Labour defence spokesman Phil Goff is calling for an independent ministerial inquiry into safety in the Defence Force after an investigation into the drowning of Linton soldier Michael Ross.
The inquiry found multiple failures, including a faulty lifejacket and problems with two army boats contributed to the death in Lake Moawhango near Waiouru in September.
"There are so many things that didn't happen that should have happened – put that on top of the Anzac Day helicopter crash and serious questions need to be asked," Goff said.
"Were rules broken because morale was shot or are there too many inexperienced and not enough experienced people left?"
A range of inquiries into Ross' death were already underway, but what was needed was an overarching inquiry into safety in the Defence Force (NZDF), Goff said.
That should be by someone independent of the NZDF who was prepared to "tell it like it is" to Defence Minister Jonathan Coleman.
Coleman has received an interim report of a Court of Inquiry into the death during a training exercise, which showed it was "entirely preventable".
He said it will reveal some "painful lessons" that pose questions about systemic failures in the way the NZDF handles the safety of its personnel. Ross' death was a tragedy that must never be allowed to occur again.
Ross, 29, had been wearing a faulty lifejacket and could not be saved because of problems with two army boats that tried to rescue him, a Fairfax investigation revealed.
The investigation showed that Ross should have been able to inflate his lifejacket after he fell from a boat, but it was later discovered the jacket's gas canister, triggered by pulling a cord, was empty.
Ross, weighed down by equipment – including a 20-kilogram machinegun attached to his body – screamed to his colleagues that he couldn't inflate the lifejacket, but problems with the boat meant they couldn't get to him in time.
"Even though the Court of Inquiry has yet to be concluded I expect it will outline some painful lessons," Coleman said.
An independent health and safety investigation by the Ministry of Business, Innovation and Employment is being conducted with a potential for prosecution.
Police have provided a report for the coroner for consideration.
As well, NZDF military police are conducting an investigation.
Coleman said: "The bigger question which I've pressed the chief of Defence Force on is we actually have to ensure there aren't systemic health and safety issues throughout the Defence Force."
Chief of Defence Force Lieutenant General Rhys Jones said he acknowledged the tragedy and had "left no stone unturned" in identifying the Defence Force's role in it.
Jones said management of risk and reduction of harm was central to its work and it had prioritised health and safety as one of the key organisational issues of 2013. It placed its vice-chief of the Defence Force in charge of this area.
The revelations into Ross' death come two weeks after it was revealed the family of Corporal Douglas Hughes had concerns about his suicide in Afghanistan.
An inquiry found his commanders knew about his suicidal thoughts and he was in the care of his sergeant when he died, just hours after admitting his feelings for a male soldier.
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