It took seven minutes for the man in charge of Westfield's emergency response to reach the control centre after the initial radio call for help during a fatal stabbing spree.
Scentre Group retail manager Joseph Gaerlan was the chief warden for Westfield Bondi Junction on the afternoon of April 13, 2024 when Joel Cauchi went on a rampage with a pigging knife.
In just over three minutes, he fatally stabbed six people and injured 10, including a nine-month-old baby.
Mr Gaerlan told an inquest into the tragedy the first radio broadcast from a distressed security guard came through at 3.33pm.
"Code black, code black, alpha, there's lots of blood, you need to hurry," he recalled her saying.
In the days after the stabbing, he reported that he heard there had been "a man with a knife" and a "possible fatality" during the call.
But he revised his statement after reviewing the CCTV, telling the inquest those terms would have triggered a "very different response" because they would have signalled an active armed offender situation.
He had been "highly emotional and highly stressed" when writing the initial statement and hadn't had time to reflect on the tragic events, the retail manager explained.
The call sparked confusion and he had been heading to verify what was unfolding when he received the first clear radio call confirmation that it was an active armed offender situation.
Mr Gaerlan said the radio traffic was congested with a "constant stream of messages" and it was difficult to transmit messages during the spree.
However, he decided not to direct everyone to move to a dedicated emergency radio channel.
After receiving confirmation of the attack, he radioed the control centre to contact police, make an announcement over the public address system and display an emergency warning on the digital screens.
The inquest was told announcements were not broadcast throughout the centre until 3.52pm - 14 minutes after Cauchi was shot dead by NSW Police Inspector Amy Scott.
Mr Gaerlan was "immensely frustrated" about the lack of information surrounding the attack and only received confirmation there was a single offender who had been shot after reviewing CCTV.
He assumed that information was passed onto police but did not direct the control room operator to do so.
Despite receiving training in active armed offender scenarios just 11 days before the stabbing, he said he had never faced anything like the mass casualty event.
"I was terrified," Mr Gaerlan said.
"I was doing the best I could with the information I had coming through various sources at the time."
The inquest, which is examining the effectiveness of the security response to the mass casualty event, has been told alarms activated after Cauchi was shot were also incorrect.
The alerts told customers to evacuate, rather than to escape and hide due to an armed offender in the premises.
Security guards who responded to Cauchi's unprovoked rampage have been commended for their work, including Faraz Tahir, 30, who was fatally stabbed.
Dawn Singleton, 25, Ashlee Good, 38, Jade Young, 47, Pikria Darchia, 55, and Yixuan Cheng, 27, also died in the tragedy.
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