Byron Solomon loved the navy and loved being at sea. His parents knew their son's fledgling career on a warship carried a degree of risk.
But they assumed his employers took seriously their responsibility to minimise any hazards.
"Byron was entitled to carry out his duties in the knowledge that all practical steps had been taken to ensure his safety," his mother, Jayne Carkeek, told the inquest into his death last February.
He drowned in October 2007 when a patrol boat launching exercise went wrong with HMNZS Canterbury making just over seven knots in a moderate swell off Cape Reinga.
He was trapped in the lifting strops of a Rhib (rigid hulled inflatable) which broached and overturned while still hooked up to its hoisting davit and may have been knocked unconscious.
It took 25 minutes to extract him from the upturned boat, despite frantic efforts by crew who jumped from the moving ship in defiance of standing orders.
Coroner Brandt Shortland's findings, released yesterday, back the family's long-held conclusion that the loss of life was foreseeable and avoidable and resulted in part from the navy's "make-it-work" culture.
Nearly four years on, Mr Shortland has linked the tragedy to the haste with which the $177 million ship was rushed into service.
Byron Solomon, 22, was a promising trainee navigator who had won awards and the respect of his naval colleagues and superiors. He was also a son, a trout fishing buddy to his father, Bill, and a brother to younger sisters Nicole and Deborah.
"They have had to complete their studies without him," Ms Carkeek noted yesterday, in her East Auckland home where portraits of Byron with his sisters feature prominently.
"It has been a traumatic experience having Byron ripped from our lives," she said. "We are left with grief and anger, a surreal disbelief of the tragedy we are now living with."
His drowning was inevitable, she said. Discrepancies between the contract requirements for the new ship and the capabilities of the Rhib launch system were masked by certification errors and the navy was tasked with making it work.
The navy had a culture of unsafe work practices, which made the incident "inevitable".
Yesterday, she slammed the oversight of the project by the joint Ministry of Defence/NZ Defence Force team.
"They were weak, there was no leadership, and they were in over their heads."
She is pleased with Mr Shortland's findings that the death was unnecessary and preventable and that pressure to rush the ship into service contributed.
But she remains frustrated by restrictions on the coroner's ability to delve into issues which lay behind the failure of the Rhib launch system.
The dead man's father, Bill Solomon, while also pleased with the findings, wants to see those responsible held accountable for the flawed launching system installed by Tenix (now owned by BAE Systems), the certification failings by Lloyd's Register, the lack of technical expertise and oversight by the ministry and a navy culture which meant little was done about identified problems.
As to the coroner's suggestion that design and acquisition issues be resolved in a royal commission or other legal forum, the family are seeking advice about their next move.
"I would like to see someone held accountable," Mr Solomon said. "Nothing will bring Byron back but this should never have happened."
WHAT THE CORONER CONCLUDED
* Byron Solomon's death was unnecessary and preventable and has been linked to the haste with which HMNZS Canterbury was rushed into service.
* It happened just four months after the Ministry of Defence took delivery of the Canterbury from Australian prime contractors Tenix.
* The Canterbury was commissioned without the navy having the opportunity to familiarise itself with the boat. While individual components had been certified as fit for purpose, safety and reliability for the ship as a whole remained a significant issue.
* The coroner's key recommendation: "No naval ship or major military asset should be accepted into service until proper and credible trials are completed and have been critically reviewed."
* Last August, Mr Shortland "ringfenced" issues including design and contractual disputes, technical expertise and compliance issues which he said should be argued before a royal commission or other legal forum. The inquest's purpose was to establish the circumstances surrounding Byron Solomon's death.