OPINION: Coronial inquests are a court of bitter experience.
In that respect the inquiry into the Canterbury Television building collapse is proving much more than just a sorrowful exploration of things that went wrong.
It is not about naming and shaming, or just a therapeutic venting of reproach and recrimination.
Corpses and survivors were hauled from that rubble at the time. Now its lessons that are being dragged painfully to the surface.
They stand as compelling warning that for all the personal bravery, compassions and passions of the professionals at the site, none of that amounted to anything approaching functional collective preparedness.
Amid the extremity of the disaster, these people scarcely knew what to do.
They certainly did not know how to do it together.
Even with Christchurch in such a state of widespread chaos, it was chastening to hear the in-hindsight acknowledgment from the first senior fire officer at the site that the book went "out the window".
The honesty of that comment can be accepted. But situations like this need to be where the book kicks in big-time.
We need a better book.
The coroner has heard of a lack of command and of a situation in which the person who spoke the loudest or seemed the most confident was listened to. Poor communication and a lack of resources at the site were a major frustration.
It appears that at times it was knowledgeable civilians stepping forward to plug abject failures of preparedness when the personnel supposedly trained for emergencies were presented with equipment they did not know how to use.
Attempts to use the expertise of a nearby Southern Demolition crew, notably boss Alan Edge, were hampered by the USAR officer who, the coroner was told, appeared overwhelmed by occupational health and safety concerns.
The coroner has heard conflicting evidence about whether the human chain lifting rubble should have been replaced by available heavy machinery which, though far more indelicate, could have shifted so much more.
An open police acknowledgment that they were not equipped or trained to deal with such an event is serious enough in itself. But the lessons learned go beyond that because there was scant sign that they were trained to mesh into a wider co-operational matrix. Or perhaps they were, but the matrix had ceased to exist.
Beyond question, those at the scene ached to get the people trapped under the concrete from three - say it with us, jerry-built - storeys to safety.
Survivors were texting their pleas for help. Above ground their loved ones were anguished. Such memories must be wretched to live with.
However much, or little, this may mitigate the personal sense of loss for those whose lives have been directly touched, abiding good may yet emerge from the tragedy.
The findings have the potential to guide authorities to a flat-out better understanding of what is required and how to achieve it.
We need that.
- © Fairfax NZ News
Will you attend an Anzac service tomorrow?