The death of a soldier who drowned when he fell off a boat during a training exercise on a lake was accidental but could have been prevented, a Court of Inquiry has found.
Private Michael Ross, 29, died at Lake Moawhango near Waiouru on September 25 last year.
The findings of a Court of Inquiry were released today.
It found that while his death was accidental, personnel not adhering to a number of appropriate safety procedures contributed to the accident and the drowning, and it could have been prevented.
"The NZ Defence Force is taking this tragedy seriously, and is striving to improve its processes and practices to minimise the risk of an incident of this nature occurring again in the future," Chief of Army Major General Dave Gawn said.
"While the nature of our jobs requires that service personnel are often put in dangerous or risky situations, this is not an excuse for a training accident during which safety procedures were not followed correctly," he said.
"Our thoughts are with the family of Private Ross during what will be a difficult time for them."
As a result of the Court of Inquiry, the Defence Force is implementing a number of measures in an effort to prevent or minimise further accidents, specifically around Army waterborne activities. These include:
a) The Royal New Zealand Navy becoming the 'centre of excellence' for all small boating watermanship across the three Services.
b) The Maritime Operational Evaluation Team will validate the revised Enhanced Infantry Company watermanship procedures.
c) The Royal Australian Engineers will conduct an Audit of our Safety in Training Procedures across a number of Engineering fields, including small boating.
d) New safety guidelines governing the use of Zodiac and other similar boats have been developed with associated detailed briefing and training requirements.
e) Propeller guards have been installed on safety boats and are being investigated for all boats.
f) Water temperature will be monitored and when required access to Water Immersion Suits made available.
g) A check of all NZ Defence Force lifejackets has been completed. Procedures have been revised for equipment checks.
h) The modification of the Mustang lifejacket, which is an auto-inflating lifejacket, has been completed. These lifejackets have been re-certified for use by Army personnel and re-issued.
i) All personnel are being retrained in the emergency operation of lifejackets while under stress and new lifejacket training processes are being introduced.
j) Measures to ensure personnel remove unnecessary equipment whilst in small boats have been reinforced. Additional emergency related equipment such as knives and marine radios have been issued.
k) Extant man overboard drills are being reinforced in training, as are crew duties of those in Zodiacs and safety boats.
A Health and Safety review has also been instigated to address any deficiencies in safety management and a Military Police investigation into the incident remains ongoing.