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Act
LessoNZ Report
Information
Aerial Shot White Island and New Zealand Police's Deodar III. Photo: NZ Police
Official
the
under Whakaari/White Island
Volcanic Eruption
Response
Released
November 2020
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Authors
1982
LessoNZ Community of Practice
Act
Des Hosie, NEBOSH
National Operations Advisor – Safety, Continuous Improvement & Lessons
Management
Fire and Emergency New Zealand
Claire Pettigrew, BA, MMgmt, AMBCI
Information
Capability Development Advisor
National Emergency Management Agency (Secondment)
Advisor Business Continuity & Emergency Management
Ministry of Education
Official
Senior Sergeant Claire Bibby, MIntlSy
the
Continuous Improvement Advisor, Emergency Centres
New Zealand Police
under
Released
2
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Contents
1982
Purpose
5
Act
Executive
Summary
6
Part
I
Recommendations
7
Part
II
Background
9
Information
Part III Approach and Methodology
13
Part
IV
Findings
17
Official
Insights
19
the
Lessons
23
Part V Operation Deans – Recurrence of Lessons
24
under
Concluding
Comments
from
LessoNZ
29
Document
Information
30
Released
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A just culture is about balancing demands for
Act
accountability regarding failures with an ability to collect
enough information to make sense of the situation
to contribute to learning and safety improvement. A
non-judgmental just culture encourages learning and
maximises the potential for ongoing improvement.
Information
If stakeholders do not feel safe to speak up without fear
of ridicule or blame, or if others declaring a contrary
view challenge them, they can be discouraged from
sharing their experiences.
Official
the
Australian Government. (2019, p.11).
Lessons Management. Australian Disaster Resilience Handbook Collection.
under
Released
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Purpose
1982
This report has been prepared by
The report is in five parts:
Act
members of the LessoNZ community of
Part I is the recommendations
practice at the request of the Chair of the
Part II explains the background to the Whakaari/
Officials Committee for Domestic and
White Island event
Part III explains the Lessons approach and
External Security Coordination (ODESC).1
methodology that informed the recommendations
Part IV is the findings, including successes, insights
The LessoNZ community of practice was tasked
and lessons identified
to collate and assess key overarching themes and
Information
lessons identified during the National Security
Part V is an assessment of the lessons identified
System (NSS) activation for the Whakaari/White
for the Whakaari/White Island response with the
Island Volcanic Eruption which occurred on Monday,
recommendations of the
Post Operation Deans
9 December 2019, and produce a consolidated
National Security System Review. The assessment
summary report including recommendations.2
ascertained whether any Operation Deans
Official
recommendations resurfaced as lessons in the
This report is prepared for learning purposes and
Whakaari/White Island response.
does not apportion blame or criticism to any agency
the
or individual.
Operational demands to support the Covid-19
response have delayed an earlier release of this report.
The report includes:
Recommendations
under
The LessoNZ community of practice is
Insights and lessons identified in the Whakaari/
formed from personnel working across
White Island response
government agencies in the field of
An analysis as to whether issues identified in
continuous improvement. The group
the
Post Operation Deans National Security
meet several times a year to share
System Review (June 2019) reoccurred during the
experiences and learnings to improve
Whakaari/White Island response.3
operational practice.
Released
1 A committee of Chief Executives, which, during an emerging or actual security event, is responsible for providing strategic direction and coordinating the
all-of-government response.
2 Officials Committee for Domestic and External Security Co-ordination. (19 December 2019). Whakaari-White Island Volcanic Eruption, Inter-Agency Working
Group Meeting #2 [Minutes].
3 Operation Deans is the name given to the emergency response to the terrorist attack of 15 March 2019, in which 51 people in Christchurch lost their lives.
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Executive Summary 1982
Whakaari/White Island, off-shore from the The LessoNZ community of practice collated and
Act
Whakatāne township in the Bay of Plenty, assessed observations from 25 agencies that
responded to the eruption.
New Zealand, erupted at 14:11 New
Zealand Daylight Time on 9 December
Findings
2019.
The observations were summarised into nineteen
insights. Common themes were the need for better
Earlier that morning, the National Emergency
understanding of roles and responsibilities (eight
Management Agency (NEMA) had activated its
insights) concerns with the flow of information
Information
National Coordination Centre (NCC) in support
(six insights) and matters relating to resourcing
of a South Island Severe Weather event. Some
and capability (two insights). The insights were
government agencies were responding to both
developed into eight lessons that were further
emergencies.
developed into five recommendations.
Official
NEMA had only recently been established on 1
Included in agencies observations were positive
December, to replace the Ministry of Civil Defence
reflections on the themes of leadership and
& Emergency Management (MCDEM). The Scientific
professionalism, skills and expertise of individuals
the
and Technical Advisory Committee (STAC), an
and groups contributing to the whole, and systems
entity providing scientific and technical guidance to
and facilities that supported leadership and
response agencies and Incident Management Teams, enabled collegial support and teamwork. These are
was brought together for its first emergency event.4
summarised in this report as successes, or “what
under
worked well.”
In mid-December 2019, Government agencies were
asked to submit their reviews, debriefs and feedback The Whakaari/White Island lessons were assessed
from the Whakaari/White Island event, to LessoNZ,
against the recommendations from the
Post
to inform an analysis of the all-of-government
Operation Deans National Security System Review.
response to the event. This is the first time a Lessons It was found that the Whakaari/White Island
Management methodology has been used to inform
recommendations reinforce ten of the 18 Operation
continuous improvement across all-of-government
Released
Deans recommendations.
for a major emergency event.
4 STAC is the Scientific and Technical Advisory Committee for Hazmat (hazardous materials) and CBRNE incidents (chemical, biological, radiological, nuclear
and explosive). STAC is referenced in the
National Security System Handbook (2016, p. 14).
The National Counter Terrorism Standard Operating Procedures
Version 15 11 July 2016 (Draft, Restricted) informs that STAC is chaired by FENZ. The draft STAC charter (2019) informs that STAC is activated through the on
call National Commander, FENZ.
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Part I Recommendations
1982
Five recommendations for improvement Recommendation 2
Act
have been developed. These are
That the National Exercise Programme (NEP)
supplemented with guiding information. is reviewed to determine whether it is making
maximum use of lessons identified. This review
Recommendation 1
should take into account international best practice
and could consider:
That a comprehensive plan is developed to increase
Whether the current objectives contribute to
agency and community understanding of the
the implementation of identified lessons and
governance structure and functions of the National
recommendations post-exercise.
Security System (NSS), and the importance of the
Information
Whether the objectives could be more flexible,
information flow. This could include:
driven by a Continuous Improvement framework
The development of an accessible online
incorporating Lessons Management via
induction package for all personnel in central
evaluation of both exercises and emergency/
and local government and the general public
event responses.
about the relationship between the NSS, the
Official
How performance is evaluated in NEP exercises
Coordinated Incident Management System
and how lessons are identified and shared.
(CIMS) and the National Civil Defence Emergency
How exercise design could best support clarity
Management Plan (CDEM Plan). This induction
the
around lead agencies and other roles and
package could include links to the online NSS
responsibilities.
and CIMS handbooks.5,6
Training to facilitate understanding of the NSS
embedded into emergency management training
under
pathways and qualifications.
The provision of portable NSS and CIMS
handbooks for quick reference in the office
and Coordination Centres, to assist the agency
response.
5 An example of an accessible free training approach, is the anti-corruption training provided by Transparency International New Zealand. A free 1.5 hour
online learning module provides comprehensive anti-corruption training designed by leading experts in the field, and enables organisations to provide
Released
training for their personnel. Refer https://www.transparency.org.nz/anti-corruption-training/
6 Online reference material currently includes:
•
The National Security System Handbook which explains The National Security System, National Security Governance structures and NZ’s National
Security System in response to a potential emergency or actual event.
•
The New Zealand Coordinated Incident Management System (CIMS) handbook which describes how New Zealand agencies coordinate, command, and
control incident response of any scale, how the response can be structured, and the relationships between the respective CIMS functions and between
the levels of response
•
The National Exercise Programme objectives. The objectives allow for regular inter-agency exercises, which help prepare agencies (and communities) to
be able to conduct an effective response (and recovery planning) to a significant incident or emerging threat on and offshore.
•
The National Civil Defence Emergency Management Plan 2015, and its guide, which sets out the roles and responsibilities of everyone involved in
reducing risks and preparing for, responding to and recovering from emergencies. This includes central and local government, lifeline utilities,
emergency services and non-government organisations.
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Recommendation 3
Recommendation 5
Act
That the government invests in a national Lessons
That agencies recognise the importance of mental
Management system, including the establishment
health and well-being for those managing the all-
of national guidelines, a common language and
of-government response at higher levels and within
consistent practices.
coordination centres, and work together on a joint
Consideration could be given to interoperability
mental health and well-being plan during an event.
with international partners (for example
Supporting mechanisms could include:
Australia) who already have established Lessons
The consideration of psychological support
Management systems.
within the ‘Guidelines to support consistent CIMS
Information
The Lessons Management system should
implementation’ currently under development
have the NEP as a key component, with work
by NEMA.
programmes coordinated accordingly.
Lead agencies supporting a culture of mental
health and well-being at all levels, not just first
Recommendation 4
responders, within their Standard Operating
Official
Procedures and guidelines.
Invest in a "Common Operating Picture” and note
All agencies incorporating appropriate
this was also a recommendation in the Technical
guidelines, training and best-practice
the
Advisory group’s Ministerial Review
Better responses
psychological support into their higher-level
to natural disasters and other emergencies in New
management response (i.e. mental health and
Zealand (2018).7
well-being is for everyone, it’s not just for first
A Common Operating Picture will provide
responders).
standardised reporting templates and ways of
under
communicating to ensure everyone involved
provides, and receives, full, not partial
information.
A Common Operating Picture would support
enhanced information flows to Mayors and in the
public information/social media space – critically
important in an emergency.
Released
Families of victims of the White Island eruption were welcomed
and supported at a Whakatāne marae. Photo: Associated Press
7
Delivering better responses to natural disasters and other emergencies: Government response to the Technical Advisory Group’s recommendations (2018).
https://dpmc.govt.nz/our-business-units/ministry-civil-defence-emergency-management/ministerial-review-better-responses
8
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Part II Background
1982
Whakaari/White Island
Situation
Act
Whakaari/White Island is New Zealand’s most active
The Whakaari/White Island volcano erupted on
volcano and is located 48km off the North Island’s
Monday, 9 December 2019 at 14:11 New Zealand
Bay of Plenty coast, north-east of Whakatāne.
Daylight Time.
The island is approximately 2km in diameter, with 70 There were 47 people on the island at the time of the
per cent of the cone under the sea and the highest
eruption. These were:
point at an elevation of 321 metres. It is at the
Thirty eight passengers from the
Ovation of the
northern end of the Taupo Volcanic Zone. The main
Seas cruise liner operated by global cruise ship
Information
crater takes up much of the island, with the crater
company Royal Caribbean
floor less than 30m above sea level. Whakaari/White
Four White Island Tours guides (guiding the
Island has been active for at least 150,000 years.
cruise liner tourists)
One Volcanic Air helicopter pilot
Whakaari is within the traditional tribal area of Ngāti
Four tourist passengers of the Volcanic Air pilot.11
Official
Awa, who are based in the eastern Bay of Plenty.8
Whakaari is significant to Te Whānau-ā-Apanui iwi.9
There were 21 fatalities in total. Nineteen people
died in New Zealand and two people later died in
the
The island is a private reserve and has been owned
Australia. The fatalities were as follows:
by one family since 1936.
Five people were confirmed deceased on arrival
at Whakatāne
Prior to the eruption, Whakaari/White Island was a
Six deceased people were later recovered from
under
popular tourist attraction (more than 10,000 visitors
the island
annually) and visited by tour operators flying above
Two people reported missing have since been
and around the island, helicopters and boats landing
declared deceased
on the island, and boats mooring near the island.10
Eight people later passed away in hospital (six in
New Zealand, two in Australia).12
Released
8 Harvey, L. (2020).
Ngāti Awa - Origins, Te Ara - the Encyclopedia of New Zealand. http://www.TeAra.govt.nz/en/ngati-awa/page-1
9 Paora, R. (2020).
Te Whānau-ā-Apanui, Te Ara - the Encyclopedia of New Zealand. http://www.TeAra.govt.nz/en/te-whanau-a-apanui
10 Bay of Plenty Civil Defence Emergency Management Group. (2019).
Whakaari/White Island Response Plan. http://www.bopcivildefence.govt.nz/media/1362/
whakaari-white-island-response-plan-2019-operational-draft-eruption-9-december-2019-redacted-lgoima.pdf
11 NZ Police, personal communication, March 3, 2020
12 NZ Police, personal communication, March 3, 2020
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Experts from GNS Science identified the event as a
for the integration of iwi/Māori perspectives and
Act
phreatic eruption - a release of steam and volcanic
tikanga.15
gases that caused an explosion, launching rock and
ash into the air.
There were complexities to the central government
response, with different agencies leading on different
The ongoing seismic and volcanic activity in the area, aspects.
as well as heavy rainfall, low visibility and toxic gases
hampered recovery efforts over the week following
the incident.
National security challenges are often
Information
complex and cut across a range of
All-of-Government Response
agencies and sectors. When there is
ambiguity as to who should be the lead,
At the time of the eruption on Whakaari/White Island,
agencies are expected to consult with the
NEMA was already running its NCC in support of a
Chief Executive of DPMC at the earliest
South Island Severe Weather event.
opportunity in order to resolve doubt and
Official
confirm arrangements.
When the eruption occurred, the NEMA Duty Team
called in additional staff to support response
the
Department of Prime Minister and Cabinet. (2016, p. 19)
operations across the two events, with the NCC
National Security System Handbook
Activation Mode elevated to Mode 2 (Engage). On
Tuesday, 10 December, the NCC Mode of Activation
for the Bay of Plenty event was raised to Mode 3
From central government, NEMA was the lead agency
under
(Assist).13, 14
supporting the CDEM Group as per New Zealand’s
emergency management system arrangements. New
The Bay of Plenty Civil Defence Emergency
Zealand Police led the rescue and body recovery,
Management (CDEM) Group led the coordinated
with support from the New Zealand Defence Force.
response from Whakatāne, where they activated a
The Ministry of Health and District Health Boards led
combined local and regional Emergency Operation
the provision of medical treatment for victims.
Centre (EOC). Ngāti Awa was the iwi lead, providing
Released
13 The four Modes are 1 = Monitor, 2= Engage, 3 = Assist, 4 = Direct. The role of Mode 3 Assist role is, in addition to engagement activities, to process or
co-ordinate requests for support from regional and local organisations, including assistance from overseas, and international liaison and to report to or
advise Government. For further information about Modes, refer to
The Guide to the National Civil Defence Emergency Management Plan 2015. https://www.
civildefence.govt.nz/assets/guide-to-the-national-cdem-plan/Guide-to-the-National-CDEM-Plan-2015.pdf
14 Activation Modes and timings provided by NEMA, personal communication, May 6, 2020.
15 The Government aims for greater recognition, understanding and integration of iwi/Māori perspectives and tikanga in emergency management and
greater recognition, understanding and integration of the capacity and capability of marae to look after people in an emergency. For further information
refer to Chapter 4: Role of Iwi in the publication
Delivering better responses to natural disasters and other emergencies: Government response to the
Technical Advisory Group’s recommendations (2018). https://dpmc.govt.nz/our-business-units/ministry-civil-defence-emergency-management/ministerial-
review-better-responses
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This response was also the first opportunity for the
The NSS provides for a coordinated government
Act
recently re-established Scientific and Technical
response in which:
Advisory Committee (STAC) - an entity providing
Risks are identified and managed
scientific and technical guidance to response
The response is timely and appropriate
agencies and Incident Management Teams - to play
National resources are applied effectively
a role.
Adverse outcomes are minimised
Multiple objectives are dealt with together
The all-of-government response to the Whakaari/
Agencies’ activities are coordinated.17
White Island eruption lasted 11 days in total. The
Information
NCC remained operational until Friday 20 December
In order to support robust decision-making to
2019, when it was stood down for the Christmas
achieve the desired outcomes, over the course of
holiday period (but with enhanced duty and standby the all-of-government response, the NSS held two
arrangements in place).
ODESC meetings (10 and 11 December 2019), two
Watch Groups (10 and 12 December 2019) and two
National Security System activation
Inter-Agency Working Groups (12 and 19 December
Official
2019).
Crises or events that impact New Zealand or its
interests can occur at any time, and at a variety of
the
scales. The NSS is activated when one or more of the
following apply:
Recovery teams go through the
decontamination process after
Increasing risk, or a disaster or crisis, affects New
returning from Whakaari/ White
Zealand interests
Island. Photo: NZ Police
under
Active, or close coordination, or extensive
resources are required
The crisis might involve risk to New Zealand’s
international reputation
An issue is of large scale, high intensity or great
complexity
Multiple smaller, simultaneous, events require
Released
coordination
An emerging issue might meet the above criteria
in the future, and would benefit from proactive
management.16
16 Department of Prime Minister and Cabinet. (2016, p.40).
National Security System Handbook. https://dpmc.govt.nz/publications/national-security-system-
handbook-html
17 Department of Prime Minister and Cabinet. (2016, p.40).
National Security System Handbook. https://dpmc.govt.nz/publications/national-security-system-
handbook-html
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Diagram 2 National Security System roles and relationships in a crisis
Act
This can refer to either the full Cabinet
CABINET
Officials Committee for Domestic and
or a group of Ministers relevant to the
External Security Co-ordination - A
specific response.
committee of Chief Executives which,
during an emerging or actual security
event, is responsible for providing
ODESC
strategic direction and coordinating
A Watch Group may be called by the
Information
the all-of-government response.
DPMC’s National Security System
Directorate to monitor a potential,
WATCHGROUP
developing, or actual crisis. A Watch
Group provides situational clarity and
Lead agency means the agency with
is responsible for ensuring systems are
the primary mandate for managing
in place for effective management of
Official
the response to an emergency, as
complex issues.
LEAD AGENCY
legislated in the National Civil Defence
Emergency Management Plan Order
the
2015.
under
Released
Helicopter returns to Whakatāne
Airport after the body recovery
operation. Photo: DPA
12
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Part III Approach and Methodology 1982
Background to LessoNZ
from Ngāti Awa, private business, local government
Act
or community groups in the Whakatāne area. The
New Zealand does not have a national standard for
local debrief was led by Bay of Plenty Civil Defence
Lessons Management and unlike Australia, doesn’t
Emergency Management Group.
have a handbook with best practice guidance for
Lessons Management in disaster resilience.
In 2018, the emergency response sector recognised
Contributors
there was a keenness to enhance interoperability and Contributions were received from people
organisational learning and there was a willingness
representing the agencies listed below. It includes
to share lessons identified across agencies. As a
feedback from people seconded into centres
Information
result, the multi-agency LessoNZ community of
managing the event, for example, the National Crisis
practice was established in October 2018.
Management Centre (NCMC), Whakatāne EOC and
The group currently has 47 members from 25
the Police Major Operations Centre.
agencies representing emergency services, Defence
Accident Compensation Corporation including
and key infrastructure providers. Participation
Whakatāne Branch
Official
operates on the principle of trust (particularly in
Crown Law
matters of confidentiality) and a willingness to share
Department of Conservation
debriefs, reviews and lessons.
Department of Internal Affairs
the
Department of the Prime Minister and Cabinet
Data Collection
Ministry of Health
Fire and Emergency New Zealand
In mid-December 2019, Government agencies were
Immigration New Zealand
asked to submit their reviews, debriefs and feedback
under
Institute of Environmental Science and Research
from the Whakaari/White Island event, to LessoNZ, to
Ministry for the Environment
inform an analysis of the all-of-government response
Ministry of Business, Innovation and Employment
to the event.
Ministry of Foreign Affairs and Trade
Ministry of Justice
Constraints
Ministry of Transport
LessoNZ worked with the information provided
Ministry of Social Development
Released
to them by agencies responding to the request
Ministry for Primary Industries
to submit feedback. This consultation was at the
National Emergency Management Agency
high-level inter-agency response, not local level. As
New Zealand Customs Service
a result, there was no information received directly
New Zealand Defence Force
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New Zealand Police
observations, insights, lessons identified, lessons
Act
Oranga Tamariki
learned) to review and analyse the data. This method
State Services Commission
collates observations and uses a thematic process
Te Puni Kōkiri
to stream them into insights and lessons identified.
Tourism New Zealand
Recommendations were developed from the lessons
WorkSafe New Zealand.
identified.
Contributions were also received from people in
The agency reports, debriefs and feedback were
the Scientific and Technical Advisory Committee.
analysed for:
Information
Emerging trends
Observations from the Whakaari White
Issues that warranted highlighting
Island event
Success stories of what went well
As there is currently no all-of-government national
Opportunities for improvement.
standard or guidelines for capturing and submitting
Official
feedback for lessons, the observations received by
LessoNZ were varied in structure, detail and format.
the
Observations were obtained via the following
sources:
A dive search team at Whakaari/
White Island. Photo: NZ Police
A Lessons Observation Survey circulated
under
with an invitation to submit individual or
organisation observations
A dedicated email address provided for
submitting relevant documents and reports
that were not captured by the survey
Debrief sessions organised by National Security
System Directorate (NSSD).
Released
Methodology
Practitioners from the LessoNZ community
of practice used the OILL methodology (i.e.
14
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Diagram 1 Lessons Management
Act
COLLECTION
DEVELOP OBSERVATION
Risk Identific
ANALYSIS
Information
a
INSIGHT
tion
What LessoNZ
LESSONS IDENTIFIED
has done in this
Official
report
Next steps (for
ement and Sharing
ag
NSS consideration)
VALIDATION
Eng
the
IMPLEMENTATION & MONITORING
MONITORING & REVIEW
under
LESSONS LEARNED
Elements of a Lessons
LM Process
Management Process
OILL
Released
15
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The Lessons Management handbook
Act
for further analysis. Insights can be
(2019) for Australian Disaster Resilience,
positive or negative, and can contribute to
provides definitions to assist in
reinforcing positive behaviour or changing
understanding O.I.L.L terminology.18
practices. An insight defines the issue, not
the solution.
LESSON: A lesson is knowledge or
OBSERVATION: A record of a noteworthy
understanding gained by experience.
Information
fact or occurrence that someone has
The experience may be positive (a
heard, seen, noticed or experienced as
good practice) or negative (a gap in
an opportunity for improvement or an
performance or doctrine).
example of good practice.
LESSON IDENTIFIED: A conclusion with
Official
INSIGHT: A deduction drawn from the
a determined root cause based on the
evidence col ected (observations), which
analysis of one or more insights and a
needs to be further considered.the
viable course of action that can either
sustain a positive action or address an area
Insights occur when there are multiple
for improvement.
observations (pieces of evidence), which
are similarly themed. As a general rule,
under
LESSON LEARNED: A lesson is only
a minimum of three observations (from
learned once the approved change is
multiple sources) should be used for
implemented and embedded in the
an insight although an insight may be
organisation. Depending on the changes
developed when a single observation
required, it may take several years for the
poses a high risk to the organisation.
change to be institutionalised across the
Insights may also identify an opportunity
organisation.
Released
18 Australian Government. (2019, p.24).
Lessons Management. Australian Disaster Resilience Handbook Collection. https://www.aidr.org.au/media/1760/aidr_
handbookcollection_lessonsmanagement_2019.pdf
16
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Part IV Findings
1982
This part of the report covers successes
3. An agency noted that the importance placed
Act
(what worked well), insights, and lessons
on Tikanga Māori processes (the Maori way of
doing things) was valued. Early engagement with
identified.
Ngāti Awa was considered central to community
Successes
responsiveness and support.
Observations acknowledging things that went well
4. An agency noted that the early establishment of
during the Whakaari-White Island response centred
the Transport Recovery Team was proactive and
on three themes:
enabled the team to build agency relationships
Information
Leadership and professionalism
early, thereby enabling the effective handling of
Skills and expertise of individuals and groups
two concurrent significant events.19
contributing to the whole
Systems and facilities that supported leadership
5. An agency commented that the early
and enabled collegial support and teamwork.
establishment of an inter-agency Border working
group comprising of the New Zealand Customs
Official
The following successes were noted by
Service, Immigration New Zealand and the
contributing agencies:
Ministry for Primary Industries enabled a co-
the
ordinated approach and response.
1. An agency commented that bringing operational
agencies together in the EOC, close to the centre
6. The facilities arranged for the agencies providing
of the event, contributed greatly to the ability to
Welfare services worked well. The Welfare hub
develop and deliver the body recovery plan.
was established away from the centre of the
under
operational response and was appropriate in
2. STAC was valued by several agencies for its
the context of this event due to welfare staff
expertise, operational strengths and live
working directly with affected family members.
interaction with the operational teams at the
The hub was in a vacant building which had a
Whakatāne EOC.
large meeting space, smaller breakout rooms for
private interviews, a kitchen with fridge, WiFi-
connectivity, and a cleaning crew.
Released
19 The transport sector agencies involved in the Transport Recovery Team for the Whakaari/White Island response were the Ministry of Transport, the Civil
Aviation Authority and Maritime New Zealand (including the Rescue Coordination Centre for New Zealand). Two other transport sector entities were
involved in the response, although not part of the Transport Recovery Team. These were the MetService, for volcanic ash forecasts, and Airways New
Zealand who issued a Notice to Airmen (NOTAM) in accordance with Civil Aviation procedures for volcanic eruptions.
17
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7. Deploying a strategic communications group to
Act
work at the operational (front end) of the event
was reported by an agency to have worked well,
with the suggestion that this should be done
“STAC was able to pull
early in an event.
together expertise and best
8. An agency noted that the continuity of the liaison
practice advice at very short
officer, and other agency personnel, led to
notice, and to respond
improved inter-agency co-operation.
to a situation that posed
Information
9. Special mention was made of the:
unprecedented challenges.”
Leadership of the Police Acting
Superintendent who led the planning for the
- Observation
return to Whakaari and the body recovery
phase
Official
Bravery and professionalism of the NZ SAS
personnel who volunteered to return to
the
Whakaari to recover bodies.
under
Released
Rescuers land on New Zealand’s
White Island after a volcanic
eruption on 9 December. Photo:
Xinhua/Barcroft Media
18
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Insights
c) STAC provide valued scientific/technical advice
Act
and expertise to response agencies and Incident
Insights can be positive or negative and
Management Teams. Observations highlight that
can sustain a positive action or address
there wasn't a clear understanding internally and
an area of improvement.
externally as to the function or capabilities of this
team. This should be addressed to ensure better
outcomes in the future.
(Insight 5. Contributes to
Nineteen insights were formed into the following
Lessons 1 and 3)
themes:
Roles and responsibilities (eight insights)
Information
d) Observations reflect the eruption was a type
Information flow (six insights)
of event new to most of those involved in the
Resourcing and capability (two insights)
response. Given New Zealand's geothermal
Facilities, mental health and well-being and
make up, specific training around roles and
Continuous Improvement (one insight each)
responsibilities during volcanic events should be
considered along with taking the opportunity to
Official
Roles and responsibilities
allow for trainees to shadow key roles in incident
a) Observations highlight challenges identifying
management teams and in the NCMC to cater for
the
who was the lead agency in the early stages,
a greater spread of experience and succession
who were support agencies and who had
planning.
(Insight 8. Contributes to Lesson 5)
responsibility for some roles and whether it was
locally or nationally led. More education of senior e) Feedback indicates the application of CIMS worked
leaders is required on the CDEM Plan and the
well for this event. Feedback also highlighted
under
NSS Handbook which lays out the requirements
the need for a Memorandum of Understanding
for these roles and functions.
between First Response agencies and Iwi partners.
(Insight 2. Contributes to Lessons 1 and 2)
(Insight 12. Contributes to Lesson 2)
b) Observations indicate there is room for
f) The STAC has no formal processes, templates or
improvement in tasking, and follow up. There
Standard Operating Procedures. These are yet to
was confusion over who had responsibility for
be developed.
(Insight 13. Contributes to Lesson 1)
Released
tasking. Reference should be made to the current
CDEM Plan and NSS Handbook which state who
is responsible for what tasks to alleviate this
issue.
(Insight 3. Contributes to Lessons 1 and 2)
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g) Observations report conflicting reactions to some Information flow
Act
people in liaison roles at the incident. Some were i) Observations indicate the communication,
good and operated within the scope of their
actions agreed and accountabilities between
duties and some tried to take on more than they
agencies needs improvement. There was
were tasked with or capable of. This resulted in
no formal structure to some meetings and
some hard conversations that detracted from the
inconsistencies in recording or disseminating
good work being done. It is important that the
information from them.
(Insight 1. Contributes to
right people are appointed to these roles and the
Lessons 1, 2, 3 and 4)
functions and requirements of the role are clearly
Information
defined.
(Insight 17. Contributes to Lessons 1 and j) Observations point to some concern
2)
about information protection. Information
requirements were not clear to all external
h) Observations highlight there needs to be early
agencies, including the handling of distribution
engagement with the all-of-government group
lists. The absence of an all-of-government
of agencies. Some agencies felt they missed
Official
Common Operating Picture featured prominently
opportunities to be involved and add value
in the NEMA debriefs.20
(Insight 4. Contributes to
in their specialist areas. A list of agencies and
Lessons 3 and 4)
the
their responsibilities should be made available
to the lead agency for each event. It may not
k) Feedback from the NEMA debrief highlight that
be apparent at the start of an incident that the
the NCMC, although adequate in this response,
span of responsibilities may need to stretch to
is not truly fit for purpose as a national response
cover multiple phases in response and recovery
under
centre. There is a need for more workspaces,
and also have implications for other agencies.
breakout rooms, and easier access for support
This is especially true for services engaging with
staff. The ability to link directly with the Police
the community and Iwi liaison/Tikanga Māori.
National Command and Coordination Centre
(Insight 18. Contributes to Lessons 1 and 2)
Released
20 “A Common Operating /picture (COP) is a representation of relevant incident information that can be shared across relevant functions and agencies during
a response. A COP is achieved through a system of protocols, procedures and tools that facilitate shared awareness and understanding of the situation and
enable consolidated planning.” NZ Government. (2019).
Coordinated Incident Management System (CIMS). Officials’ Committee for Domestic and External
Security Coordination.
The Government’s response to the Technical Advisory Group recommendations relating to a Common Operating Picture can be found in the document
Delivering better responses to natural disasters and other emergencies. Government response to the Technical Advisory Group’s recommendations. August
2018. https://dpmc.govt.nz/our-business-units/ministry-civil-defence-emergency-management/ministerial-review-better-responses
These are R 3.4 (p. 24), Rec 7.1 (p. 35), R 7.2 (p. 36), R 8.1 (p. 38) and R 8.4 (p. 40).
20
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(NCCC), or running the NEMA and Police
Resourcing and capability
Act
responses side-by-side, and linking with the
o) Feedback from the NEMA debrief is that agencies
Whakatāne based EOC would have been more
were generally subject to resourcing constraints.
resource efficient and enhanced the response.
The matter of surge staffing and cross agency
(Insight 7. Contributes to Lesson 4)
resource sharing featured prominently along with
the issue of managing concurrent responses,
l) Observations highlight the high information
noting that dual responses have a strain on
demand at both public and official levels, and
resources. Dual responses functioning at
the importance of consistency of information
different paces require an appropriately balanced
Information
through a single source of truth. Challenges were
approach and while having the potential for
experienced catering to the international media
joined national reporting, this may not be the
that had no physical presence in New Zealand
right approach. Guidelines are required.
(Insight
because they couldn't attend media briefings.
11. Contributes to Lesson 5)
(Insight 9. Contributes to Lessons 4, 5 and 8)Official
p) Observations from STAC members highlight
m) Inaccuracy around the number and status of
the need for succession planning for prolonged
the victims was a continuous issue in the first
responses. This may require assistance from
the
few days of the incident with several agencies
overseas. This is also true for all specialist
reporting different figures. Unfortunately these
response positions where there is a limited
inaccuracies made their way into the public
pool available. Consideration could be given to
space.
(Insight 10. Contributes to Lessons 3 and 4)
creating a list of specialists that can be drawn
under
from across all government agencies.
(Insight 14.
n) Observations from STAC suggest a central
Contributes to Lesson 5)
document repository would ensure all relevant
information, inputs and outputs are captured
Facilities
and a directory of experts and their contact
details would be available. This may be relevant
q) Observations from the Welfare providers indicate
to all government agencies involved in an
the welfare hub concept, set up at a location
incident, to provide a consistent source of
near the Whakatāne based EOC, worked well
Released
information and prevent multiple tasking for
with a dedicated space to meet and deal with the
work already underway or completed.
(Insight
needs of whanau and the community. It could be
15. Contributes to Lessons 3 and 4)
beneficial if each CDEM area identifies suitable
spaces in their locality that could be utilised in
this way for future events.
(Insight 6)
21
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Mental health and wellbeing
Act
r)
Medics at Marae Photo: John
Feedback from the NEMA debrief indicate there
Boren Getty Images
was high appreciation for collegial (peer to peer)
support among staff. There was mixed feedback
about formal psychological support. While some
staff appreciate the presence and accessibility
of the Employee Assistance Programme (EAP
Services), some question the appropriateness
and timing of having EAP Services present in the
Information
NCMC. In some cases psychological support is
left to a person's home agency or is assumed
rather than confirmed and this appears to be
an area without clear agency responsibility
boundaries.
(Insight 16. Contributes to Lesson 6)
Official
Continuous Improvement Advisor
the
s) A key observation reported the opportunity for
Lessons Management/Real-Time Monitoring
when NCMC/NCC is stood up by providing
a neutral observer rostered on for lessons
management/observations/immediate
under
White Island Memorial Flowers.
efficiencies.
(Insight 19. Contributes to Lesson 7)
Photo: John Boren Getty Images
Released
22
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1982
Lessons
LESSON 5
Act
There is a shortage of well-trained and capable staff
The 19 insights were developed into eight who can surge across to support the lead agency
lessons. These lessons in turn inform the and operate in responses to different hazards
recommendations.
(while being mindful of the need for agencies to
also manage their own response) and a system that
enables this.
(Contributes to Recommendation 1 and
LESSON 1
2)
It is important that roles and responsibilities
between agencies, coordination centres and incident
Information
LESSON 6
management team functions are identified early
Formal psychological support for those involved
in the incident and made visible to all involved.
in the response should be accessible, appropriate
(Contributes to Recommendation 1 and 2)
and well-timed, with clear agency responsibilities.
(Contributes to Recommendation 5)
LESSON 2
Official
Responsibilities of agencies and Iwi at the
LESSON 7
operational level and the governance level need to
A real-time and independent continuous
be clearly delineated and consistent with the CDEM
the improvement advisor embedded in the response
plan, the NSS handbook and the CIMS manual.
structure would enable the early identification
(Contributes to Recommendation 1 and 2)
of inefficiencies, issues, and concerns, and allow
for timely continuous improvement advice that
LESSON 3
under
takes into account lessons previously identified.
Agencies need clarity about how information
(Contributes to Recommendation 3)
flow works, to ensure information is reaching the
right people at the right place at the right time.
LESSON 8
(Contributes to Recommendation 1 and 4)
A more visible and integrated system is required
to manage the relationship with international
LESSON 4
media and international inquiries.
(Contributes to
The ability to share information in real-time in a
Released
Recommendation 4)
virtual environment between the National and
Regional Coordination Centres (i.e. between the
NCMC at Parliament, the Police NCCC and the
Whakatāne EOC) would have been more resource
efficient and enhanced the response.
(Contributes to
Recommendation 4)
23
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Part V Operation Deans – Recurrence of Lessons1982
This part relates to an assessment of
Within the grouping, Recommendation 3 and 18 from
Act
the eight Whakaari/White Island lessons
the Operation Deans review resurfaced the most
often in the Whakaari/White Island lessons. These
against the 18 recommendations from
are:
the
Post Operation Deans National
Operation Deans Recommendation 3, which is
Security System Review.
about improving agencies understanding of the
National Security System
The intent of this assessment is to ascertain whether
Operation Deans Recommendation 18, which
the Operation Deans recommendations resurfaced
relates to agencies streamlining information
Information
as lessons identified in the Whakaari/White Island
about the status of victims.
response.
Key Findings
The Whakaari/White Island recommendations Official
reinforce ten of the 18 Operation Deans
“The event emphasised the
recommendations.
importance of the Tikanga
the
The Operation Deans recommendations, which
Māori process in response
resurfaced as lessons identified in the Whakaari/
White Island response, are demonstrated on pages
and recovery.”
- Observation
25-28.
under
Released
People wait to be evacuated
amid smoke from the volcanic
eruption of Whakaari, on Monday,
December 9, 2019. Photo: Via
social media via Reuters
24
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LESSON 1
LESSON 2
1982
It is important that roles and responsibilities
Responsibilities of agencies and Iwi at the
between agencies, coordination centres and
operational level and the governance level need
Act
incident management team functions are
to be clearly delineated and consistent with the
identified early in the incident and made visible
CDEM plan, the NSS handbook and the CIMS
to all involved.
(Contributes to Whakaari/White
manual.
(Contributes to Whakaari/White Island
Island Recommendation 1 and 2)
Recommendation 1 and 2)
OPERATION DEANS
OPERATION DEANS
Recommendation 13
Recommendation 3
Information
Reinforce with lead agencies that, in the context
DPMC and the MCDEM [NEMA] to collaborate
of an ODESC-led or emergency management
on ways to improve agencies understanding of
initiated response, responsibility for coordinating
coordination mechanisms, including through the
the welfare services function rests with MCDEM
second edition of the NSS handbook; forums,
[now NEMA] at the national level, and CDEM
conferences and training events; and the NEP.
Official
Groups at the regional and local levels.
Recommendation 4
Recommendation 14
The NEP to plan exercises based on responses
the
Confirm which agency should be responsible for
led by agencies from outside the NCMC.
the broader social environment, particularly in
transitioning to recovery.
Recommendation 13
Reinforce with lead agencies that, in the context
under
Recommendation 15
of an ODESC-led or emergency management
Ensure transition of responsibility of welfare
initiated response, responsibility for coordinating
functions to a lead agency is clearly identified
the welfare services function rests with MCDEM
and understood when the ODESC response
[NEMA] at the national level, and CDEM Groups
phase concludes.
at the regional and local levels.
Recommendation 14
Released
Confirm which agency should be responsible for
the broader social environment, particularly in
transitioning to recovery.
25
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LESSON 3
LESSON 4
1982
Agencies need clarity about how information
The ability to share information in real-time in a
flow works, to ensure information is reaching
virtual environment between the National and
Act
the right people at the right place at the right
Regional Coordination Centres (i.e. between
time.
(Contributes to Whakaari/White Island
the NCMC at Parliament, the Police NCCC and
Recommendation 1 and 4)
the Whakatāne EOC) would have been more
resource efficient and enhanced the response.
(Contributes to Whakaari/White Island
OPERATION DEANS
Recommendation 4)
Recommendation 3
DPMC and the MCDEM [NEMA] to collaborate
Information
on ways to improve agencies understanding of
OPERATION DEANS
coordination mechanisms, including through the
Recommendation 5
second Edition of the NSS handbook; forums,
ODESC to review processes for sharing
conferences and training events; and the NEP.
information outside of the core response
agencies.
Recommendation 5
Official
ODESC to review processes for sharing
Recommendation 18
information outside of the core response
the
The Ministry of Foreign Affairs and Trade, NZ
agencies.
Police, Ministry of Business, Innovation and
Employment, and the Department of Internal
Recommendation 17
Affairs to consider how to streamline information
DPMC will incorporate lessons learned into the
sharing about victims of mass casualty events.
under
work programme underway to reinforce the
core areas of cooperation that need to exist
between central and local government in times
of emergency response.
Recommendation 18
The Ministry of Foreign Affairs and Trade, NZ
Released
Police, Ministry of Business, Innovation and
Employment, and the Department of Internal
Affairs to consider how to streamline information
sharing about victims of mass casualty events.
26
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LESSON 5
LESSON 6
1982
There is a shortage of well-trained and capable
Formal psychological support for those
staff who can surge across to support the lead
involved in the response should be accessible,
Act
agency and operate in responses to different
appropriate and well-timed, with clear agency
hazards (while being mindful of the need for
responsibilities.
(Contributes to Whakaari/White
agencies to also manage their own response)
Island Recommendation 5)
and a system that enables this.
(Contributes to
Whakaari/White Island Recommendation 1 and
2)
NIL recommendations
OPERATION DEANS
Information
Recommendation 1
The National Exercise Programme to continue
to run exercises focused on non-natural hazards
emergencies, to allow agencies to practise their
response.
Official
Recommendation 4
the
The National Exercise Programme to plan
exercises based on responses led by agencies
from outside the National Crisis Management
Centre.
under
Recommendation 16
All government agencies to continue active
efforts to build capability so that they can
better understand and deliver for the diverse
Tribute to victims of the Whakaari/White Island eruption near
communities they serve.
the port of Tauranga berth cruise ship Ovation of the Seas, which
carried passengers who travelled to the volcano when it erupted.
Photo: John Boren, Getty Images
Released
27
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LESSON 7
LESSON 8
1982
A real-time and independent continuous
A more visible and integrated system is required
improvement advisor embedded in the
to manage the relationship with international
Act
response structure would enable the early
media and international inquiries.
(Contributes
identification of inefficiencies, issues, and
to Whakaari/White Island Recommendation 4)
concerns, and allow for timely continuous
improvement advice that takes into account
lessons previously identified.
(Contributes to
OPERATION DEANS
Whakaari/White Island Recommendation 3)
Recommendation 11
Following the review, the Disaster Victim
Identification Committee to provide
OPERATION DEANS
information for domestic and international
Information
Recommendation 3
audiences on disaster victim identification
DPMC and the MCDEM [NEMA] to collaborate
processes in New Zealand.
on ways to improve agencies understanding of
coordination mechanisms, including through
Recommendation 18
the second Edition of the National Security Official
The Ministry of Foreign Affairs and Trade,
Handbook; forums, conferences and training
NZ Police, Ministry of Business, Innovation
events; and the NEP.
and Employment, and the Department of
the
Internal Affairs to consider how to streamline
Recommendation 17
information sharing about victims of mass
casualty events.
DPMC will incorporate lessons learned into the
work programme underway to reinforce the
under
core areas of cooperation that need to exist
between central and local government.
Released
28
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Concluding comments
From LessoNZ
1982
The Whakaari/White Island volcanic
The Lessons Management approach is that of a
Act
eruption on Monday, 9 December 2019
non-judgemental just culture, which encourages
learning and maximises the potential for ongoing
presented extraordinary challenges for an improvement. Therefore, we were heartened by
all-of-government emergency response. the observations received from the government
The rescue of people and recovery of
agencies. They spoke of a commitment to working
bodies from an active volcano on an off-
together, getting it right, and collegial support.
At the same time, the agencies were open and
shore island was unprecedented in New
honest in their feedback about the gaps and where
Zealand.
Information
improvements could be made.
The ongoing seismic and volcanic activity in the area The five recommendations should now be formed
as well as heavy rainfall, low visibility and toxic gases into an implementation plan, which is monitored
hampered recovery efforts over the week following
and reviewed, so that continuous improvement of
the incident.
the National Security System is realised.
Official
There were 47 people on the island at the time of the Acknowledgments
the
eruption. Twenty one people died.
The authors from LessoNZ would like to thank the
The Chair of the Officials Committee for Domestic
government agencies for sharing their observations,
and External Security Coordination invited the
LessoNZ members Charlotte Penman, Ministry of
LessoNZ community of practice to collate and assess Transport and Shane Briggs, Oranga Tamariki for
under
key overarching themes and lessons identified
contributing to early analysis work, and Marika
during the National Security System activation for
Hughes of the National Security Systems Directorate
the Whakaari/White Island volcanic eruption and
for her guidance and commitment.
produce a consolidated summary report including
recommendations.
Released
29
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Document information 1982
Document details
Act
Criteria
Details
Document title:
LessoNZ Report, Whakaari/White Island Volcanic Eruption Response
Document writer:
Claire Bibby, NZ Police for LessoNZ Community of Practice
Document designer:
Sabrina Turner, NZ Police
Information
Document approver
Name
Title
Organisation
Official
Director
Dept. Prime Minister &
Marika Hughes
National Security Systems Directorate
Cabinet
the
under
Released
White Island aerial photo
after it's eruption. Photo:
George Novak, New
Zealand Herald
30
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1982
Document acronyms
Act
Acronyms
Description
CDEM
Civil Defence Emergency Management
DPMC
Department of Prime Minister and Cabinet
EAP
Employee Assistance Programme Information
EOC
Emergency Operation Centre
GNS Science
Institute of Geological and Nuclear Science Limited
NCC
National Coordination Centre
Official
NCCC
National Command and Coordination Centre
NCMC
National Crisis Management Centre
the
NEP
National Exercise Programme
NSSD
National Security System Directorate
under
NEMA
National Emergency Management Agency
ODESC
The Officials Committee for Domestic and External Security Coordination
STAC
Scientific and Technical Advisory Committee
Released
31
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1982
Act
Whakaari/White Island Volcanic Eruption Response
November 2020Information
Official
the
under
Released
LessoNZ Report
32
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