Two hours into an i-Catcher excursion in September 2022 the boat capsized off Good Bay, killing five of the 11 passengers. Photo: Supplied / Transport Accident Investigation Commission
A boat capsize that claimed five lives off Kaikōura has shown up failings in the outdated 111 emergency call system yet again.
The boat of a bird-watching party hit a whale off Goose Bay and turned over, trapping five of the 11 people in a fume-filled pocket underneath. They knocked on the hull for a few minutes.
The skipper up on the overturned hull called police but the 111 system caused "unnecessary delays" and risks.
Then, when police tried to give ambulance the accident's coordinates, a second fragmented tech system, called CARD, would not accept it because the sea is outside usual ambulance range.
Instead, CARD produced "an error message". The system has a years-long track record of similar outages as it is fragmented between police and ambulance, as RNZ reported in 2024.
Successive governments have been warned the 111 and CARD systems are flawed.
But the capsize inquiry released on Thursday stated, "the emergency 111 system ... introduces delays to the emergency response".
"No action has been taken to address this safety issue."
The Transport Accident Investigation Commission (TAIC) chief commissioner David Clarke said there were "delays in the system, there was restricted information flow and incompatibility of systems".
"While it's unlikely that any of these issues contributed to the outcome of the tragedy in this case, in other circumstances, these delays could be critical," he said.
Upgrade shelved
An upgrade project of the systems was shelved by the previous government and has not gone ahead under this government, under funding pressures.
RNZ reported last year on internal advice to government about the systems' deficiencies causing actual harm, for instance, a woman stabbed to death by a partner who overheard her making a 111 call. If the system could take text this could have been averted.
A business case in 2023 said the restriction to phone-only requests and poor integration between apps and agencies was "risking lives, health and wellbeing".
The system broke down 59 times in the year 2021-22.
RNZ has approached Police Minister Mark Mitchell and police for comment.
Fourteen months ago Mitchell said, "It has become obvious to us as the incoming government the police have not had core functions funded properly and I am working with the police executive on solutions to that."
RNZ has asked what he and police have achieved since then.
Prime Minister Christopher Luxon said in 2024: "We know there are challenges to that triple-one system, I know the Minister's all over it."
The capsize preceded this, however, the new TAIC findings said:
"The communication and resource deployment (CARD) platforms of the three emergency services [police, ambulance, fire] are not integrated, which delays and restricts the flow of information necessary to coordinate a multi-agency response.
"No action has been taken to address this safety issue."
The boat that capsized off the coast of Kaikōura in 2022, killing five people. Photo: Supplied/Transport Accident Investigation Commission
Clarke said the people involved in the rescue worked together "in the best way possible and presented an integrated response", but were delayed by the systems.
TAIC was calling for reviews and improvement by police, MBIE and the Next Generation Critical Communications Agency, or NGCC, he added.
NGCC has been working since 2020 on a billion-dollar-plus Public Safety Network based on digital radios. But this is complementary to and not a substitute for 111 and CARD.
"The commission has recommended that NGCC lead the establishment of a common communication platform for emergency services, to support the sharing of inter-agency communications during a response," the TAIC report said.
One minute, eight seconds
The report shows it took one minute and eight seconds for the skipper's 111 call to make it from the first calltaker to the second stage. The police target is just 10 seconds.
When the first calltaker asked the skipper what emergency service he wanted, he replied, "You tell me, we're capsized and we're off the coast of Goose Bay, Kaikōura."
"The design of the two-stage system created unnecessary delay and increased the risk of a call being dropped before the caller had explained their emergency to police," the findings said.
"When this occurs the [calltaker] can provide police with a verbal summary" but not with a recording of the 111 call unless police have a warrant.
"For the public it is not always clear who the most appropriate emergency service is, and often multiple agencies are required to attend. This confusion could result in callers selecting the wrong emergency service, delaying the response," TAIC said.
When CARD failed to accept the coordinates, police had to do a workaround and call the ambulance service verbally.
The fragmentation problem then affected the Coastguard. "To connect to the ambulance CARD platform, police searched for the nearest land-based address to the accident and entered it into the system. Later, when Coastguard contacted the police emergency comms centre seeking the coordinates ... the location in the system had to first be changed back to the original coordinates.
"As a result, Coastguard was informed that the accident occurred in Goose Bay, but the coordinates provided were for a different location."
NGCC told TAIC on 25 March its priority was to deliver the Public Safety Network.
But it was also "actively engaging with stakeholders looking at how NGCC might evolve in due course, including to support government priorities regarding strengthening New Zealand's broader public safety and emergency management communications capability and connectedness".
"This will consider future users of our current Public Safety Network services and whether and how we might develop further technologies. We will remain in contact with you as we make progress in considering the recommendation."
Police have previously told RNZ the three services were making improvements to CARD.
"We are focused on improving processes within the confines of our current systems," it said in February 2024.
The agency said yesterday it was working with Rescue Co-ordination Centre on the findings of the Goose Bay report.
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