Our disaster defence failed, now what?

Our councils this week released the independent report they commissioned on how the region’s Civil Defence and Emergency Management Group handled Cyclone Gabrielle.

By all accounts the investigation and report completed by Bush International Consulting was thorough and clear in its recommendations.

The report recounts vividly the information and communications gaps that led to actions taken/not taken as the scale and impact of the disaster fully unfolded.

“The scale, extent and speed of this weather event was beyond what the New Zealand civil defence and emergency response system is set up to manage. As one respondent put it to us: “Our system was designed to manage crisis in a region, not a region in crisis.

“Although they were overwhelmed and stressed, they often utilised interpersonal relationships effectively, innovated on the fly, and coordinated the work of disparate agencies and organisations in the interests of their communities. Civic leaders communicated with empathy, in spite of incomplete information. Individuals worked tirelessly through the response.

“This was the number 8 wire New Zealand way in action. But worked on basis of relationships, heroics and adrenalin rather than proven systems and frameworks.

“As the weather event intensified, the Hawke’s Bay Civil Defence Emergency Management Group Emergency Coordination Centre (HBGECC or GECC) lacked situational awareness and intelligence about much of the danger and damage until too late. With only partial understanding of the severity of the event, they struggled to direct and coordinate first responders, partner agencies, tangata whenua, volunteers and other territorial authorities.

“Communications failures, lack of data and the speed, severity and extent of this event overwhelmed staff in the GECC. They, and their partners in the other territorial authority Emergency Operations Centres did some brave and innovative things. They also had significant blind spots and made some mistakes. But above all else, they were simply overwhelmed.”

The Report give examples illustrating all of the above. But more important now are the lessons learnt and recommendations to be implemented. Here are the ones that most struck me.

And I would note at the outset that the Report is at least as critical of deficiencies in national emergency preparedness as it is regarding our regional response. Indeed many of its recommendations are actually addressed at central government policy makers. The current national system sets people up to fail, said Mike Bush, former Police Commissioner, who led the review.

Lessons (all verbatims from Report)

“HB Civil Defence and Emergency Management Group plans were as sound as any we have seen but lacked the operational detail needed to address an event of this scale and magnitude.

“CDEM staff were overconfident about their readiness on the basis of prior emergency events such as COVID-19. They lacked a scenario planning mindset, had low multi-agency operational exercise experience and suffered from optimism bias. We have formed the view that they tended to take a best case scenario rather than a precautionary approach to planning, communication and warnings. 

“Communities, volunteers, the contractor sector, businesses and utility providers provided critical and heroic response activity. These local resources were not well utilised by the CDEM Group in the response to this event.”

“Engagement of iwi Māori and Māori communities was more a matter of ad hoc relationships than the product of systematic and formalised effort. At the operational level, Māori agencies and marae felt that their proven abilities to deliver welfare services at scale were either ignored or hampered by bureaucratic decision making from the centre. 

“Reduction activity in the form of precautionary river dredging to remove excess shingle, active management of forestry byproducts, stop bank, drain and flood management device maintenance proved inadequate to the event.

“From a CDEM perspective the response and early-stage recovery were based on personalities and relationships, as opposed to repeatable and proven systems and frameworks. Response tended toward the reactive and tactical, as opposed to taking a more strategic view. Things were often chaotic. They were based on a consensual approach to decision making, as opposed to decisions made on the basis of intelligence and clear command lines.”

Dare I say … while everyone talks enthusiastically about the spirit of cooperation across the region’s leadership, no one has really discussed whether having five cooks in the kitchen (i.e., our five councils and staff) was helpful during this fast-breaking disaster.

Recommendations (culled from the 75 offered)

Regarding proactive, preventative measures, more attention/priority to …
“Risk reduction operations such as: 

i. River management (dredging, maintenance of river mouths and tributaries etc.) 

ii. Stop bank planning and maintenance. 

iii. Drain and flood scheme maintenance. 

iv. Management of forestry by products. 

v. Plans for mitigation of utility and service outages; 

“Ensuring that CDEM partnerships with lifeline utilities, iwi, PSGEs, mana whenua, volunteers, the private, contract and philanthropic sectors, media and communities are more inclusive, mature and enduring. 

“Establishing reliable detection and early warning systems that are resilient to outages and provide adequate warning of potential or pending disaster. [This was clearly a top concern of many individual submitters to this review. About 1000 responses to the review’s online survey. An interesting point in the Report about information not getting communicated. Before flooding worsened, “FENZ and Police had been door knocking in Esk Valley and that few residents wanted to move”. ]

“Ensuring officials take a precautionary approach to potential disasters, reducing the risk of optimism bias inherent in a best case scenario approach. A precautionary approach will ensure advance warnings are given to at risk areas and communities. 

“Ensuring at risk and vulnerable communities have the resources required to be self-sufficient when a disaster occurs; 

“Developing better and more resilient communications systems to ensure that all officials have real time information and can communicate with the public, partners and other authorities. 

“Ensure improved operational command leadership clarity and capability. 

“Develop improved mechanisms for situational awareness and intelligence gathering that are resilient under most disaster scenarios. 

“Utilise marae as distribution and welfare hubs throughout the region and ensure they are supplied with current sitreps and action plans. Ensure that their role in the CDEM system is both appropriately resourced and clearly communicated to local communities. 

“Ensure that multiple scenarios are planned for in multi-agency sessions and subsequently tested in realistic simulation events. 

“In a major event, the CDEM Group should publish daily updates to the community that include both achievements and setbacks to manage public expectations and proactively shape the narrative. 

“HBCDEM exercise plans should be reviewed, to provide a greater emphasis on the balance between frequent smaller-scale training events and larger, inter agency operational exercises. Both should be mandatory for all CDEM personnel. 

“Create greater clarity for controllers and first responders about who is in command at what stage of an event and where tasking for supplemental resources (such as volunteers and NZDF) sits. 

“NEMA should consider developing fly in teams of expert professionals, (with a particular focus on controllers, but also including other experts, such as welfare, engineering, science, and communications) in order that (mostly part time) local CDEM staff can be supported by full time, technical experts. Fly in controllers need a mechanism enabling them to act in the role of CDEM controller in any region.” [Several of our mayors have commented about what they considered undue delay in national expertise and material support being brought into the region.]

 Now what?

The Report says: “All of this suggests that changed system settings, culture and policies are urgently required. We believe that New Zealand needs to invest additional resources in a more fit for future emergency management system. The future system must get the balance right between local planning, regional delivery, and national professionalism, enablement and assurance.”

In releasing the Report, speaking as the CDEM Joint Committee, our mayors, Regional Council chair and Iwi leaders said all the expected things about their determination to act upon the recommendations made. 

“What is clear is that as a region we need to be prepared to undertake a complete overhaul of our approach to civil defence to ensure that our communities are better prepared to manage or mitigate the devastating impacts of an event like Cyclone Gabrielle.

“To be clear, this is not about incremental change – we see this as a complete overhaul of how we approach emergency management in Hawke’s Bay, and we intend to establish a dedicated workstream to ensure this important mahi is fully resourced with the support and expertise needed to deliver meaningful change for all of our communities for the future.”

No point in regurgitating more of the rhetoric. What we now need to see is their action plan, which, like the review just completed, is to be informed by independent external advice.

The Joint Committee and review leader Mike Bush have been adamant that the review was not conducted to place blame. 

As the Report observed regarding formally declaring an emergency (which confers considerable power to local officers): “The key decision makers were human and thus fallible. They reflected carefully on the matter and made the best call they could at the time. They asked the right questions. They tried hard to take multiple perspectives into account.” 

From reading the record and talking to participants, the same could be said of decision-making throughout the immediate response.

It’s disappointing that some media would focus on ‘heads falling’, as in the case of TV3’s reporting, which went to the extreme of specifically targeting two individuals.

Individuals didn’t fail during this event. In fact heroic efforts were made inside and outside local government. The word that comes up over and over is “overwhelmed”.

Nature dealt Hawke’s Bay – not just a single town or catchment – an unprecedented blow and is on a course to deliver more. Given that warning, we can be better prepared. It’s less clear that we can expect to be perfectly safe.