the search earlier.

Mr Ojeda says while the rescue effort could have been better co-ordinated, that would not have resulted in more survivors. He says he would have pulled rescuers out earlier, because they would have had a better chance of finding survivors elsewhere.

Mr Ojeda said in California, the divide up a city and hand each fire station responsibility for searching a particular sector. If communication is lost, they can deploy and carry out their jobs regardless.

The Fire Service's national commander, Paul Baxter, has conceded the service wasn't as well prepared as it should have been and has since introduced changes to improve its response in future.

Mr Baxter says he has given a personal assurance to the families of those who died that the service will learn from its mistakes.

The firefighters' union says management failings should not detract from the good work done by firefighters at the scene. Spokesperson Denis Fitzmaurice told Radio New Zealand's Nine to Noon programme on Monday the lack of leadership at the CTV site was not the fault of his members.

"It wasnt their responsibility to set up a control point," he said. "That was the executive officers' role - and they weren't there."

USAR also criticised

Urban Search and Rescue also comes in for criticism in the Coroner's inquest report.

The head of the sole USAR group in Christchurch initially had no vehicle to transport valuable equipment such as concrete cutters and listening devices from the base in Woolston. Because the cellphone network was overloaded, he had no way of contacting his colleagues to establish where they were needed.

Eventually, he found a television set at the base and plugged it in to discover what was going on in the city.

Many of the USAR team didn't turn up to their base at all because area commander Stephen Barclay had incorrectly put out a radio message early in the piece that the base had collapsed.

USAR teams from Auckland and Palmerston North didn't arrive in the city until midnight - almost 12 hours after the earthquake - because the Air Force plane they were using couldn't take their incorrectly packed rescue equipment.

When they did arrive they were without this gear, including much-needed cameras used to look for signs of life under the rubble. Their equipment travelled separately and didn't arrive on-site until 4am, three hours after the last person thought to be alive was last heard from by their cellphone.

Case of Tamara Cvetanova

The coroner devotes a large part of his findings to the case of Alec Cvetanov, who was in regular cellphone contact with his wife Tamara Cvetanova, who was trapped in a cavity under the rubble with five others.

Alec Cvetanov.

Alec Cvetanov. Photo: RNZ / Belinda McCammon

She told him by cellphone that she wasn't worried because she knew rescuers were working to free them. It appears they were agonisingly close, because at one stage Mr Cvetanov knocked on the rubble with a piece of concrete and Mrs Cvetanova told him she could hear him.

It's believed a final call just before 1am, in which no words were spoken, was the last contact she made with anyone.

Like many of the eight victims, Mrs Cvetanova suffered massive crush injuries, either from the movement of rubble during aftershocks or as large pieces of concrete were lifted off the site by cranes. Others died from smoke inhalation from the fire that started burning almost immediately after the collapse.

The eight people who are the focus of the Coroner's findings all managed to make contact with the outside world by cellphone, and are therefore just the people known about. It's not known exactly how many others might have survived the initial collapse and later died.

Coroner's recommendations

The wreckage of the CTV building in February 2011.

The wreckage of the CTV building in February 2011. Photo: AFP (file)

Gordon Matenga says an email system introduced since the February 2011 earthquake so USAR members can contact each other when cellphone networks are down is to be commended.

He is recommending work to ensure USAR has its equipment loaded in compliance with airline requirements; training for USAR members in how to operate cranes and diggers; and for help from the United Nations to be accepted in all disaster situations.

He's also calling for joint exercises between USAR and local government; for the Fire Service to adopt a standard post-quake operating procedure; and for an emphasis on establishing incident control points.

Internal Affairs Minister Peter Dunne says it's crucial that emergency services know who is in charge and work to establish clear lines of communication in the event of another major emergency. Mr Dunne says emergency services work well together every day in response to smaller events, but that must also be the case for major disasters.

Christchurch mayor Lianne Dalziel, says she read the Coroner's report with a heavy heart, knowing how painful its release will be for the families involved. She says her heart goes out to all those who lost loved ones and who continue to seek answers and accountability for what happened.

An expert in emergency management says Gordon Matenga's findings don't go far enough. Steven Jensen, a witness at the inquest, says the deeper, more important issue is the extent to which the leadership within the service is willing to collaborate with other emergency services. Dr Jensen says the Fire Service needs to develop an ability to learn from its mistakes and make improvements, instead of waiting for outside agencies to point out problems.


  • 1986: The CTV building is designed by Christchurch engineer Alan Reay's firm and granted building consent.
  • January 1990: Holmes Consulting Group prepares a building structural report for a potential purchaser. The report notes concerns about the tying of floors to some shear walls.
  • December 1990: Madras Equities buys the building and leases it to ANZ Bank.
  • September 2010: After a 7.1 earthquake, the building is green-stickered after two quick assessments by the city council.
  • October 2010: Building deemed safe to occupy.
  • 22 February 2011: Building collapses during a 6.3 earthquake, killing 115 people inside.
  • 2012: The Canterbury Earthquakes Royal Commission sits; coroner Gordon Matenga holds an inquest into the CTV deaths.
  • 31 March 2014: The coroner's findings are released to the public.