Internal probe tears apart rule-breaking and risk-taking culture of service.
The air force's safety record was torn apart in an internal investigation into the Anzac Day tragedy of 2010, according to a report which found it placed civilians at risk.
It was found to have "seriously endangered" the lives of all aboard an Air New Zealand flight to Vancouver and almost caused the death of two other civilians.
In those three cases, previous inquiries had recommended safety improvements which the air force had not put in place. In the other two cases, the failures had direct links to the Anzac Day 2010 helicopter crash which killed three servicemen.
The Accident Analysis Report was written by the air force's most experienced accident investigator, Squadron Leader Russell Kennedy. Mr Kennedy, and co-author Squadron Leader Andrew Cant, cast doubt on the ability of the air force to operate.
They stated: "The RNZAF does not have the appropriate and effective processes to adequately and reliably ensure safe and effective military air operations."
Chief of Air Force Air Vice-Marshal Peter Stockwell, in reply to Herald questions about air force safety, said: "In my role as Chief of Air Force I have not received any reports that have caused me to lose confidence in our ability to conduct safe air operations."
The Herald holds a document showing the vice-marshal is aware of the Accident Analysis Report.
The air force view is that the report was one of many which studied the cause of the accident.
It conceded large portions of the Court of Inquiry report were lifted from the far more damning Accident Analysis Report although some judgments were not accepted. The stark difference between the reports is one is damning of the entire air force while the report which was made public focuses closely on failings at 3 Squadron, the home squadron of the servicemen.
The Accident Analysis Report showed concerns far wider than issues with 3 Squadron - and told the air force it had a bad record for improving safety.
Serious concerns were raised about the Court of Inquiry process. The report stated the air force acted on only 47 per cent of formal orders to make specific changes which would improve safety over a 10-year period (see related story).
Under the heading "RNZAF Operation Culture", the report stated of rule-breaking and risk-taking culture "to some extent the attitudes are pervasive through the RNZAF".
"The investigation notes command is aware of the adverse operating culture and has been for some time." It described the problem as indicating "serious deficiencies in RNZAF operational processes".
It found problems with flight manuals and safety checklists which had still not been updated to reflect previous safety issues.
Investigators found "the RNZAF does not have a robust process to train flying supervisors".
It found no instructor guide even though the squadron's headquarters oversight was meant to make sure they were being kept up to date.
The probe also examined the audit process used by the air force, finding there was no way for higher command to have "any reliable indication of the quality of the processes and procedures used to plan and execute military air operations".
The report found the system used for dealing with "Flight Safety Events" failed to function. A backlog of reports stretching months beyond what the process allowed, lead investigators to find "the RNZAF does not have an effective process to investigate and achieve meaningful action as a result of flight safety events".
The air force has repeatedly stood by the Court of Inquiry as a rigorous process - briefing notes released under the OIA show military leaders were prepared to deal with questions about investigating itself.
The answers leaned largely on the reputation of Squadron Leader Kennedy. The work by Mr Kennedy led to a formal recommendation that a wider inquiry be undertaken into air force safety.
In a letter to the Herald, defence force chief Lieutenant General Rhys Jones said no wider inquiry had taken place.