When the Aratere ferry ran aground in Picton Harbour, it wasn't clear who was leading the emergency response, Marlborough's harbourmaster says.
That's partly because it kept changing, and the handovers between agencies weren't "defined".
Harbourmaster Jake Oliver has presented his report into the grounding in June to the Marlborough District Council.
The report, presented to the council's environment and planning committee on Thursday, had 26 recommendations. Work had already started on some of them.
The Interislander ferry ran aground about 9.30pm on 21 June in Titoki Bay. KiwiRail, Maritime NZ and the Transport Accident Investigation Commission (TAIC) were still investigating the incident, which was potentially down to an issue with the ferry's autopilot.
Oliver said it was lucky the ship grounded where it did.
"It was a very fortuitous location they chose; a soft sediment beach, the rocks are further away, they did it in 4 knots of wind, and they did it pretty much on high water," Oliver said.
One councillor joked it was as if the grounding was a simulation.
Oliver's report said police were initially the lead agency for the incident, but it was not clear where or how they were doing that.
"To the best of the Marlborough District Council's team knowledge, police had not stood up an incident control point."
During the response, it became apparent police were standing down as the lead, but there was no defined handover to another lead agency, Oliver said.
When there were concerns of a "Tier 2" marine oil spill, the lead agency became the council. However, they were packed into the harbourmaster's office in Mariner's Mall, which wasn't big enough for them.
Oliver questioned whether future responses should be run out of Blenheim, rather than Picton.
Meanwhile, the overall lead agency in respect of the grounding was not clear, his report said.
Oliver's report said the council's media team saw reports that Maritime NZ was managing the incident. Maritime NZ had been in touch about the oil spill but had not sought "situational awareness" from the harbourmaster.
While support from the Maritime NZ response team based in Auckland and Wellington was instrumental, it did not last long, Oliver said.
That left a "notable burden" on the council's team.
"The burden is exacerbated by the return to normal operations and running of the harbour, whilst the ongoing clean-up both of equipment and processing of incident documentation must continue."
Oliver's report, based off debriefs with the council's team, Coastguard, Civil Defence and others, also highlighted problems such as a "vulnerability" in communications due to a reliance on mobile phones, and a call for an investigation into handheld radios capable of secure communication.
The report also called for a "fatigue management plan" and policy to guide teams during a response.
'Always going to be incidents'
Some of the recommendations, such as upskilling staff, had already started.
"The nature of the business we're in, in shipping, is there is always going to be incidents," Oliver told the council committee.
"So we have a good opportunity here from a large scale incident ... to give us lots of really good learnings as council and a team.
"Council can be the lead agency for oil spills, but we're not the lead agency for grounding.
"So one of the parts of the work we're doing with Maritime [NZ] is about establishing who's going to run the show and who is leading this."
More tabletop exercises were floated for training, and there was a call to ensure the harbourmaster's team all had a skipper's licence.
A formal handover needed to occur if a new agency took over, there should be upgrades to the navigation warning system and marine emergency manual, and Oliver also suggested finalising a drone company contract for future events.
Some of the recommendations in the report would be scoped before being brought back to council for approval.
LDR is local body journalism co-funded by RNZ and NZ On Air.