Findings from first phase of Whakaari inquest ‘valuable’, but questions remain for bereaved families

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Source: Radio New Zealand

Anna Adams, is the Counsel assisting the Coroner for bereaved families and survivors. (File photo) RNZ/Calvin Samuel

The first phase of the coronial inquest looking into the 2019 Whakaari/White Island eruption has drawn to an end.

Twenty-two people died and 25 people were injured, most of them seriously, after they were on the island when it erupted on 9 December 2019, sending ash 3.6km into the air.

The bodies of two victims were never recovered.

Phase one of the inquest, which began in October 2025, focused on the emergency and medical response.

Counsel for bereaved families and survivors, Anna Adams said while the first phase had been valuable, for the bereaved families and survivors to properly understand the events that day, questions still remained.

“Was it ever appropriate to run tours to White Island during volcanic alert level 2, where the best rescue that could be achieved in the event of an eruption was an 83 percent civilian rescue?

Whakaari/White Island during the eruption. (File photo) Supplied/Auckland Rescue Helicopter Trust

“Was the official civil defence and police plan that after an eruption tour operators would self-evacuate ever appropriate given how heavily this relied on people who may or may not have had rescue and first aid training?”

Adams said it was acknowledged the plan to have the operators self-evacuate was in practice the fastest way to get everyone off the island and to medical treatment that day.

“However, the bereaved families and survivors continue to express surprise and disappointment that this plan was considered acceptable by government agencies because it relied so heavily on people who may not be trained or available.”

Adams said she’d submitted that the Coroner could make a recommendation regarding the manner in which scientific or technical advice was communicated to the emergency services in connection with high-risk volcanic activities in New Zealand.

Phase two of the inquest would start next year and explore the events the day before the eruption and whether victims had enough information about the risks of a potential eruption.

“Many of the families and survivors continue to hold the view that they should not have been present walking in the crater of the Whakaari Island volcano that day,” Adams said.

Recovery teams heading to the island. (File photo) Robin Martin

“Or at least they should not have been as under-informed about the risk, under-prepared for an eruption, and under-protected by the clothing and equipment as they were.

“It is the families’ hope that New Zealand learns from this experience, so that we better protect the people who tour this country, especially when engaging in adventure activities, and so that we do not have another tragedy like that which befell the 47 people visiting Whakaari,” Adams said.

While giving their closing submissions, counsel representing numerous agencies admitted there were communication issues experienced in the emergency response.

It’s been clarified many of these technical communication issues had since been fixed and updated.

One of the issues on the day which was explored at the inquiry was an InterCAD notification failure between the police and St John.

InterCAD was a system that allowed essential information provided by 111 callers to be shared immediately between police, the fire service and ambulance.

The Coroner’s inquiry heard issues caused an approximately seven-minute delay in the notification of the eruption to St John.

There was also evidence of a 13-minute delay between police communications receiving the 111 call about the eruption and transferring the job to InterCAD.

Other communications related problems included the lack of a police radio at The Emergency Operations Centre (EOC) in Whakatāne which also dealt with cellphone reception and wifi internet connectivity issues.

Counsel for police, Anna Pollett, said they’d support a recommendation that a plan for an emergency response, multi-agency or otherwise, ought to be one plan.

“So rather than have multiple plans for every eventuality, having a knowledge of what expertise may be required and what is available in each circumstance may be beneficial in the future.

“This would allow consistent training of all personnel within all agencies nationwide to be more streamlined and consistent to allow for a unified approach.”

It was established during the inquiry, that Civil Defence was considered the lead agency during the emergency response, but police would be the lead agency in the search and rescue operation.

Examples of “double handling” and key information not being communicated between agencies in the crucial first hours after the eruption was highlighted.

“Defined layers of decision-making and control may be beneficial in the future. It also highlights the need for personnel to be designated for high-level communications, both upwards and downwards,” Pollett said.

“Immediate responders were challenged by the information requests being made while they were all feet on the ground to be responding to everything going on to rescue those from the island.”

Counsel for Bay of Plenty Emergency Management Amanda Gordon said they had submitted similar recommendations to the Coroner.

Gordon said evidence showed there was confusion about the terminology used in the response to the eruption.

“It’s clear that there was some confusion about who was the lead agency and the different terminologies of incident controller or local controller.

“From the group’s point of view, it’s not suggested, and the evidence doesn’t bear this out, that the confusion had any impact on the response.”

Gordon said there was a strengthening emergency management legislative reform process going on as a result of the North Island severe weather event inquiry.

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– Published by EveningReport.nz and AsiaPacificReport.nz, see: MIL OSI in partnership with Radio New Zealand

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