Canterbury Earthquake CTV Building inquiry
Minute: Inquiry into the deaths of Dr Tamara Cvetanova and others
IN THE CORONERS COURT
MINUTE OF CORONER G MATENGA
INQUIRY INTO THE DEATHS OF Dr TAMARA CVETANOVA AND OTHERS
 Following the release of my Findings dated 25 March 2014 ("the Findings") in respect of this inquiry, Ms Smith, Solicitor for NZFS brought to my attention via Memorandum dated 27 March 2014, some typographical errors which she asked to be corrected. Although there is no specific power in the Coroners Act 2006, to correct minor typographical errors, I am of the view that Coroners have an inherent power to regulate their own affairs and that such allows me to make very minor typographical corrections to paragraphs ,  and to footnotes 10 and 24.
 In addition, to give effect to orders made in paragraphs  and at 157.4, a redacted version of the Findings has been produced and is attached to this Minute. The redacted version of the Findings is to be made available to the Ministry of Justice to be placed upon its website and may be released to media. The attention of the media is drawn to the order at 157.3 prohibiting the Findings from publication, with such order expiring at 6:00 am Monday 31 March 2014.
Dated this 27th day of March 2014
Coroner Gordon Matenga
Inquiry into the deaths of Dr Tamara Cvetanova and others
IN THE CORONERS COURT AT CHRISTCHURCH
THE CORONERS ACT 2006
IN THE MATTER
of an Inquiry into the deaths of Tamara Cvetanova, Ezra Mae Sabayton Medalle, Jessie Lloyd Albarracin Redoble, Rika Hyuga, Rhea Mae Sumalpong, Emmabelle Anoba, Mary Louise Anne Santillo Amantillo, Chang Lai and others
Dates of hearing:
- 29 - 31 October 2012
- 1, 2, 5 - 9 November 2012
- 3 - 6 December 2012
- Mr N Hampton QC and Mr V Taylor for the Cvetanov family and the Hyuga family
- Mrs K Clark QC and Ms H Smith for New Zealand Fire Service
- Mr R Raymond Assisting the Court
- Mr C Lange for New Zealand Police
- Mr Hawes for Environment Canterbury
- Ms A Hall for St Johns
- Mr K Reid and Ms Daines for Christchurch City Council
- Mr C Ruane and Captain Taylor for New Zealand Defence Force
Date of findings:
- 25 March 2014
Findings of Coroner G Matenga
- Scope of inquiry
- The CTV Building
- Signs of life following the collapse
- Dr Tamara Cvetanova
- Chang Lai
- Mary Louise Anne Bantillo Amantillo
- Emmabelle Anoba
- Rhea Mae Sumalpong
- Rika Hyuga
- Ezra Mae Sabay10n Medalle
- Jessie Lloyd Albarracin Redoble
- The emergency response - the first 24 hours
- The Police
- New Zealand Fire Service (NZFS)
- Urban Search and Rescue (USAR)
- Mr Alec Cvetanov
- Cause of death - Dr Tamara Cvetanova
- Slow response to rescue Dr Cvetanova by the Police NZFS and USA
- Did the search and rescue efforts contribute to the deaths?
- Date of death
- Dr Tamara Cvetanova
- Emmabelle Anoba
- Ezra Medalle, Jessie Rodoble, Rika Hyuga and Rhea Sumalpong
- Chang Lai
- Mary Amantillo
- Civil Defence
- Emergency Operations Centres (EOC)
- Incident Control
- USAR and Light Response Teams
- The Pilling Report and NZFS Actions
- Formal findings
- Dr Tamara Cvetanova Prohibition on Publication
- Ezra Mae Sabayton Medalle
- Jessie Lloyd Albarracin Redoble
- Rika Hyuga
- Rhea Mae Sumalpong
- Emmabelle Cabahug Anoba
- Mary Louise Anne Santillo Amantillo
- Chang Lai
[1) At 12:51 pm on 22 February 2011 a magnitude 6.2 earthquake struck Christchurch on what is now commonly known as the Port Hills Fault. The existence of this fault was unknown before the February earthquake. The earthquake caused widespread damage to property and infrastructure across Christchurch, exacerbating damage caused by the earthquakes on 4 September 2010 and 26 December 2010 (and numerous aftershocks), and causing the deaths of 185 people. Of this number, 115 people died as a result of the collapse of the CTV Building situated at 247 Madras Street, Christchurch. A joint inquest was commenced by me at Christchurch on 30 August 2011. The inquest was adjourned part heard in relation to those that died in the CTV Building. Although the scope of the inquiry was limited (as I have explained at paragraphs 3 and 4) to an examination of the deaths of 8 of the victims, these findings apply in a general sense to all 115 victims of the CTV Building collapse.
[2) It is appropriate to acknowledge at the outset each of the 115 people who died in the CTV building. They are:
Kings Education Language School:
|Lalaine Agatep||Mary Amantillo||Emmabelle Anoba|
|Marina Arai||Valquin Bensurto||Heidi Berg|
|Ivy Cabunilas||Cai Yu||Cristiano Carazo-Chandler|
|Chen Yang||John Chua||Dr Tamara Cvetanova|
|Jewel Francisco||Yuki Hamasaki||Han Xiling|
|Tamara Harca||Yuki Hasumoto||Yumiko Hata|
|Miki Hayasaka||He Wen||Sandra Jen Jin Hii|
|Yuko Hirabayashi||Yoshiko Hirauchi||Megumi Horita|
|Hifuma Hoshiba||Haruki Hyakuman||Rika Hyuga|
|Toshiko Imaoka||Thanydha Intarangkun||Tomoki Ishikuro|
|Jin Man||Kayo Kanamaru||Kyoko Kawahata|
|Saori Kikuda||Yasuhiro Kitagawa||Lai Chang|
|Hsin Hong Lee||Leng Jinyan||Li De|
|Li Wanju||Li Xia||Phimphorn Liangchuea|
|Ezra Medalle||Haruthaya Luangsurapeesakul||Emi Murakami|
|Erica Nora||Noriko Otsubo||Wanpen Preeklang|
|Jessie Redoble||Deborah Roberts||Saya Sakuda|
|Yoko Sakurai||Gillian Sayers||Rhea Sumalpong|
|Yoko Suzuki||Tetaki Tairakena||Hiroko Tamano|
|Brian Taylor||Elsa Torres De Frood||Asuka Tsuchihashi|
|Tu Huiyun||Yurika Uchihira||Jittra Waithayatadapong|
|Wang Limin||Wang Tao||Siriphan Wongbunngam|
|Xu Linlin||Xu Xiujuan||Ayako Yamaguchi|
|Mina Yamatani||Ye Cai Yking||Saki Yokota|
|Gilhwan Yu||Naon Yu||Zhang Didi|
|Zhang Hui||Zhang Weiyu||Zhong Yantao|
|Dr Maysoon Abbas||Dr Husam AI-Ani||Dr Dominic Bell|
|Pam Brien||Dian Falconer||Elizabeth Jane Grant|
|Marion Hilbers||Beverley Faye Kennedy||Kyle Jack-Midgley|
|Teresa McLean||Heather Meadows||Janet Meller|
|Linda Parker||Susan Selway||Dr Allan Sinclair|
|Christine Stephenson||Lesley Thomson||Xin Sisi|
|Matthew Beaumont||Andrew Bishop||Rhys Brookbanks|
|Susan Chuter||Joanna Didham||Samuel Gibb|
|Joanne Giles||Huo Siwen||Shawn Lucas|
|Donna Manning||Isaac Thompson||Amanda Uriao|
|Valeri Volnov||Murray Wood||Stephen Wright|
|Khy Soon (Paul) Wu|
Each person was a loved member of a family who I am sure, is sorely missed. I acknowledge the families who survive them and extend to you all my sincerest condolences.
Scope of inquiry
 Pursuant to Orders in Council a Royal Commission was established to inquire into building failure caused by the Canterbury earthquakes ("the Royal Commission"). As a result, I was able to limit the scope of this inquiry given that the cause of the catastrophic collapse of the CTV Building (and others) would be investigated by the Royal Commission. Following a conference held at Wigram Manor, Christchurch on 30 April 2012 I directed that the inquiry would focus on the circumstances of the deaths of Dr Tamara Cvetanova and 5 others who died in the CTV Building. The inquiry would entail an examination of the emergency response, the role (if any) the response may have played in the deaths of Dr Cvetanova and others, and what can be learned to avoid the occurrence of deaths in similar circumstances in the future. Matters being considered by the Royal Commission were specifically excluded from the inquiry. There was evidence to suggest that Dr Cvetanova, Ezra Medalle, Jessie Redoble, Rika Hyuga, Rhea Sumalpong and Emmabelle Anoba survived the initial earthquake and in the hours immediately following made contact with friends, family and emergency services via mobile phone. This list was later extended to include Mary Amantillo and Chang Lai. All of these people were students at King's Education language school on level 3 of the CTV Building.
 As the inquiry progressed towards inquest it became clear that matters of interest centred around the CTV Building within the first 24 hour period immediately following the earthquake. I therefore issued a direction to further limit the inquiry to the events at the CTV Building and received general evidence of the emergency response at the PGC Building and across the city, for context. This approach was agreed by Counsel involved in the inquiry. This was in no way intended to diminish the enormity of the event. As expressed to me by Counsel for the New Zealand Fire Service1 ("NZFS"), the February 2011 earthquake was of such magnitude that it spawned numerous incidents across the city and further afield to Sumner, Redcliffs and Lyttieton, each demanding its own emergency response. The CTV site however, was the most prominent given the catastrophic building collapse, fire, entrapment and loss of life. No other site experienced this lethal combination.
 Section 57 Coroners Act 2006 is also relevant to the discussion of the scope of the inquiry. This section provides as follows:
57 Purposes of inquiries
- A coroner opens and conducts an inquiry (including any related inquest) for the 3 purposes stated in this section, and not to determine civil, criminal, or disciplinary liability.
- The first purpose is to establish, so far as possible,-
- that a person has died; and
- the person's identity; and
- when and where the person died; and
- the causes of the death; and
- the circumstances ofthe death.
- The second purpose is to make specified recommendations or comments (as defined in section 9) that, in the coroner's opinion, may, if drawn to public attention, reduce the chances of the occurrence of other deaths in circumstances similar to those in which the death occurred.
- The third purpose is to determine whether the public interest would be served by the deaths being investigated by other investigating authorities in the performance or exercise of their functions, powers, or duties, and to refer the death to them if satisfied that the public interest would be served by their investigating it in the performance or exercise of their functions, powers or duties.
This inquiry was not conducted to determine civil, criminal or disciplinary liability. It is not within my jurisdiction to do so. The purpose of this inquiry, given that the identities of deceased persons had previously been established, was to determine (as far as possible) when and where each person died, the cause or causes of death and the circumstances of death within the factual matrix as alluded to above. To enable the second purpose of section 57 Coroners Act 2006 to be achieved a vigorous and robust hearing process is required to seek out and record as many of the facts concerning the deaths as the public interest requires.2 While it is clearly wrong for an inquest to become a civil or disciplinary trial, to ascertain or explain how things occurred in the widest sense of the events, such comments or findings which appear to either directly or implicitly attribute fault are allowable.3
 As a framework for these findings I have tried to follow events chronologically and then dealt with issues as they arose. Issues raised by Counsel are encapsulated within this framework. I take this opportunity to express my thanks to Mr Alec Cvetanov for the way in which he conducted himself during the inquest. As he gave his evidence I was able to glimpse the frustration and hopelessness he felt at the time, being so close to his wife, and not being able to save her. My thanks go also to all Counsel for their assistance. A special word of thanks is extended to Jennifer Chalklen who has so ably assisted me in this inquiry as CSU Case Manager and Mr Richard Raymond, Counsel appointed to assist me, for his initiative and professionalism.
The CTV Building
 I begin by adopting the findings of the Royal Commission as set out in Volumes 5 and 6 of the Royal Commission's Final Report. At paragraph 1.1 Volume 6 Final Report appears a helpful general description of the CTV Building which I set out here in full to assist in setting the scene: 4
"The CTV building was six storeys high. On the original drawings, th e ground floor was called level 1, the first floor was level 2, and so on up to level 6. The floors were referred to in this way in the evidence at the hearing and we adopt the same approach. At the time of the February earthquake, the western side of level 1 was an internal car park. The remainder of level 1 and the whole of level 2 were occupied by Canterbury Television (CTV), a community broadcaster that had been a tenant since 2000. Going Places Education had occupied level 3 of the CTV building, but moved out on 20 or 21 December 2010. This move was not related to the condition of the building. Level 3 remained vacant on 22 February 2011. The principal tenancy on level 4 was King's Education, which operated a variety of language and aged care education programs. The Clinic, which was a medical centre, moved in to level 5 in January 2011 after a red placard was assigned to the building it had occupied in Gloucester Street. Relationship Services (now known as Relationships Aotearoa) occupied half of level 6 and had done so for some years. The other half of level 6 was unoccupied on 22 February."
 The Royal Commission heard evidence from a number of witnesses who described what happened to the building when the earthquake struck, describing how the building twisted as it shook then tilted towards the east. Next followed a vertical jolt. The building pancaked (ie the floor slabs at each level collapsed on top of each other), all of which took place very soon after the shaking started. The Royal Commission concluded that the collapse was completed within 10-20 seconds of the onset of the earthquake.5 A fire started shortly after the collapse and continued for some days.
 The Royal Commission found that the CTV building collapsed because the ground motion of the February earthquake was unusually intense and because of flaws in the engineering design and construction. The design of the CTV building relied on the north wall complex and the south coupled shear wall to resist the lateral loads generated by earthquakes. The flaws in the design and construction of the building meant that in the strong shaking generated, these two walls were not able to function as the designer intended. The Royal Commission found:
"After the initial period of twisting and shaking all of the floors dropped, virtually straight down, due to major weaknesses in the beam column jOints and the columns. The north wall complex was left standing, the floors having torn away and coming to rest stacked up adjacent to its base. The south shear wall collapsed inwards on top of the floors in what we consider would have been the last part of the collapse sequence. The observed damage to both of these walls showed that they had not been able to perform their intended role. " 6
Signs of life following the collapse
(i) Dr Tamara Cvetanova
 Dr Tamara Cvetanova moved to Christchurch from Serbia in 2000. She married Alec Cvetanov later that same year. Dr Cvetanova qualified and worked as a paediatrician in Serbia prior to her move to New Zealand. Alec Cvetanov and Dr Cvetanova had two children aged 10 and 8 years. Dr Cvetanova was preparing to re-enter the workforce and was studying English at the Kings Education language school as an employment requirement. The school is situated at level 3 of the CTV Building. The course commenced on 17 January 2011.
 On 22 February 2011 Dr Cvetanova was in her classroom at Kings Education when the earthquake struck Christchurch at 12:51 that afternoon, causing the building to collapse. Dr Cvetanov survived the building collapse and made contact with emergency services and later, her husband via her mobile phone.During these contacts Dr Cvetanova advised that she was trapped near 5 others who were alive but also trapped. The evidence shows that Dr Cvetanova's phone received 41 effective calls (over 4 seconds duration) and that 8 effective calls were made from her phone, the last being at 12:50 am on 23 February 2011. I accept the opinion expressed by Detective Collins7 that Dr Cvetanova was trapped in close proximity to Rika Hyuga, Ezra Medalle, Jessie Redoble, Rhea Sumalpong and Emmabelle Anoba.
(ii) Chang Lai
 Chang Lai was a 27-year-old Chinese national who was studying English at the Kings Education language school. Ms Lai was a nurse and was improving her English with a view to working in New Zealand. On 22 February 2011, Ms Lai was at the CTV Building when the earthquake struck Christchurch. It is not known where she was in the building when it collapsed.
 Ms Lai survived the initial collapse of the building. The evidence shows that 7 Brief of Detective Grant Andrew Collins at para 180.she made 3 calls from her mobile phone. The first two, were at 1 :33 pm and 1 :35
pm to her parents in Guangzhou, China. The final call was made at 2:14 pm.
(iii) Mary Louise Anne Bantillo Amantillo
 Mary Amantillo was a 23 year old nurse from the Philippines. Ms Amantillo was studying English at the Kings Education language school. Ms Amantillo came to New Zealand with Valquin Bensurto and had been in the country a little over a week. On 22 February 2011, Ms Amantillo was seen in the cafeteria on level 3, CTV Building by one of her friends, just a few minutes prior to when the earthquake struck at 12:51 that afternoon causing the building to collapse.
 Ms Amantillo survived the initial collapse of the building. She made 10 phone calls and sent 32 text messages between 12:55 pm and 3:56 pm, to friends and family advising them that she was trapped inside the collapsed CTV Building. As a result of her calls for help, contact was made with emergency services by her friends and family reporting that Ms Amantillo was trapped beneath the rubble.
(iv) Emmabelle Cabahug Anoba
(v) Rhea Mae Sumalpong
 Emmabelle Anoba was a 26 year old nurse from the Philippines. She had only recently arrived in New Zealand and was studying English at Kings Education language school in preparation for employment. Rhea Sumalpong was a 25 year old nurse from the Philippines. She was also a student at Kings Education language school studying English. Ms Anoba and Ms Sumalpong were flatting together in Christchurch while studying. On 22 February 2011, Ms Anoba and Ms Sumalpong were seen in the CTV Building a few minutes prior to when the earthquake struck Christchurch at 12:51 that afternoon causing the building to collapse.
 Both Ms Anoba and Ms Sumalpong survived the building collapse and were trapped in close proximity to Rika Hyuga. The phone belonging to Ms Hyuga was used by Jessie Redoble, also trapped in close proximity, to call Ariel Caballero, a friend of Ms Sumalpong. Mr Redoble advised Mr Caballero that he was trapped in the collapsed CTV Building with Ms Sumalpong, Ms Anoba and others and needed help. Activity on that phone occurred between 2:00 pm and 4:27 pm.
(vi) Rika Hyuga
 Rika Hyuga was a 30 year old nurse from Japan. She was studying English at the Kings Education language school situated on level 3, CTV Building. Ms Hyuga lived in Burwood, Christchurch with Mark and Shelley Bromley. On 22 February 2011 Ms Hyuga was at the CTV Building when the earthquake struck at 12:51 that afternoon, causing the building to collapse.
 At 2:00 pm a text message was sent from Ms Hyuga's phone to Shelley Bromley's phone asking for help. Mark Bromley responded to the text message by calling Ms Hyuga's phone at 4:27 pm. Mr Bromley spoke to a man he did not know (Jessie Redoble) who advised that Ms Hyuga was near him, trapped and still alive, that Ms Hyuga had a broken leg and he could not get to her. Mr Bromley then contacted emergency services and tried to re-establish phone contact with Ms Hyuga's phone. He was not able to do so but sent a text message.
(vii) Ezra Mae Sabayton Medalle
(viii) Jessie Lloys Albarracin Redoble
 Ezra Medalle was a 24 year old nurse from the Philippines, who had travelled to New Zealand with her boyfriend, Jessie Redoble, also a nurse from the Philippines. Ezra and Jessie were studying English at Kings Education language school. On 22 February 2011 Ezra and Jessie were at the CTV Building attending their first day of classes when the earthquake struck Christchurch at 12:51 that afternoon, causing the building to collapse.
 Ezra and Jessie survived the initial collapse of the building. Jessie has used the mobile phone belonging to Rika Hyuga to make telephone calls and send text messages seeking help. Jessie called a friend, Divinia Leitch and left a message on her voicemail asking for help and advising that Ezra's legs were "stuck". Jessie and Ezra were trapped beneath the rubble of the collapsed CTV Building in close proximity to Rika Hyuga, Rhea Sumalpong and Emmabelle Anoba.
The emergency response - the first 24 hours
(i) The Police
 Sergeant Michael Brooklands was en route to Christchurch from Kaiapoi to deliver a Police vehicle for repairs at the Christchurch Central Police Station. While in the city he responded to a job where burglars were suspected as being present in a two storey building. He made his way to the building and at the front of the building located and arrested a man, then, with the assistance of another officer, commenced a search of that building looking for a second person. It was in the process of searching for this person when the earthquake struck.
 Sergeant Brooklands exited the building onto Hereford Street where he was met by three other officers. It was clear that the quake had caused serious damage. Sergeant Brooklands decided that it was best to try and steer people towards Latimer Square and to get them into the middle of the road to avoid falling debris. Sergeant Brooklands walked up Cashel Street coming upon the collapsed CTV Building site. The CTV Building was not previously well known to him. Sergeant Brooklands was not sure if the building had been occupied at the time of the collapse but after speaking to people close by, was informed that there were approximately 150 people inside, including a creche.
 Sergeant Brooklands called using his mobile radio, for urgent assistance. Detective Sergeant Mark Keane heard his calls and made his way on foot to the CTV Building. Detective Sergeant Keane had been directed to assist with a bus on Colombo Street that had been crushed by rubble but could not travel there due to the road being blocked by fallen masonry and debris. Detective Sergeant Keane arrived at the CTV Building, he thought, about 10 or 15 minutes after the earthquake. Sergeant Brooklands had assumed command of the scene. Other Police were in attendance and with members of the public, were busily engaged in searching the rubble for survivors.
 Sergeant Brooklands and Detective Sergeant Keane were of equal rank and as Sergeant Brooklands was the first ranking Police officer to arrive on the scene, and given that he had assumed command, retained command of the scene following discussion with Detective Sergeant Keane.
 Detective Sergeant Keane described the scene as follows:8
"When I arrived, the whole building was a pile of rubble and masonry with only the lift shaft tower remaining upright. There was already smoke coming from within the building, but I could not see any flames. It appeared that the smoke was coming from deep within [the] building on the northwest corner .... Given the size of the pile of rubble it was evident that the building would have been substantial, therefore my assessment was that there was potential for a large number of people being in the building when the
earthquake struck. "
 Sergeant Brooklands had initially arrived on the western side. He noted that there were pockets of space which allowed rescuers access into the pile to search for survivors. On the eastern side, he met with Detective Sergeant Keane where following a discussion, it was decided that the CTV site would be divided into two sectors, east and wes!. Detective Sergeant Keane would remain on the east (the Madras Street side of the site) and take charge of rescue efforts and command over the Police and civilians who were searching for survivors. Sergeant Brooklands would return to the west side of the site and continue in command of efforts there and retain overall command. The men then separated and attended to their tasks.
 Detective Sergeant Keane described the challenges to rescuers in this area. There were large concrete slabs, rubble and beams that were present which could not be lifted by hand. This he described as being in contrast to the western side where as well as having large items, there was a lot of rubble that could be shifted by hand.9 Police and civilians were climbing on the rubble and searching through looking for survivors. Smoke was coming from the rubble but no flames were visible at this stage. There were also significant aftershocks occurring. The safety of Police and other rescuers who were crawling over the pile of rubble searching for survivors, was a concern to both Sergeant Brooklands and Detective Sergeant Keane. The lift shaft was the only part of the building still standing. It was felt that the lift shaft looked very unstable and could collapse at any stage given the aftershocks. There were also concerns about the shifting of the unstable rubble.
 Sergeant Brooklands contacted Police communications and requested the assistance of the Fire Service. This took a number of attempts as radio communication was difficult because of congestion on the Police radio network.Communications were a difficulty in the first 12 to 18 hours post earthquake. These difficulties will be discussed later in these findings.
 Sergeant Brooklands, assisted by Constables Kneebone, Lee and construction workers who had been working nearby, were all working together and effected a number of rescues of people that were trapped just below the surface of the rubble pile. The rescued people were being treated as best as could be with the limited resources then available and transferred to Latimer Square for follow-up first aid. Latimer Square was becoming the centre of operations.
 Detective Sergeant Keane was able to assist a member of the public who had located two women trapped in a cavity near the lift well under some large concrete slabs. The member of the public and Detective Sergeant Keane had to crawl into the pile about three metres and were able to free one of the women and then pass her to others for removal from the rubble pile and treatment. The two men then returned to the cavity and freed the other woman. This type of activity was happening all over the site. Police and members of the public worked together to effect such rescues as they were able.
 Sergeant Brooklands (on the western side), was becoming more concerned about the safety of the rescuers given the perceived instability of the lift shaft tower and rubble pile. As a result, he ordered most people off the building remaining on the rubble pile himself with only a few rescuers. They then set about calling out and listening for tapping sounds or voices and were able to locate and rescue, he estimated, eight to ten people using this method.
 The Fire Service had not yet arrived. The smoke was becoming thicker indicating that the fire beneath the rubble was building. Sergeant Brooklands discussed with one of the digger drivers the possibility of dropping dirt and water onto the area where the fire seemed to be burning most in an effort to control it. Those efforts were not successful.
 One lady was rescued from amidst this thick smoke. She told her rescuers that there was another woman trapped nearby. Attempts were made to re-enter the void but no contact could be made with the other woman. It is not possible to tell exactly how many people were involved in these early attempts at rescuing survivors. I am satisfied however from the evidence I have received, that Police were quickly on the scene performing rescues and establishing command and control of the rescue efforts in these very early stages.
 Detective Sergeant Barnett tasked Detective Drake and Constable McClatchy to set up a temporary morgue on the vacant building site on Cashel Street on the western side of the CTV Building. The constables received and made records of their work including such details as they had of the bodies that were found until around 10:00 pm that night. By this stage, other Police from the Disaster Victim Identification Unit (DVIU) attended and took over this role. The records taken by Detective Drake and Constable McClatchy, were handed over to the DVIU. Police remained on the scene with Sergeant Brooklands in charge, until he was relieved in the early hours of 23 February 2011.
(ii) New Zealand Fire Service (NZFS)
 Alan Butcher was a Station Officer in the NZFS based at Addington Fire Station. He was on duty with other members of Blue Watch at the time of the earthquake. Following the earthquake the firemen, in accordance with protocol, moved the fire truck out of the fire station. Mr Butcher then directed his crew to check on their families. Once that had been done, Mr Butcher decided to deploy to see what the damage was in the area near the fire station.
 Based on the radio traffic, Mr Butcher decided to respond into the city to see if they could be of any assistance. He then headed down Brougham Street towards Nazareth House which Mr Butcher considered to be the closest building with a potential life risk. The traffic on Brougham Street he described as horrific. Consequently, progress along the street was slow. Again based on radio traffic, Mr Butcher decided to, instead of proceeding to Nazareth House, head into the city as there were buildings down. Mr Butcher advised, or tried to advise, the Southern Communications Centre (Comms) that his appliance would assist other trucks that were heading to an incident down Cashel Street. They went down Moorhouse Avenue, along Fitzgerald Avenue and proceeded down Cashel Street heading in the direction of flashing lights. They came upon the CTV Building and it was evident that there had been a major collapse. Although they had not been despatched to attend the CTV site, Mr Butcher and his crew were the first fire appliance to arrive. Incident reports records them as arriving at 1.33 pm, 42 minutes after the earthquake struck.
 Mr Butcher described his arrival at the scene as follows: 10
"We pulled into the empty lot, just past the CTV Building car park entrance, to the west of the site. We did not know that it was the CTV Building as it was barely recognisable but from the height of the tower that remained standing I could tell that the building had suffered a major collapse. There were a lot of people on the site who appeared very task driven. Members of the public were lifting material off the site, climbing into holes and were doing whatever they could to rescue people. There was a fire on site amongst the rubble. The first signs of smoke that I saw were in the area on or around the tower and in the centre of the building; approximately three to four metres from where our fire appliance was parked on the empty lot. Although I could see smoke coming up out of these areas I knew that it did not necessarily mean that the fire was burning in those locations. "
 Mr Butcher then instructed his crew to find a hydrant to start getting water on the fire while he completed an assessment of the site. In the course of his assessment, Mr Butcher noted that, "". the west side ". looked like a pi/e of rubble, the east side looked like a pile of massive concrete slabs leaning across each other at great angles.11
 The next fire appliance to arrive was under the command of Station Officer Stephen Warner. Mr Warner was in charge of the Pump Rescue Tender (PRT).After the quake the officers at the City Station decided that the appliances would self-deploy into the city. The first two trucks would go to the left, towards the city, and Mr Warner said he would go right. At that stage, they had no information as to what was going on across the city aside from what they could hear from the radio traffic. Two of Mr Warner's crew were members of USAR Task Force 2 (TF2).
 Mr Warner's truck went right towards Barbadoes Street and stopped on the corner of Barbadoes and Kilmore Streets where he sent members of his crew to check on damaged buildings on that intersection. They then responded to a call from Comms and were sent to the Stonehurst Hotel on Gloucester Street by Latimer Square. There, they rescued a woman who had been buried under rubble. They left her in the care of a doctor that was at the scene and at this stage, heard requests for assistance at the CTV Building. Mr Warner and his crew then proceeded to the CTV site arriving at 1.45 pm.
 Mr Warner described what he saw as follows: 12
"When we came up Madras Street I could see the CTV Building was burning. The bottom of the building was exposed as the walls had fallen down and so you could see some flames in there and smoke.
The tower was still standing on the north side of the building which held the lift and stairways. I could see part of the tower was burning right up the face of the tower. It seemed that the tower was standing by itself and all the floors had fallen off it. Aside from the tower the Madras Street side of the CTV Building was "pancaked" down.
A bit later when I walked past the tower up Madras Street and looked back at the tower, the combustible material on the face of the tower was burning and looked like it had been burning for some time. Overall it looked as if the fire was pretty deep seated and had been burning for some time. . .. I saw people walking away from the building in various stages of distress. There were injured people, people being supported by other people. "
 Mr Warner then instructed his crew to immediately aUack the fire. His options though were limited as the fire appliance carried only 1500 litres of water and Mr Warner knew that there would be no water in the water mains. He was not prepared to put his crew in between the CTV and Arrow Buildings given the dangers presented by aftershocks and the possibility of further building debris falling onto his men. With the assistance of some volunteer fire fighters, who offered their services, attempts were made to attack the fire until they ran out of water. Mr Warner called for water tankers and asked for a helicopter with a monsoon bucket. Although Mr Warner realised that a monsoon bucket would be ineffective, he felt that it was the only way they were going to get water reasonably quickly and that it was the only thing he could do in the circumstances while he waited for water tankers to arrive.
 Mr Warner felt that as some rescues had already been achieved in the area near the lift tower that there was a good possibility there may be people inside the tower block itself who may have been evacuating using the stairway. After checking with an engineer who worked in the neighbouring building and being assured that the tower block was reasonably stable, Mr Warner employed the use of a crane that was on site, to put two of his men on top of the lift tower to access the stairway and search for survivors. Using breathing apparatus, the two fire fighters attempted to explore the stairway but were unable to explore further than one floor because of the heat and smoke.
 Senior Station Officer David Berry was the next highest ranking member of the Fire Service to arrive at the scene. Mr Berry is a member of USAR as the Hazmat Officer for TF2, based in Christchurch. When the earthquake struck, Mr Berry was at his home in Prebbleton. After checking on his wife and daughters he then headed to the USAR base in Woolston. While he was there at the base, a helicopter arrived carrying Assistant Area Manager Dave Burford who had come to collect tents and to check on USAR equipment. After realising that the tents would be too heavy to go on the helicopter, Mr Berry and two other members of TF2 got into the helicopter and the men were flown towards the city, landing in Latimer Square at 3.15 pm. Mr Berry then proceeded to the CTV site where he had a iscussion with Mr Warner that led to the decision to order a helicopter and monsoon bucket to attack the fire. From the east side of the building Mr Berry proceeded around to the west side of the building. Mr Berry described things as being chaotic in that there were people on the rubble yelling for tools, two lines of people having formed a human chain which Mr Berry felt was not effective. He then took steps to take control of the site and gathered ome expertise around him from amongst those that he knew to assist him in making decisions regarding how best to proceed. By this time it was now three hours after the earthquake and work, led by Sergeant Brooklands and other Police and civilians, was well underway to rescue rapped victims. Although Mr Berry did not regard himself as being in charge of the incident, others certainly regarded him as being so. I will return to this point (of command and control) later in these findings. Mr Berry was the most senior member of NZFS present at that time. I accept the evidence of Mr Warner that as between them, Mr Warner was in charge of the east side and Mr Berry was in charge of the west side.
 As the evening wore on, more help arrived at the CTV site as it became available. Help was coming from all quarters including other fire service staff, volunteer fire fighters, Police and other members of TF2 from outside of Christchurch. Members of the public from within the Christchurch community were also seeking to help. Contractors and business owners who were working in the city brought with them gear that they felt could be needed.13 p>
 Mr Warner said that at some time between 3.00 and 4.00 pm (the exact time is not known) a decision was made to start lifting rubble off the pile on the east side of the building, in an effort to locate survivors. The type of material to be removed from the pile was too heavy to be removed by hand and so a plan was made to use the heavy machinery that was onsite from Southern Demolition and Frews Contractors to assist in this work. There was some reluctance from the digger drivers as they felt there was a risk they may hurt someone trapped beneath the pile. It was a difficult position given the deep seated fire. Firemen could not properly attack the fire and have any success with extinguishing it, without being able to access the seat of the fire. The fire continued to smoulder deep beneath the rubble pile creating smoke which was permeating through the pile and into the voids within the pile. This was a danger to trapped victims. Rescuers had to work quickly to locate and free survivors. However as layers were removed, oxygen was provided to the smouldering pile. There were risks in commencing the de-layering process but there were also significant risks in sitting by and doing nothing.
 The predicament faced by the first responders was nicely summarised by Captain Ojeda at paragraph 157 of his statement to the Court:
"A decision not to put water onto the pile for fear of drowning people, means that the fire continues to burn. On the other hand, putting water on the fire presents a risk of drowning some survivors. Lifting heavy debris could cause injury or death to those beneath the rubble, but not moving heavy debris delays the timeframe to access possible voids. There are no easy answers and USAR rescuers are faced with these difficult decisions all of the time. It is not possible, with the benefit of hindsight, to say what could or could not have been done at any particular point in time. We have to rely on the experience and judgements of the specialists on the ground at the time assessing the situation minute by minute as it unfolds before them, making difficult decisions according to the circumstances."
 The fire could not be extinguished without removing layers but removing layers would provide the oxygen necessary for fire to burn. In the end, the correct decision was made. Time was of the essence. It was necessary to cornmence the delayering process at that early stage and to make use of the heavy machinery that was available. This decision was made based on the experience and judgment of these men who were risking their lives and the lives of others, to save lives. The delayering proceeded with care and caution.
 Mr Warner's decision to start the delayering process was immediately vindicated. Mr Warner got everyone off the site and lined them up along Madras Street on the other side of the road facing the CTV Building. He then told the people that they would use the diggers to pick up rubble from the top of the pile and ask them to watch the pile to look for signs of survivors. If any signs were noticed, then the people were asked to wave to him and he would tell the diggers to stop. Mr Warner then stood with his back to the CTV Building so he could see the digger drivers and the people standing behind the diggers, and the digger drivers could see Mr Warner. After only two or three grabs of building material from the top of the pile, people on Madras Street started waving their arms. The diggers were instructed to stop what they were doing.
 Rescuers then went back onto the pile and found one woman who had been trapped under the rubble which had been removed, and was now accessible. She was trapped however between two floors. Her foot was jammed around the back of a filing cabinet. One of those present was able to crawl into the space and free her foot. She was then able to be removed. Rescuers were told by this woman that she had been talking to someone else in the rubble just underneath and further in from her. Members of TF2 who had arrived at the site by this stage, were then left to rescue this person. It took some time but they were able in the end to free a man who walked away without seemingly a scratch. He was the last live rescue on the east side of the building.
 While there was some confusion in the evidence over when other senior officers arrived, the evidence shows that Senior Station Officer Wilson arrived at some stage after Mr Berry. Mr Wilson assumed that Mr Berry was managing the USAR response on the west side. Mr Wilson regarded himself as being in charge.'14 Mr Wilson was relieved of command by Senior Station Officer Ralph Whiten after being in charge for only a relatively short time. Mr Wilson then left the CTV Building site to check on his family.
 Mr Whiten had been sent to the CTV Building by Assistant Area Manager Dave Burford. He was instructed to try and get a structure in place and that he was to be in charge of the Fire Service there. He was told that crews were flat out all over the city and that as far as resources were concerned, Mr Burford had nothing else to deploy to the CTV Building except the truck and crew that would take him there. Finally, Mr Whiten was instructed he would not be relieved until morning.15
 Mr Whiten then did a walk around the site to see what was going on and assess the resources that were available to him. He received a report from Steve Warner and Saskia Rose both of whom then left the site with their crews. Mr Whiten noted two more fire crews working under the direction of Station Officer Bohnenn. There were also two volunteer fire crews and tankers supplying water. Mr Whiten was told that the water was being pumped out of the Avon River so there was a plentiful supply. Mr Whiten decided to use the volunteer crews as an emergency crew in case the rescuers required rescuing.
 Mr Whiten was concerned at the number of people on the site, at one stage counting over two hundred people there. A list was made on paper which was later transferred to a whiteboard when a cornrnand unit arrived the next morning.
 During the night, Mr Whiten received a warning that the Hotel Grand Chancellor could fall. Although the CTV Building site was far enough away from the Hotel Grand Chancellor to be directly affected, I mention it as an indication of the types of issues facing Mr Whiten and others working at the CTV Building site that night.
 During the evening Mr Whiten met Mr Cvetanov. Mr Whiten was told that Dr Cvetanova, Mr Cvetanov's wife, had been in the CTV Building on the third floor, that there were five other people with her. Mr Cvetanov explained to Mr Whiten that he had been talking to Dr Cvetanova on the phone. Mr Cvetanov was described as distressed and anxious
 Mr Cvetanov tried to describe where he thought his wife would be in the pile of rubble before them. Mr Whiten felt that this was right in the middle of where he had seen slumping movement earlier that evening. Mr Whiten passed the information over to the Police who then dealt with Mr Cvetanov.
 Mr Whiten remained onsite and in command of the Fire Service until he was relieved at 8.30 am on 23 February 2011. Mr Whiten did not establish an incident control point (ICP) and it is clear from the evidence that while he regarded himself as being in command of the NZFS response, he regarded USAR and Police as having their own command structures with USAR and Police taking care of the rescues.
 During the night Mr Whiten did see three different NZFS executive officers who were conducting reconnaissance of the city. None of them remained to assist. A command unit arrived from Dunedin and was deployed in the early hours of 23 February 2011.
(iii) Urban Search and Rescue (USAR)
 USAR is a specialist technical rescue capability with personnel who are trained and equipped to locate, access, stabilise and extricate people who are entrapped or entombed within a collapsed structure environment. It is operated and maintained by NZFS with some financial support from the Ministry of Civil Defence and Emergency Management (MCDEM). USAR operates primarily under the Emergency Response Provisions of the Fire Service Act 1975 and relevant operational instructions issued by the National Commander.16
 At the time of the earthquake, USAR had three teams located in Auckland, Palmerston North and Christchurch. The unit in Palmerston North was the first to be established and was called Task Force 1 (TF 1 ). The unit in Christchurch was called Task Force 2 (TF2) and the unit in Auckland was called Task Force 3 (TF3). All members of USAR are volunteers and maintain operational readiness over and above their day-to-day roles. Each task force is resourced with the same cache of equipment. Although they were resourced and operated within the NZFS, USAR had its own command and management structure. Many of the members of USAR were also fire fighters
 At the time, USAR was led nationally by a national management team which included a number of Fire Service officers trained to manage the USAR response. Each task force was led by a Task Force Leader who was responsible for command and control.
 At the time of the Christchurch earthquake James Samuel Stuart-Black was the National Manager, Special Operations for NZFS. Mr Stuart-Black had responsibility for USAR. He had no background as a fire fighter. Senior Station Officer Paul Burns was the Task Force Leader of USAR TF2 based in Christchurch. TF2's management structure consisted of a Task Force Leader, Deputy Task Force Leader, Logistics Manager, Operations Managers, Squad Leaders and Team Technicians. This is further supported by a Logistics Section. In all, TF2 consisted of around 56 members. The team also comprised specialists including dog handlers, structural and geotechnical engineers and advanced paramedics.
 On 22 February 2011 Paul Burns was at his brother-in-Iaw's place at Templeton when the earthquake struck. After checking his own home, family and the neighbourhood, Mr Burns attempted to contact Mr Stuart-Black in Wellington. Mr Stuart-Black was engaged in a meeting at the time so was unavailable. A message was left for him by Mr Burns requesting that Mr Stuart-Black mobilise TF1 and TF3. Mr Burns then drove to the USAR Base at Woolston. This proved impossible for him due to traffic. Area Commander Stephen Barclay had by this stage made his way to the Woolston Base on his four wheel drive NZFS vehicle under lights and sirens. When he arrived at the Woolston Base, Mr Barclay became aware that Mr Burns had become stuck in traffic and so went to pick up Mr Burns using his NZFS vehicle. Mr Barclay left Mr Burns at the Woolston Station. They had arrived shortly after the helicopter carrying Mr Burford, Mr Berry and others had left.
 Mr Burns was then left with the task of trying to mobilise TF2 along with their cache of equipment. At that stage, information was patchy. Mr Burns knew there was a building down in town but was not sure which building. He also knew that there were people trapped.
 In assessing the situation of TF2, Mr Burns noted that the majority of his task force members were on duty that day as fire fighters. These task force members would be required to carry on their normal duties as fire fighters but could of course, use their USAR training.
 The Woolston USAR Base was affected by liquefaction. The cache of equipment had been unaffected. The difficulties included vehicles to move the cache and effective communications to know where best to move the cache to. Mr Burns could not get through to Comms either by phone or radio. He had no vehicle available to him to drive around the city to get a sense of the damage but did manage to get a TV set up and working at the Woolston Base and from that, was able to appreciate the extent of the damage at the CTV Building and central city
 Mr Burns then began to make plans for the city deciding upon Latimer Square as being a suitable site for a base of operations (BOO). He then deployed, with others and gear, into the city proceeding to Latimer Square. At some stage, he was contacted by Mr Stuart-Black and directed to establish the onsite operations command centre (OSOCC).
 USAR staff did not come into the Woolston Base. One of the reasons for this could have been that Mr Barclay indicated over the radio that the USAR Base had collapsed and was not functional. This was incorrect. While it cannot be said how many of the members of TF2 actually heard this radio communication, such an incorrect communication would have added to the confused picture at the time, given the difficulties being experienced with the communication systems generally.I do acknowledge that the evidence I heard suggests that USAR staff deployed wherever they thought that they might be of best use, those coming to Christchurch from out of the city, deploying directly to the CTV Building.
 Mr Stuart-Black had directed TF1 and TF3 to mobilise to Christchurch. Arrangements were made with the NZDF to transport TF3 personnel and equipment from Auckland to Christchurch via Ohakea, to collect TF1 and their cache of equipment. There were some difficulties which resulted in TF1 and TF3 arriving later than expected with only part of their cache. (I deal with this as a separate issue below.)
 TF1 and TF3 arrived at Christchurch airport at 10.27 pm. Buses and trucks provided by the Army were used to transport the group to the BOO which had been established at Latimer Square. After unloading the gear and taking some time to confirm information, Senior Station Officer Bryce Coneybeer, Task Force Leader of TF1 then deployed USAR personnel. TF3 were sent to the PGC site and two squads from TF1 were sent to the CTV site. Some were held back at the BOO in case they were needed to rescue the rescuers.
 I accept the evidence of Mr Summerhays who approximated the arrival of TF1 to the CTV Building as being around midnight.17
 Mr Summerhays became Sector Leader of the east side of the CTV Building site in respect of the USAR operations. Mr Summerhays and his team located a number of bodies during their initial search at the commencement of their shift. As a body was located, it was notified to the Police DVIU Team and Police would take care of removing the body to the temporary mortuary set up nearby.
 Mr Summerhays was one of a number of rescue workers that spoke to Mr Cvetanov regarding Dr Cvetanova. Mr Summerhays was advised that Dr Cvetanova was trapped with other people beneath the rubble, that she was alive and had been talking to Mr Cvetanov. Mr Summerhays communicated this information to other members of the USAR team.
 In the early hours of the morning of 23 February 2011, rescuers on the east side were performing what Mr Summerhays referred to as a, "quiet period" to listen for trapped persons.18 This involved walking over the pile of rubble, calling out and listening for responses. Mr Pickering employed his Sewerin acoustic location device during this time. I accept that he received a positive response to his taps and I also accept that he heard a female voice. I accept also the evidence of Ian Penn, USAR technician from TF1, that he had a response to his calling and tapping on concrete. Mr Penn it seems was not aware of Mr Pickering and it is impossible to tell if the knocking and shouts that I accept both men heard, were from the same person. It is also impossible to know if the female voice heard by Mr Pickering or the taps heard by both men was Dr Cvetanova. There is insufficient evidence from which to draw that conclusion. It may have been Dr Cvetanova or one of the others trapped with her but equally, it could have been someone else trapped in another void in the same general area. This was evidence of life beneath the rubble and further, evidence that the rescuers (USAR, NZFS and others) were working in the correct general area to free those trapped within.
 TF1 continued to work through the night using their personal equipment that they had brought with them on the plane from Ohakea and borrowing what equipment was available to them. This was partly from the TF2 cache and making use of equipment provided by local businesses and contractors. The TF1 cache did not arrive until after 4.00 am. Further time would have been taken to unload the cache and organise it at Latimer Square. It is important to note that on the east side of the CTV Building, work was proceeding without core drills, working cameras and a Delsar Unit. A concrete cutter was there at the site prior to the arrival of the TF1 cache and was used on the west side.
 TF1 worked through until about 1.00 pm on 23 February 2011. At that stage, Mr Summerhays handed over to an Australian USAR team and his team was given an opportunity to rest. The fire was still burning and there had been no further "live hits" or live rescues.
Mr Alec Cvetanov
 Mr Cvetanov was at work at Metro Glass Tech when the earthquake struck. Following the quake, he collected his children from Burnside Primary and took them home. In that post quake traffic, a 25 minute journey took him over four hours. He tried to call Dr Cvetanova a few times but could not get hold of her due to telephone network problems. Around 5.00 pm he decided to go, accompanied by a friend, to try and find his wife. The children were left with a neighbour.
 Mr Cvetanov first went to locate his wife's car. The car was in the Wilson carpark where it was normally parked. From there Mr Cvetanov could see the CTV Building. He could see that it had collapsed. The two men then made their way to get closer to the CTV Building. Mr Cvetanov was able to get to Latimer Square and watched what was going on from under nearby trees.
 During the evening Mr Cvetanov spoke to some people who had been able to escape from the building as it was collapsing. He learned that there were survivors who were alive but trapped and were sending text messages to relatives overseas. Those relatives were then sending messages back to New Zealand. Mr Cvetanov watched as efforts were made to rescue people from the kitchen area of the Kings Education Language School, on the west side. At this stage he did not know where in the building his wife would be but felt that she was most probably in her classroom on the east side of the building. His perception was that very little seemed to be happening on that side as compared to the activity on the west side.
 Mr Cvetanov had been trying unsuccessfully, to contact his wife on her mobile phone. At 10.48 pm Mr Cvetanov tried again. Dr Cvetanova answered the call but only had time to say yes when the call was lost. He managed to call her again and this time had a discussion. He discovered that she was in her classroom. He brought this information to the attention of Police. Over the course of the next hour, there were further calls in which he learned that his wife:
- Had lost the tips of four fingers on her left hand but was otherwise uninjured;
- Was not scared because she knew that people were there trying to rescue her and others trapped with her;
- Was in a tunnel with four other Philippino ladies from her classroom all of whom were alive and in the tunnel with her;
- The lady beside her had her left hand caught under a concrete block and they could not pull it out;
- The other Philippino ladies were uninjuried;
- Dr Cvetanova thought she was still only one metre away from a window facing Madras Street.
 Mr Cvetanov climbed up onto the rubble pile and with a piece of concrete, knocked on what he thought was the floor of the fourth floor of the CTV Building. In a subsequent phone call, Mr Cvetanov was told by his wife that she could hear his knocks. Mr Cvetanov says that this was all done in front of Police (Constable Martindale) and that they were aware of the area in which he was trying to locate his wife.
 The last time Mr Cvetanov was able to speak to his wife, Dr Cvetanova told him that she would turn her cellphone off so that she could save the battery.
 Dr Cvetanova's first recorded attempt to call emergency services was (according to phone records) at 9:34 pm on 22 February 2011. On her next attempt she managed to leave a message which Telecom passed on to Police. After four more attempts, Dr Cvetanova was able to speak with an operator at Police Communications at 9:38 pm. She explained her situation. Contact was next made at 10:21 pm where Constable Martindale, who was at the CTV Building site, was able to speak with Dr Cvetanova. Although communications were difficult I am satisfied on the evidence that Police, USAR and others working at the site, were aware that Dr Cvetanova, with others, was trapped beneath the rubble, on the east side of the building
 Mr Cvetanov had a number of concerns outlined in the first schedule to his statement dated 16 June 2011. I summarise these concerns and reorganise them under general topics as follows:
- The cause of death of Tamara Cvetanova;
- Slow response to rescue Dr Cvetanova by the Police, NZFS /USAR;
I turn now to deal with these particular issues.
(i) Cause of death· Dr Tamara Cvetanova
 During the course of the search of the collapsed rubble at the CTV Building, a body, which was given the unique identifying number 15393 was located on 24 February 2011. No specific details are recorded on where the body was found other than that it was recovered at the CTV Building. The body was transported to the temporary mortuary facility at the Burnham Military Camp. A post mortem
examination was ordered.
 The human remains identified as 15393 was the xxxx Identification was established by extracting a sample of the femur bone taken from body 15393 and upon comparison with a reference sample taken from the toothbrush used by Tamara Cvetanova. In addition, DNA samples from Alec Cvetanov and Todor Cvetanov provided additional DNA evidence in support of the proposition that body 15393 was Dr Tamara Cvetanova.
 Forensic Pathologist, Dr Martin Sage concluded that death was due to massive crush injuries of the head, torso and limbs. There was also fire damage present. Dr Sage opined that it did not appear that Dr Cvetanova had inhaled significant amounts of smoke and fumes. However, he cautioned that this could only be a guarded opinion given the constraints placed on the pathologists by the direction from the Coroner that the post mortem was limited in that a complete internal examination was not undertaken. Dr Sage suggested that a review of the post mortem results of those who died in that area might assist to answer that question if some consistent pattern could be shown.
 I have already accepted the opinion of Detective Collins and found that Dr Cvetanova, Rika Hyuga, Jessie Redoble, Ezra Medalle, Rhea Sumalpong and Emmabelle Anoba found themselves injured but alive and trapped in the same area under the rubble with Dr Cvetanova. Following then the suggestion of Dr Sage, I have considered the post mortem findings in respect of each of the above named. Unfortunately, it was not helpful. The body of Rhea Sumalpong was not recovered.Emmabelle Anoba died due to the effects of fire. Dr White, the pathologist that ompleted the autopsy noted that she saw definite evidence of smoke inhalation nting soot in the trachea. It suggests that Ms Anoba had been overcome by the soke and fumes given the soot that was found in her respiratory system. Fagments of the body of Rika Hyuga were recovered. After reviewing the file, Dr Sage concluded that the cause of death for Rika Hyuga could not be ascertained other than to comment that there was evidence of fire and crush damage. Fragments of the body of Ezra Medalle were recovered. There was insufficient evidence to enable a pathologist to determine the cause of death and so has been recorded by the pathologists as being unascertained. Fragments of the body of Jessie Redoble were recovered. The cause of death was unable to be ascertained due to extensive post mortem damage.
 The above analysis takes me no further and does not assist with the determination of the cause of death of Dr Cvetanova. Ms Anoba may have been trapped in the same general area as Dr Cvetanova but it cannot be known how close they were to each other. Prior to death there must have been movement of the rubble which had them trapped. Such movement could have changed the shape of the void in which they were trapped and possibly separated them from each other. There are many possibilities. The evidence is insufficient to further inform Dr Sage's opinion. It was his view that the fire damage he saw at autopsy occurred after Dr Cvetanova had died.19 Accordingly, I find that Dr Tamara Cvetanova died as a result of massive crush injuries of the head, torso and limbs.
 Mr Cvetanov suggested:
"If a collapse killed Tamara, it is a collapse that was caused by rescuers. For example, the one operating the scissors on a digger at 1.30 am (refer paras 121 to 123 of my statement).20
 Even if I accept Mr Cvetanov's evidence that there was an uncontrolled movement, of the cutting scissors which caused the bond beam to shake and pull up towards Madras Street causing parts of the fourth and fifth floor slabs he had been knocking on to shake, that evidence must be balanced against the uncertainty that Dr Cvetanova was in fact in the area where Mr Cvetanov perceived her to be and the general activity that was going on at the scene. Dr Cvetanova'$ last contact by phone was a call made from her phone to 111 at 12:50 am on 23 February 2011.The call was connected for 18 seconds but there was no talking recorded. No other person had used her phone that night. The inference I draw from this evidence is that Dr Cvetanova was alive at 12:50 am. The timeline prepared by Police (Exhibit 2) shows ten further aftershocks of magnitude 4 or more through until 6:39 pm on 23 February 2011. Anyone of these shocks could have caused some imperceptible (to the outside observer) movement within the rubble pile in the area where Dr Cvetanova lay trapped or there could have been other "slumping" of the rubble pile as described by Mr Whiten. Delayering may have caused the pile to move or settle in a way described by Mr Cvetanov but it cannot be said with any certainty that a particular movement or slumping has been the operable cause. For these reasons, I accept the submission of Counsel for NZFS that the operable cause or causes of the fatal crush injury are not ascertainable. There was too much going on to attribute any particular movement as being responsible for the massive crush injuries which caused the death of Dr Cvetanova.
(ii) Slow response to rescue Dr Cvetanova by the Police NZFS and USAR
 Mr Cvetanov submitted that Police and NZFS I USAR, " ... did not attempt to rescue Tamara and the other people trapped with her yet they attempted to rescue Japanese students trapped in the kitchen as early as 8:00pm on Tuesday - even though conditions above the kitchen looked worse than around where Tamara was." 21 There is no evidence that Police, USAR or NZFS delayed or were slow in responding to the pleas for help from Dr Cvetanova. The evidence establishes that Dr Cvetanova spoke to emergency services before she was able to speak to her husband. Her first call was made at 9:34 pm where she left a message. The first effective voice call was at 9:58 pm. Information was passed on to the police at the CTV Building. Constable Martindale was able to speak to Dr Cvetanova at 10:21 pm. Efforts to locate her were commenced immediately and continued in conjunction with Mr Cvetanov as he made himself known to Constable Martindale. "Dirty" holes were subsequently cut in the pile by rescuers in an effort to locate the voids containing survivors. The voids and the survivors could not be located.
 I accept that at times it must have appeared to Mr Cvetanov that not much was being done to rescue his wife especially when it seemed that the work in the western sector seemed to be yielding more results in the form of live rescues. More rescues were performed in the western sector because there were more opportunities for rescue given the larger voids due to the way in which the building had collapsed. There is no evidence to support any suggestion that preference was given to rescue any specific group. Having regard to all of the evidence I have reached the view that the rescuers were aware that Dr Cvetanova was alive but trapped beneath the rubble and were doing what could reasonably be done to locate and rescue her.
 Mr Cvetanov submits that the delayering should not have commenced when it did as there were signs of life and the delayering placed people trapped and alive in danger. This point has already been covered above.22 It was necessary for the progress of rescuing survivors and fighting the fire that selective delayering occur as early as it did. I accept that rescue personnel assessed all potential rescue opportunities and voids down the length of the pile on the eastern side and that in general, a careful and cautious approach was adopted to the removal of material from the pile.
 Mr Cvetanov submitted that he did not see any sophisticated equipment used at the site to attempt to rescue Tamara. He accepted that there was a listening device present but says that it was antiquated and not part of rescue services. Concrete cutters were not used until a USAR team arrived at 9:00 am the next morning and he felt that the USAR team was just hammering around the holes they had cut with big hammers and just listening with their ears.23
 Mr Cvetanov submitted that Tamara's location beneath the rubble was not relayed to anyone, that there was no-one in charge overall, that things seemed to be better organised on the western side of the building as opposed to the eastern side, that there was no communication between the two sectors and no communication between Police when changing shifts.
 The starting point on this issue is the opinion of Captain Ojeda commencing at paragraph 64 of his brief. Captain Ojeda said:
"As an initial observation, I note that the USAR TF2 did the very best they could in the circumstances which confronted them. As observed throughout the evidence, it is particularly difficult for USAR teams to respond in an urban environment which they themselves have been in through the course of the disaster. They are already embedded in the fire service and also dealing with their own personal circumstances, checking on how their family is and how their homes might have fared in the earthquake. USAR members who are not on duty have to respond from wherever they are in the city or district, get to their base at Woolston if possible and thereafter get into the city to commence their work. "
 Some of TF2 reported to the base at Woolston but others, perhaps being confused by an announcement that the Woolston Base was down and not functional, decided not to go there. It highlighted an issue for NZFS and made plain by this incident. That is, that when the mobile phone network is down, how does NZFS/USAR contact it's off duty officers. I understand from the evidence that a new email system is now being used and that problem has been addressed.
 Although the Woolston Base was affected by liquefaction and gear had been tossed around, the TF2 cache was unaffected and went out as fast as vehicles became available to take it. If the equipment did not go straight into the field, it went to Latimer Square where Mr Burns established the BOO.24 Earlier that afternoon,Mr Berry and two members of his team left the Woolston Base by helicopter with Mr Burford. The helicopter was too small for them to carry gear but I was told that the purpose of the flight was to undertake a reconnaissance of the CBD. The helicopter however flew straight to Latimer Square whereupon Mr Berry and two members of TF2 immediately went to the CTV Building. No reconnaissance was undertaken.
 In the early hours of the emergency response at the CTV Building the evidence clearly shows that there were limited tools and equipment available. More equipment arrived as other USAR teams arrived. NZFS and TF2 resources were stretched fairly thin at that early stage dealing with two major sites (CTV and PGC) along with other potential sites such as the Cathedral.
 A Delsar Unit (a listening device used to locate buried survivors) was used on the western side of the building. Those working on the eastern side of the building were not aware that the Delsar Unit was even there. It could have been deployed on the eastern side but was not. A concrete cutter was made available by locals and was used on the western side. However, those working on the eastern side did not know a concrete cutter was at the site available for use. It also, could have been used on the eastern side. Core drills were not available for use at the CTV Building site until TF3 arrived with their cache.
 Although Mr Stuart-Black did mobilise TF1 and TF3 at an early stage, there was a delay in transporting the teams to Christchurch. TF3's cache was delayed as there was no room on the plane provided by NZDF for the cache to travel with its team. I accept the evidence of Captain Ojeda that it is international best practice that a USAR team should not be separated from its cache of equipment. Clearly, a USAR team is most effective when all of its equipment is available for use.
 As submitted by Counsel, this was one of the most significant issues to have emerged from this inquiry. It is not necessary for me to recite the facts or make any specific findings in relation to the facts on this issue, except to say that the only aircraft available (a B757 in Auckland) to the RNZAF to carry TF1, TF3, their respective cache of equipment and St John's personnel from Auckland to Christchurch via Ohakea, was too small for the task. Communication issues which came to light at the inquest are now immaterial given the steps taken by NZFS and NZDF in December 2012 and will not be discussed further.
 Delays were also caused to the flight leaving Auckland because the Auckland equipment needed to be repacked and stowed to meet the International Air Transport Association (lATA) carriage requirements. Having lATA certified logistics staff with USAR would have been of assistance and could have averted some of the delay.
 I am advised25 that NZFS and NZDF have met to discuss deployment arrangements and on 6, 7 December 2012, conducted a loading exercise with the USAR team based in Auckland and NZDF on RNZAF C-130H Hercules and Boeing 757-200 aircraft. NZFS has also met with Air New Zealand in December 2012 to discuss USAR's resource movement requirements. NZFS has also met with DHL in
December 2012. NZDF, Air New Zealand and DHL have all expressed strong support to enter into a common transportation agreement with NZFS for USAR deployments. A formal memorandum of understanding is proposed to ensure the requirements of each organisation are clearly expressed and understood. I am not aware of the progress made in regards to concluding the memorandum. A recommendation will follow to support and encourage this initiative taken by NZFS and NZDF.
 I am also advised26 that NZFS has considered its position in relation to lATA certification. As a result of evidence given at the inquest hearing and the discussions held between NZDF and NZFS in December 2012, NZDF has recommended to NZFS that USAR logistics staff hold lATA certification as this will maintain NZFS familiarity with air transport arrangements and speed up packaging and loading of equipment. NZFS is committed to ensuring sufficient personnel are lATA certified. This position will be supported by a recommendation.
 Immediately after the earthquake, it became apparent that NZFS staff lost contact with their Communications Centre and that when it was regained after a short time, the channel was extremely busy and congested. This created many difficulties. Whilst there were protocols in place in the case of the earthquake which required fire appliances to be moved out of the buildings as soon as possible, there seems to be an uncoordinated approach to what to do next. As a result, Station Officers were, amongst themselves, deciding to deploy around the city without having an appreciation of what had happened and the extent of damage caused.
 Captain Ojeda discusses this issue at paragraphs 36 - 42 of his brief. He explained that in California there is a standard operating procedure for earthquake events. It is that when an earthquake occurs, fire engines leave the stations and perform a company accountability report and report in by their numeric call sign, following the numerical call sign order, to allow the Comms Centre to know who is available. Stations follow the numerical sequence so that they do not talk over the top of one another - something which was happening in the aftermath of the Christchurch earthquake. Once the stations have checked in, a drive through of their immediate district is performed. The drive through must be completed before operations begin. Captain Ojeda acknowledged that there can be some difficulties as it can be very difficult to drive past someone in need, but commends the procedure as being something useful for NZFS to consider an adaptation of it. At paragraph 39 Captain Ojeda says:
"It is not a natural reaction for fire fighters to drive by an incident and not stop and address the emergency. However, in a major disaster, as with Christchurch, where there is little communication or awareness of the citywide nature of the damage, it is, in my view, imperative. You may stop if your assistance would save a life and will take no more than a couple of minutes."
Stopping to try and render assistance at a single family dwelling for example and not completing the drive through of the immediate district, risks not immediately attending at (for example) a school which may have 10 children trapped in it. Or, if they stop at the school, they risk not assessing the hospital. Proper emergency management requires an understanding of the various problems being faced so that appropriate decisions can be made as to the deployment of resources.
 The point was addressed by Counsel for NZFS. At paragraph 3.5 of their closing submissions it was suggested that each station undertook an assessment of key buildings in its area which may have been identified as presenting a significant risk in the event of fire or hazardous substance incident. It was thought that such was a matter of overall response and so no evidence was provided other than as it related to the background of the NZFS response to the CTV Building. The evidence that I did hear suggested that there was no standard protocol or if there was, the protocol was not followed as appliances deployed to wherever those in command of each appliance felt impressed to go. This, with respect, seems a haphazard approach which demands some further attention. A standard protocol would I suggest be of great assistance to the NZFS staff on duty were an event of this magnitude ever to strike again. The issue requires consideration. Accordingly, a recommendation will follow.
 Another area of concern under this heading of Communications, is communication from the Civil Defence EOC out to the various trouble spots throughout the city. Mr Pickering made us aware during his evidence of the difficulty he faced in offering services and equipment and then waiting to be deployed. During the Christchurch earthquake, Civil Defence would wait for a request for services before despatching someone who could provide the assistance sought. It was suggested by Mr Raymond to Mr Sinclair (Manager of the Christchurch City Emergency Operations Centre), that it should possibly be the other way around, that the EOC should notify police / NZFS / USAR of the resources being offered as available from members of the public. Mr Sinclair accepted this proposition.27 I agree and raise the issue here as something worthy of consideration for future planning.
 Finally, under this head of Communications, Captain Ojeda was critical of the radio communication system in use by NZFS suggesting that it needed a time out system and more channels so that communications within teams working on a site could be ensured by selecting a channel independent of other sites. That is to say, that all the NZFS personnel using hand radios that were on the CTV site, could have selected channel X and all those working at the PGC site could have selected channel Y. Thus communication could have continued independently of each site and keep the main channels used by Comms, free of unnecessary traffic. This was not done at the CTV site: an issue that could have been addressed by an Incident Controller.
 I was advised by Counsel for NZFS that NZFS operates seven channels on their hand held radios: two duplex channels and five simplex. The capabilities of the radio system were not fully utilised. I am advised that further training is planned.
 It was common ground by the end of the inquest, that the lead agency amongst the emergency service providers that attended the CTV Building, was NZFS. This was the case because of the fire burning beneath the rubble pile. Police were the first to arrive and so were lead agency initially, until Mr Butcher arrived with his crew and appliance. It is from that stage, that NZFS should have become the lead provider and assumed overall control of the incident.
 All of those officers who took a command role early on such as Sergeant Brooklands, Detective Sergeant Keane, Station Officer Butcher, Station Officer Warner, Detective Sergeant Barnett, Senior Station Officer Berry, Senior Station Officer Wilson and Senior Station Officer Whiten, performed their particular tasks and unit command well with the exception that not one of them took any steps to establish NZFS as the lead agency, identified an incident controller or established an incident control point in accordance with the Coordinated Incident Management System (CIMS). The Police were the first emergency agency on site and so assumed incident control and lead agency. Once NZFS arrived, there should have been a hand over from Police to NZFS to make it clear that NZFS were the lead agency. This would have encouraged NZFS to establish an incident controller and an incident control point. Because this did not happen, there was confusion which was amplified by dividing the site into two sectors i.e. east and west. Problems were further compounded once USAR, in the form of Senior Station Officer Berry, arrived on the scene. At the time he was the most senior NZFS officer and also had seniority within USAR. Mr Berry did not regard himself as being in charge of NZFS while he was there although others did.
 I accept that the CIMS model required NZFS and Police to come together so that the baton could be properly passed between the two agencies and those at the site would be aware it had been passed. This clearly did not happen and should be addressed.
 Counsel for NZFS submits that in future emergencies where there are multiple sub-incidents, the overall incident controller could take a role in ensuring that incident control of a sub-incident has been determined. I agree. A recommendation will follow.
 While it is common ground that an incident control point should have been established, it was submitted28 that the demands on senior Police and NZFS at the 28 Supra note 1 at para 4.20. CTV site were significant given that they were immersed in the event and were then faced with one of the most complex sites from a search and rescue perspective, with the "perfect storm of difficulty". It was the complexity of the CTV site it is argued, and the operational demands which overwhelmed resources and capabilities and resulted in different tactics being adopted to respond to the demands of the incident. This argument however presupposes that the officers who should have established an ICP considered doing so but then chose not to as part of a considered tactical decision making process. There is little or no evidence to support that submission. Mr Whiten appears to have given the point some thought but my impression from the other sergeants, station officers and senior station officers involved is that the thought simply did not occur to them. Station Officer Rose made some attempts to establish an ICP but was not able to do so. I am advised that incident control points and controllers were set up at other important sites around Christchurch including the PGC Building which leads me to the view that those involved in the rescues in the early hours at the CTV site, were indeed overwhelmed by the experience.
 It is common ground that the establishment of an incident control point would have resulted in benefits to the way in which the response was managed, such as:
- More effective deployment of contractors, resources and equipment;
- A point to brief and debrief personnel as they arrived at or departed from the site;
- A point at which intelligence could be collected, collated and coordinated;
- Better coordination between the east and west sectors;
- A sense of order and confidence that there was a plan in place, someone in authority and somewhere for that authority to be managed from.
 In the course of the hearing it became clear that from around 11.00 pm there were 13 NZFS executive officers in Christchurch. It was difficult for me to understand why it was felt at the time, that one or more of these 13 executive officers, could not have been sent to the CTV site to set up a proper structure and provide support to those that were working there. An opportunity was missed. This was an appropriate concession made by NZFS Deputy National Commander McGill.29 The executive officers missed the opportunity to show clear leadership and coordination at what was clearly the most serious single incident across the Christchurch region. It was also appropriate of Mr McGill to concede that NZFS had not adequately prepared their people to cope with all the demands of that situation and committed NZFS national command to making improvements necessary to ensure that next time NZFS will be prepared. This concession was made on behalf of the National Commander and Mr McGill on behalf of NZFS as an organisation and was I believe a firm commitment to the public and to NZFS staff that NZFS is serious about making the necessary improvements.
 Within this same timeframe decisions were being made regarding the formation of the OSOCC and managing the international USAR teams responding to the disaster. UNDAC, (United Nations Disaster Assessment and Coordination), is part of the international emergency response designed to help countries during the first phase of a sudden onset emergency. UNDAC assists in the coordination of incoming international relief and has teams that can deploy at short notice anywhere in the world. The UNDAC team would set up and manage the OSOCC. An UNDAC team is provided upon the request of the disaster affected government.
 The evidence that I received was that the National Controller, Mr John Hamilton decided, after taking the advice of Mr Stuart-Black, the National Commander of Special Operations NZFS and other members of his team, that an UNDAC team was not necessary. Mr Stuart-Black felt satisfied that the personnel and experience already on the ground in Christchurch, was sufficient and that further overseas assistance would not be required.
 Captain Ojeda and Mr Coneybeer, strongly disagreed with Mr Stuart-Black's view. Both men felt that the UNDAC structure should have been implemented and hat it was a mistake not to do so, given that the alternative was Mr Coneybeer and Mr Burns (the Task Force Leaders of TF1 and TF2) being absorbed into an administrative function running the OSOCC at Latimer Square, when their services could have been deployed at the CTV site, with their teams. When this position was put to Mr Stuart-Black by Mr Raymond, Mr Stuart-Black accepted the point but did not resile from his initial advice to the National Civil Defence Controller that an UNDAC team was unnecessary.
 Although it is impossible to say whether or not bringing an UNDAC team onboard to run OSOCC would have made a difference to the search and rescue at the CTV site in terms of more live rescues an UNDAC team would have provided more leadership on the ground at both the OSOCC and at the CTV Building by freeing up Mr Coneybeer and Mr Burns. Given that NZFS resources were stretched I cannot understand why Mr Stuart-Black gave such advice when the assistance is offered freely. I accept the submission of Mr Raymond that the UNDAC structure should have been implemented and that it was a mistake not to do so.
(vii) Did the search and rescue efforts contribute to the deaths?
 Regarding the issues discussed in paragraphs 101 to 129 above, the question I must consider is whether any or all of these issues identified, have contributed to the deaths of Dr Cvetanova, Ezra Medalle, Jessie Redoble, Mary Amantillo, Emmabelle Anoba, Rika Hyuga, Chang Lai and Rhea Sumalpong. The suggestion is that the problems identified caused delays in finding these people and therefore, the delayed search and rescue response must have contributed to the deaths of those known to be alive and trapped beneath the collapsed CTV Building.
 Counsel for NZFS submitted30 that there is no evidence which supports a conclusion that the search, rescue and recovery operation contributed to the deaths of those who died in the CTV Building. It was argued that while there are some aspects of the search and rescue response which would be conducted differently should an event of this nature strike again, it does not follow that having more specialist equipment available earlier, having TF3 on the ground with their cache of equipment earlier, that being able to communicate around the CTV site and across the city without difficulty, or having a more structured emergency response at the CTV site, would have altered the tragic outcome for those who could not be rescued. More people and equipment earlier may have meant that more holes could be cut, but does that necessarily equate to more live rescues?
 The point was addressed by Captain Ojeda at paragraph 125 of his brief:
"We will never know whether the establishment of an incident command point or clearer lines of authority being established, would have made any difference to the overall rescue efforts. That is, whether more people would have been able to have been pulled from the rubble alive. That day cannot be relived. "
At paragraph 161 he said:
'The correct tools and more teams of men culling more holes (in the absence of a crane) meant a much greater chance of reaching survivors than was the case on the south eastern side. Instead of one hole being cut in the early hours of the 23'd, when the fire had had much more time to spread, three or four more holes could have been cut with more equipment and more men from 21:00 hours on the 22nd to 3:00 am on the 23'd. I cannot, of course, say whether any survivors would have been found or not, but, in my opinion, the chances of finding people alive could have been increased."
 I accept the evidence of Captain Ojeda. My view is that the Police, USAR, firemen and members of the public were doing all they could in a difficult situation to effect rescues and save lives. The rescue efforts of those who worked at the CTV Building were outstanding, courageous and selfless and a number of people were saved because of it. The rescuers could not save everyone but they expended every effort and resource that was available to them in attempting to do so. More people, more resources, better communication and a better structure would, I am satisfied on the evidence, have improved the situation overall and may have improved the chances of saving more lives. However, I am not satisfied to the standard required that such improvements would have resulted in actually locating and saving the lives of Dr Cvetanova, Ezra Medalle, Jessie Redoble, Mary Amantillo, Emmabelle Anoba, Rika Hyuga, Chang Lai or Rhea Sumalpong, or created a reasonable prospect of locating and saving their lives. Accordingly, I find that the search and rescue efforts did not contribute to the cause of deaths of Dr Cvetanova, Ezra Medalle, Jessie Redoble, Mary Amantillo, Emmabelle Anoba, Rika
Hyuga, Chang Lai and Rhea Sumalpong.
Date of death
(i) Dr Tamara Cvetanova
 The evidence has established that the last effective call from those trapped and communicating by mobile phone with friends, family and rescuers, was at 12:50 am on 23 February 2011 from Dr Cvetnova's mobile phone. There is no way of knowing that it was Dr Cvetanova that made the call but it is, in my view, a reasonable inference to draw from the circumstances, as no other person appears to have used her phone that night. Dr Cvetanova's remains were found on 24 February 2011. Dr Cvetanova suffered serious crush injuries and fire damage which most likely occurred after her death. Based on this evidence I find that Dr Tamara Cvetanova died on 23 February 2011.
(ii) Emmabelle Anoba
 The evidence establishes that Emmabelle Anoba died as a result of the effects of fire. Ms Anoba was trapped in a void close by Dr Cvetanova. Dr Cvetanova's body suffered post mortem fire damage. A reasonable inference to draw from the evidence is that Emmabelle Anoba died after Dr Cvetanova. (iii) Ezra Medalle, Jessie Redoble, Rika Hyuga and Rhea Sumalpong  Ezra Medalle, Jessie Redoble, Rika Hyuga and Rhea Sumalpong were trapped nearby. It is a reasonable inference to draw from the evidence that they were each affected by the same events that caused the deaths of Dr Cvetanova and Emmabelle Anoba such as movement of the rubble and the fire. For these reasons, I fix the date of death as 23 February 2011.
(iv) Chang Lai
 Chang Lai made 3 calls from her mobile phone following the earthquake. The first two, were at 1 :33 pm and 1 :35 pm to her parents in Guangzhou, China. The final call was made at 2:14 pm. It is reasonable to infer that Chang Lai succumbed to her injuries and died on 22 February 2011.
(v) Mary Amantillo
 Mary Amantillo made 10 phone calls following the earthquake and sent 32 text messages between 12:55 pm and 3:56 pm, to friends and family advising them that she was trapped inside the collapsed CTV Building. It is reasonable to infer that Mary Amantillo succumbed to her injuries and died on 22 February 2011.
 Although I heard evidence regarding the Civil Defence response from Christchurch City Council I have deliberately avoided any review of the Civil Defence emergency response in relation to the CTV Building. My reason for this is that a comprehensive review was conducted by direction of the Director of Civil Defence and Emergency Management. The report, entitled "Review of the Civil Defence Emergency Management Response to the 22 February Christchurch Earthquake" dated 29 June 2012 ("the Review") I have received as part of the evidence in this inquiry. I have also received a copy of the Corrective Action Plan ("CAP") which followed the Review. Of the 102 recommendations made by the Review, plans were made in regard to selected recommendations and are, as I understand it, being actioned. I now mention 3 of the plans outlined in the CAP as hey have some relevance to the matters I have already discussed earlier in these Findings.
(i) Emergency Operations Centres
 Initially, following the earthquakes in Christchurch, three separate EOC's (Emergency Operations Centres) were established. Environment Canterbury set up an EOC at the University, Christchurch City Council set up an EOC at the art gallery and the third EOC was at the NZFS and Police headquarters. Under the CAP, strong emergency operations centres which are able to become operational with minimal infrastructure is recommended. A single emergency operations centre is to be developed for Canterbury. This plan is taking shape in the form of the Justice and Emergency Services Precinct Project. I am satisfied that this initiative properly addresses the issue of multiple EOC's and will assist by alleviating pressure on communications and other infrastructure (such as buildings housing Police and NZFS) issues highlighted by the earthquake.
(ii) Incident Control
 Incident Control was raised as an issue in the Review. The CAP proposes a joint NZ Police/NZFS training programme is to be developed for 2013/2014. The evidence in this inquiry highlighted a failure by Police and NZFS in that an Incident Control Point and an Incident Controller was not established at the CTV Building, contrary to the CIMS model. As I have pointed out above, the establishment of an Incident Control Point and Incident Controller was a joint responsibility. Further training is clearly needed and will be supported by me through recommendations.
(iii) USAR and Light Response Teams
 NZFS was encouraged to consider more flexible operational control and tasking arrangements for USAR deployments as well as a greater understanding of the capabilities of New Zealand response teams with a view to larger integration into operations. NZFS have already undertaken changes to the structure of USAR within NZFS. The changes are set out below. In relation to the response teams, it was clear to me from the evidence that they felt underutilised. While the response teams do not receive the same level of training as a USAR team, there are ways in which a response team could be better utilised as part of a co-ordinated response. Two suggestions made to me in evidence were in a reconnaissance role, and as a runner for USAR technicians. NZFS have also committed to better utilisation of response teams and clearly joint training would be beneficial.
The Pilling Report and NZFS Actions
 Simon Pilling, in his report to NZFS said the following: 31
'The Christchurch earthquake was an extraordinary event that required extraordinary levels of management, command, leadership, commitment, resolve, resilience, discipline, organisation, communication, and bravery. All that, in part and by many was delivered. 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."
I have included the quote from Mr Pilling as I believe that NZFS has as an institution, accepted the findings of the Pilling Review that there were some things that could have been done better, and are committed to be better prepared for future major incidents. I accept that the steps taken by NZFS show the "fresh focus and investment" suggested by Mr Pilling. I acknowledge that NZFS is in the process of significant changes, which include.32
- Developing and publishing a National Response Plan;
- Working with Ministry of Civil Defence and Emergency Management on reviewing the CIMS Manual;
- Approving a mandatory incident management course for all executive officers;
- Upgrading fire stations including earthquake strengthening together with auditing and testing of NZFS facilities;
- Ongoing liaison with Police to investigate further opportunities for working together to develop the agency's incident management training systems and skills including in the USAR environments;
- Restructuring of the USAR by combining the three task forces into a single New Zealand Task Force;
- Introducing mainstream fire service rank and command level into USAR Task Force;
- Changing the USAR uniform so that it is now more closely aligned to the NZFS personnel uniform;
- Introducing specialist USAR technical search teams and training in heavy rescue equipment including cranes, referred to as the 'Dog man' course;
- Reviewing all USAR policies to ensure that USAR dovetails into the NZFS response;
- Appointing an Assistant National Commander with responsibilities for liaising with the NZFS Incident Management Team;
- Meeting with NZDF to discuss deployment arrangements and conduct a loading exercise with the USAR team based in Auckland and NZDF on RNZAF C-130H Hercules and Boeing 57-200 aircraft on 6 - 7 December 2012;
- Meeting with Air New Zealand and DHL in December 2012 to discuss New Zealand's USAR's resource movement requirements;
- Working with NZDF, Air New Zealand and DHL to enter into a common transportation agreement with NZFS for USAR deployments;
- Entering into an arrangement with the Ministry of Health and St John whereby St John has contracted to provide USAR with 18 paramedics nationwide.
I commend NZFS for their initiative in taking these steps.
 I acknowledge NZFS submissions that the NZFS is only one agency within the Civil Defence and Emergency Management structure in New Zealand and that coordination with other agencies will be required to develop and implement identified improvements.
 I acknowledge also limitations placed on NZFS by the Fire Service Act 1975.NZFS must of course work within its empowering legislation and within the constraints of resources allocated by central government. I note that the Department of Internal Affairs is conducting a review of the fire service functions and funding. A report entitled, "Report of the Fire Review Panel dated 11 December 2012" was released on 7 February 2013. At paragraphs 138 and 139 of that report, it was recognised that fire services had moved from solely fire fighting to a multipurpose emergency and rescue service without there being a conscious decision by the government for these functions to be carried out by NZFS. The functions were undertaken as there was an existing capacity to respond and fire fighters saw themselves as having a duty to protect the community. The review found however that the lack of a formal mandate had led to gaps and overlaps in the provision of these services. This, the review finds, creates uncertainty as to which is the mandated agency at an incident, who is in support or whether any agency has responsibility for ensuring that there is a response.
 The Minister of Internal Affairs released his proposals for fire services reform by way of a Cabinet paper dated 20 August 2013. This document was not available to me at the time of the inquest and I only became aware of it in the course of preparing these Findings. I have received a copy of the document and admit it as evidence pursuant to section 79(1) Coroners Act 2006.
 In his paper, the Minister outlines his proposals for a, "" .comprehensive reform of the fire services legislation to ensure a modern, efficient and future proof operating platform. These changes to legislation will form part of a broader package of reform that includes priority actions for the Commission, and enhanced coordination across the emergency services sector. 33 Real progress is being made in relation to reform. I have taken this into account in formulating the recommendations that follow below.
 Section 57(3) Coroners Act 2006 provides that the second purpose for opening and conducting an inquiry is to make recommendations or comments which, in my opinion, may, if drawn to public attention, reduce the chances of the occurrence of other deaths in circumstances similar to those in which the death occurred. It is my sincere hope that nothing of this magnitude occurs in New
Zealand ever again. Prudence however would suggest that as a country we should prepare for another significant event. Captain Ojeda referred to USAR as being an insurance policy34 and that it was up to New Zealand to decide how much insurance we should have. While I do not disagree with Captain Ojeda, my view is that it is not just USAR that is the insurance policy but all of our emergency response
organisations including USAR, NZFS, Police, St John's, Civil Defence and the public at large. It is hoped that the recommendations that follow below, will enhance the opportunities of preparing the best insurance allocated resources can procure.
(i) Dr Tamara Cvetanova
 Dr Tamara Cvetanova moved to Christchurch from Serbia in 2000. Dr Cvetanova qualified and worked as a paediatrician in Serbia prior to her move to New Zealand. Dr Cvetanova was preparing to re-enter the workforce and was studying English at the Kings Education language school as an employment requirement. The school is situated at level 3 of the CTV Building, situated on 33 Cabinet paper from the Minister of Internal Affairs dated 20 August 2013, "Proposals for Fire Services Reform" at para 4 34 Notes of Evidence 6 December 2012 at page 24 Madras Street, Christchurch. The course commenced on 17 January 2011. On 22 February 2011 Dr Cvetanova was in her classroom at Kings Education when the earthquake struck Christchurch at 12:51pm, causing the building to collapse. Dr Cvetanova survived the building collapse but became trapped in a void beneath the rubble on the eastern side of the collapsed building. Using her mobile phone, Dr Cvetanova made contact with emergency services and later, her husband. Dr Cvetanova was trapped near 5 others; Rika Hyuga, Ezra Medalle, Jessie Redoble, Rhea Sumalpong and Emrnabelle Anoba who were also alive. As a result of Dr Cvetanova's phone calls to the 111 service, Police, and her husband efforts were made by NZFS, USAR, Police and members of the public to locate and rescue her and those trapped near her. Dr Tamara Cvetanova's body was recovered from the CTV Building on 24 February 2011. Tamara Cvetanova died on 23 February 2011 as a result of massive crush injuries to the head, torso and limbs. The search and rescue effort did not contribute to her death.
Prohibition on Publication
 At the conclusion of Dr Sage's evidence an order prohibiting from publication the manner and state in which Dr Cvetanova's body was recovered from the ruins of the CTV Building was made. For completeness, I record that order in these findings as a final order. Pursuant to section 74 of the Coroners Act 2006, I prohibit the making public of the manner and state in which Dr Cvetanova's body was recovered from the CTV Building on the grounds of decency and personal privacy.
(ii) Ezra Mae Sabayton Medalle
 Ezra Mae Sa bay ton Medalle was a 24 year old nurse from the Philippines,who had travelled to New Zealand with her boyfriend, Jessie Redoble, also a nurse from the Philippines. Ezra and Jessie were studying English at Kings Education language school. On 22 February 2011 Ezra and Jessie were at the CTV Building, Madras Street, Christchurch attending their first day of classes when an earthquake struck Christchurch at 12:51pm, causing the CTV Building to collapse. Ezra and Jessie survived the initial collapse of the building but became trapped in a void beneath the rubble on the eastern side of the collapsed building. Jessie used a mobile phone belonging to Rika Hyuga to make telephone calls and send text messages seeking help. Jessie called a friend, Divinia Leitch and left a message on her voicemail asking for help and advising that Ezra's legs were "stuck". Jessie and Ezra were trapped near 4 others; Dr Tamara Cvetanova, Rika Hyuga, Rhea Sumalpong and Emmabelle Anoba. As a result of phone calls made by Dr Cvetanova and calls and texts made by Jessie efforts were made by NZFS, USAR, Police and members of the public to locate and rescue Dr Cvetanova and those
trapped near her. Fragments of Ezra's body were recovered from the CTV Building rubble. Ezra Mae Sabayton Medalle died on 23 February 2011 as a result of injuries suffered following the collapse of the CTV Building. The nature of her fatal injuries could not be ascertained. The search and rescue effort did not contribute to her death.
(iii) Jessie Lloyd Albarracin Redoble
 Jessie Lloyd Albarracin Redoble was a 24 year old nurse from the Philippines, who had travelled to New Zealand with his girlfriend, Ezra Medalle, also a nurse from the Philippines. Jessie and Ezra were studying English at Kings Education language school. On 22 February 2011 Jessie and Ezra were at the CTV Building, Madras Street, Christchurch attending their first day of classes when an
earthquake struck Christchurch at 12:51 pm, causing the CTV Building to collapse.Jessie and Ezra survived the initial collapse of the building but became trapped in a void beneath the rubble on the eastern side of the collapsed building. Jessie used a mobile phone belonging to Rika Hyuga to make telephone calls and send text messages seeking help. Jessie called a friend, Divinia Leitch and left a message on her voicemail asking for help and advising that Ezra's legs were "stuck". Jessie and Ezra were trapped near 4 others; Dr Tamara Cvetanova, Rika Hyuga, Rhea Sumalpong and Emmabelle Anoba. As a result of phone calls made by Dr Cvetanova and calls and texts made by Jessie efforts were made by NZFS, USAR, Police and members of the public to locate and rescue Dr Cvetanova and those trapped near her. Fragments of Jessie's body were recovered from the CTV Building rubble. Jessie Lloyd Albarracin Redoble died on 23 February 2011 as a result of injuries suffered following the collapse of the CTV Building. The nature of his fatal injuries could not be ascertained. The search and rescue effort did not contribute to his death.
(iv) Rika Hyuga
 Rika Hyuga was a 30 year old nurse from Japan. She was studying English at the Kings Education language school situated on level 3, CTV Building, Madras Street, Christchurch. Rika Hyuga lived in Burwood, Christchurch with Mark and Shelley Bromley. On 22 February 2011 Rika Hyuga was at the CTV Building when an earthquake struck at 12:51 pm, causing the building to collapse. Rika Hyuga survived the building collapse but became trapped in a void beneath the rubble on the eastern side of the collapsed building. Rika Hyuga was trapped near 5 others; Dr Tamara Cvetanova, Ezra Medalle, Jessie Redoble, Rhea Sumalpong and Emmabelle Anoba who were also alive At 2:00 pm a text message was sent from Ms Hyuga's phone to Shelley Bromley's phone asking for help. Mark Bromley responded to the text message by calling Ms Hyuga's phone at 4:27 pm. Mr Bromley spoke to a man he did not know (Jessie Redoble) who told Mr Bromley that Rika Hyuga was near him, trapped and still alive, that Ms Hyuga had a broken leg and he could not get to her. Mr Bromley then contacted emergency services and tried to re-establish phone contact with Ms Hyuga's phone. He was not able to do so but sent a text message. As a result of Mr Bromley's call and calls made by Dr Cvetanova to the 111 service. Police, and Alec Cvetanov, efforts were made by NZFS, USAR, Police and members of the public to locate and rescue Dr Cvetanova and those trapped near her, including Rika Hyuga. Fragments of Rika's body were recovered from the CTV Building rubble. Rika Hyuga died on 23 February 2011 as a result of injuries suffered following the collapse of the CTV Building. The nature of her fatal injuries could not be ascertained. The search and rescue effort did not contribute to her death.
(v) Rhea Mae Sumalpong
 The death of Rhea Mae Sumalpong was heard at inquest by Chief Coroner Judge Neil Maclean on 16 May 2011. Her body was not recovered and the Chief Coroner made a finding of death, there being no evidence upon which a cause of death could be established other than a generic finding of injuries caused by the building collapse and fire. No further findings can be delivered in respect of this
death but I make the comment that the search and rescue effort did not contribute to the death of Rhea Mae Sumalpong.
(vi) Emmabelle Cabahug Anoba
 Emmabelle Anoba was a 26 year old nurse from the Philippines. She had only recently arrived in New Zealand and was studying English at Kings Education language school in preparation for employment. Emmabelle Anoba was flatting in Christchurch with Rhea Sumalpong. On 22 February 2011, Ms Anoba and Ms Sumalpong were seen in the CTV Building a few minutes prior to when an earthquake struck Christchurch at 12:51 pm causing the building to collapse. Ms Anoba survived the building collapse but became trapped in a void beneath the rubble on the eastern side of the collapsed building near 5 others; Dr Tamara Cvetanova, Rika Hyuga, Ezra Medalle, Jessie Redoble and Rhea Sumalpong who were also alive. The mobile phone belonging to Rika Hyuga was used by Jessie Redoble, to call Ariel Caballero, a friend of Ms Sumalpong. Jessie advised Mr Caballero that he was trapped in the collapsed CTV Building with Ms Sumalpong, Ms Anoba and others and needed help. As a result of Jessie's calls and texts, and calls made by Dr Cvetanova to the 111 service. Police, and Alec Cvetanov, efforts were made by NZFS, USAR, Police and members of the public to locate and rescue Dr Cvetanova and those trapped near her, including Emmabelle Anoba. The body of Emmabelle Cabahug Anoba was recovered from the CTV Building on 23 February 2011. Emmabelle Cabahug Anoba died on 23 February 2011 as a result of the effects of fire. The search and rescue effort did not contribute to her death.
(vii) Mary Lousie Anne Bantillo Amantillo
 Mary Louise Anne Bantillo Amantillo was a 23 year old nurse from the Philippines. Ms Amantillo was studying English at the Kings Education language school. Ms Amantillo came to New Zealand with Valquin Bensurto and had been in the country a little over a week. On 22 February 2011, Ms Amantillo was seen in the cafeteria on level 3, CTV Building by one of her friends, just a few minutes prior to
when an earthquake struck at 12:51 pm causing the building to collapse. Ms Amantillo survived the initial collapse of the building but was trapped beneath the rubble in a void. Ms Amantillo made 10 phone calls and sent 32 text messages between 12:55 pm and 3:56 pm, to friends and family advising them that she was trapped inside the collapsed CTV Building. As a result of her calls for help, contact
was made with emergency services by her friends and family reporting that Ms Amantillo was trapped beneath the rubble. Efforts were made to locate and rescue Ms Amantillo from the collapsed building. The body of Mary Louise Anne Bantillo Amantillo was located at the CTV Building on 25 February 2011. Mary Louise Anne Bantillo Amantillo died on 22 February 2011 as a result of multiple crush injuries.
The search and rescue effort did not contribute to her death.
(viii) Chang Lai
 Chang Lai was a 27-year-old Chinese national who was studying English at the Kings Education language school. Ms Lai was a nurse and was improving her English with a view to working in New Zealand. On 22 February 2011, Ms Lai was at the CTV Building Madras Street, Christchurch when an earthquake struck at 12:51 pm causing the building to collapse. It is not known where Ms Lai was in the building when it collapsed. Ms Lai survived the initial collapse of the building but was trapped in a void beneath the rubble. Ms Lai made 3 calls from her mobile phone. The first two, were at 1 :33 pm and 1 :35 pm to her parents in Guangzhou, China. The final call was made at 2:14 pm. Efforts were made to locate and rescue Ms Lai and all others trapped beneath the collapsed CTV Building. Fragments of the body of Chang Lai were located at the CTV Building on 26 February 2011. Chang Lai died on 22 February 2011 as a result of injuries suffered following the collapse of the CTV Building. The nature of her fatal injuries could not be ascertained. The search and rescue effort did not contribute to her death.
 Pursuant to section 57(3) Coroners Act 2006 I make the following recommendations:
154.1 NZFS continue work commenced to establish a Memorandum of Understanding between NZFS, NZDF, Air New Zealand and DHL to ensure that the requirements of each organisation are clearly
expressed, to ensure the expeditious deployment of USAR teams when required and undertake joint training exercises to ensure the requirements are understood;
154.2 NZFS arrange for USAR technicians to undertake the "Dog man" course to receive specialist training in the use of heavy machinery (including cranes) in search and rescue work;
154.3 NZFS arrange for USAR technicians to undertake and maintain lATA certification;
154.4 For all major disasters where international assistance is sought or accepted, it become the default position that a request be made to United Nations for the assistance of an UNDAC team;
154.5 NZFS, in conjunction with the Civil Defence Emergency Management Group, develop and undertake joint exercises with such Light Response Teams that have been established by local authorities (but with emphasis on areas where the risk of building collapse is high following a significant event - such as Auckland, Wellington and Christchurch) to beUer understand their capabilities and to ensure the
best use of this resource;
154.6 NZFS develop a standard operating procedure following an earthquake event for all on duty NZFS personnel, in the affected area to follow, prior to deployment;
154.7 NZFS and NZ Police develop and undertake further training in incident management and to emphasise the need to co-operate to establish an Incident Control Point and an Incident Controller in the
154.8 The Ministry of Civil Defence and Emergency Management give consideration to amending the CIMS model to provide for the situation where there are multiple sub-incidents, it is a role of the
overall Incident Controller to ensure that incident control of a subincident has been determined.
 Finally, I mention the significant contribution made by NZDF in allowing NZDF facilities at Burnham to be used to establish a temporary mortuary and provide a place for the teams of police, Pathologists, Dentists, CSU staff and others that were needed to assist Coroners in our responsibility to identify the deceased and return them to their families. The Burnham facilities were ideal and provided a model which I understand is now being considered internationally. I invite the Ministry of Civil Defence and Emergency Management and the Ministry of Justice to formalise, as much as possible, arrangements with NZDF and develop a contingency plan to use NZDF facilities throughout the country, (but with emphasis on areas where the risk of building collapse is high following a significant event such as Auckland, Wellington and Christchurch) in this way.
 Pursuant to section 58(3)(b) Coroners Act 2006 notice of proposed adverse comments was given. As a result I have received and considered submissions from Counsel on behalf of NZFS, Counsel on behalf of NZ Police, Counsel on behalf of NZDF and Counsel on behalf of Mr Stuart-Black (Mr J Horner). I have considered the submissions carefully. A late submission was received from Mr Vaughan on behalf of Mr Cvetanov. All submissions have now been considered. Where I have felt it appropriate, some adjustments have been made. In my view, the findings and comments above are fair and justified based on the evidence as I have found it to be. Comments and findings made should be read in the wider context of the entire finding rather than any particular comment being considered in the isolation of the sentence or paragraph in which it is made.
 In relation to the release of these findings, I direct as follows:
157.1 This document is to be released to all Counsel and families of all those that died in the CTV Building on 26 March 2014. Distribution
shall be by way of postal delivery;
157.2 A copy of the finding is to be sent to the embassies for China, Japan, Philippines, Thailand and Korea, the Ministry of Foreign Affairs and Trade and the Ministry of Business, Innovation and Employment;
157.3 An order is made pursuant to section 74 Coroners Act 2014 prohibiting these findings from publication. This order shall expire at 6:00 am on Monday 31 March 2014. This order is made in the interests of justice to allow the families to be notified.
157.4 A copy of the findings is to be made available on the Ministry of Justice website from 6:00 am Monday 31 March 2014.
Coroner Gordon Matenga
1 Closing submissions of New Zealand Fire Service K Clark QC and H Smith at paragraph 2.6.
2 R v The South london Coroner, ex parte Thompson (1982) 126 S J 625 DC per lord lane CJ.
3 louw v Maclean CP 445/87, High Court Christchurch, 10 December 1987.
4 See also the photograph Exhibit 1 page 11. At inquest, the floors in the CTV Building were labelled differently. The floor at ground level was the Ground Floor, then level 1 and so on.Thus, in these Findings, the Kings Education language School was located on level 3.
5 Canterbury Earthquakes Royal Commission Final Report Volume 6 at para 9.9
6 Ibid at para 9.10
7 Brief of Detective Grant Andrew Collins at para 180.
8 Statement of Mark James Keane at paras 12 and 14
9 Ibid at para 18
10 Statement of Alan Maurice Butcher at paras 9 and 10
11 Ibid at para 18
12 Statement of Stephen Colin Warner at paras 18 - 22
13 For example Luke Pickering (a listening device), the owners of OMC Power who provided vests, hard hats, first aid kits, high vis gear, gloves, generators, power cords, lights, crowbars, concrete cutter and a rock breaker as well as technical assistance. Southern Demolition, Frews, Smiths Cranes and others.
14 Statement of Gerald Gordon Wilson at para 28
15 Statement of Philip Ralph Whiten at para 5
16 Statement of James Samuel Stuart-Black at para 16
17 Statement of Aaron Brian Summerhays at paras 15 and 16.
18 Statement of Aaron Brian Summerhays at para 31.
19 Statement of Dr Martin David Sage at para 14.
20 Para 1.9(b) First Schedule Statement of Srecko (Alec) Cvetanov dated 16 June 2011.
21 Ibid at para 1.2(a).
22 See paras 48 - 51 hereof.
23 Supra note 20 at para 1.5.
24 Statement of Paul Francis Burns at paras 54, 61, 77.
25 Supra note 1, at para 7.10
26 Supra note 1, at 7.11
27 Notes of Evidence 1 November 2012, page 120, line 15.e
28 Supra note 1 at para 4.20.
29 Notes of Evidence, 4 December 2012 at page 81.
30 Supra note 25 at para 12.4.
31 Independent Review commissioned by NZFS produced as Exhibit 23, at page 48
32 Supra note 1 at para 13.9
33 Cabinet paper from the Minister of Internal Affairs dated 20 August 2013, "Proposals for Fire Services Reform" at para 4
34 Notes of Evidence 6 December 2012 at page 24
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