Lake Moawhango Court of Inquiry Released

25 July 2013

NZ Defence Force today released the findings of the Court of Inquiry into the death of Private (PTE) Michael Ross, who died during a training exercise at Lake Moawhango on 25 September 2012.

The Court of Inquiry found that while the death was accidental, personnel not adhering to a number of appropriate safety procedures contributed to the accident and subsequent drowning of PTE Ross, and it could have been prevented.

Chief of Army, Major General (MAJGEN) Dave Gawn said the Court of Inquiry has highlighted a number of areas for improvement, both within NZ Army and the NZ Defence Force.

“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,” MAJGEN 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.

“Our thoughts are with the family of PTE Ross during what will be a difficult time for them.”

This year NZ Defence Force is focussing on organisational health and safety as a priority.

In April Vice Chief of Defence Force set up the NZ Defence Force Health and Safety Committee to provide oversight for the Defence Force, set health and safety performance targets, review high risk areas within the Defence Force, and establish a way forward to improve on these.

A number of initiatives are underway to enable NZ Defence Force to operate in a safer manner.

A Health and Safety review has also been instigated to address any deficiencies in safety management, training and culture, and to understand where NZ Defence Force is as an organisation with our attitudes and practices towards health and safety. This review remains ongoing.

Additionally, as a result of the Court of Inquiry into the death of PTE Ross, the NZ 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 (RNZN) 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 100 percent 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 Military Police investigation into the incident remains ongoing.


For further information please contact the Defence Communications Group on 021 487 980.

This page was last reviewed on 25 July 2013.