Defence Minister Jonathan Coleman has launched an inquiry into the army's safety culture, after hearing court evidence about a soldier who died in a training accident last year.
Private Michael Ross, 29, drowned during a training exercise on Lake Moawhango, near Waiouru, on September 25.
The Defence Force pleaded guilty to negligence over his death, and the Chief of Army said he was embarrassed over the lack of professionalism in his force.
Coleman was "appalled" at the accident that "should not have happened," he told Radio New Zealand this morning.
It seemed there were safety rules in place, but they were not being followed, he said.
"Because what this court of inquiry has shown is that the rules were in place, though they needed updating, but there's an attitude that they don't need to be followed, that the completion of the mission is the primary thing," he said.
"This should never have happened, this soldier was let down...and this should never happen again."
Two military experts and one expert in workplace health and safety would be involved in the inquiry, and it would be a matter of "weeks, not months", for it to be completed, he said.
The inquiry was a priority, as was putting into action whatever was needed to turn the culture around, Coleman said.
The hearing was for a health and safety charge laid by the Ministry of Business, Innovation and Employment (MBIE) against the Defence Force in relation to Ross' death.
The maximum penalty for the offence was $250,000, but as Ross was working for the Crown, the fine couldn't be imposed, the court heard.
MBIE counsel Saar Cohen-Ronen said the Defence Force had already made an offer of amends to the family, which would total $240,000. The family accepted this.
CASE SUMMARY OF FACTS
In the case's summary of facts, read to the court by Cohen-Ronen, Ross was said to have died during an exercise with personal flotation devices (PFDs) on the lake.
As they were preparing for the exercise, two soldiers went into the lake to recover some targets and discovered they couldn't stay in the water for longer than 10 seconds.
This alerted the army to the cold temperature.
A man overboard procedure was set in place. It required the closest boat to anyone who fell in the water, not the boat they had fallen out of, to rescue them.
In the incident, the Zodiac rigid inflatable boat Ross was in was "soft or underinflated".
In normal circumstances the soldiers would not have boarded it, "but the soldiers were too tired and just wanted to get back across the lake at the end of the training session", the summary of facts said.
Ross wore his Minimi machinegun across his front with the sling around his neck.
"This action was inconsistent with army orders which require personnel on small vessels to secure their weapons to the vessel."
The Zodiac encountered choppy water and the occupants noticed it started to flex at the bow.
Ross was on the bow on the left side.
Other boats passed the Zodiac and their wakes caused its bow to flex even more.
"The soldiers asked the coxswain to slow down. As he slowed down the bow came back down and Private Ross was dislodged overboard."
A man overboard procedure was launched.
"Eyewitnesses described Private Ross as not looking panicked at this stage," the summary said.
"The soldiers yelled at him to deploy his PFD."
They turned back to pick him up.
A safety boat reached him and he made contact with the boathook pole and started drifting toward the rear end of the safety boat.
The summary said it was believed the propellers did not strike Ross. Nevertheless, he lost contact with the boat pole.
"He started drifting away from the safety boat, and was now bobbing up and down in the water, going under the surface and then popping back up, treading water."
He was wearing equipment weighing 15.185 kilograms and a weapon weighing 6.48kg, giving a total additional weight of 21.665kg.
As another Zodiac reached Ross, he sank below the water.
"The coxswain managed to grab Private Ross' helmet, but it became dislodged from Private Ross who was sinking deeper," the summary said.
The safety officer directed soldiers to jump in and three did, but due to the cold they could not dive very deep or for very long.
They then picked up a diver and returned, but it was cold and visibility was poor.
"Private Ross' body was located at the bottom of the lake on 2 October 2012, at a depth of approximately 42 metres."
An autopsy found he had drowned.
The personal flotation device Ross had used was forwarded to the importer's experts, Survitec Group.
They found that the gas canister was empty and had previously been punctured and deployed.
It had not been replaced.
Under its charge, the ministry said that the Defence Force failed to identify cold water as a hazard or make sure rules on carrying and security of weapons on Zodiacs were followed.
It charged that the Defence Force had failed to provide personal flotation devices to provide buoyancy.
The judge adjourned the case after hearing from the defence and would sentence the force in writing by the end of next week.
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