Stevin Creeggan took a private prosecution against the air force for its failures. Picture / Mark Mitchell
There will be no warnings to the future of the cost of casual disregard.
On Anzac Day, we are often driven to think of the pointless deaths of the Gallipoli campaign, those lives lost in a brave but ultimately hopeless charge up a hill soon surrendered.
Anzac Day 2010 saw three similarly pointless deaths.
Ben Carson was one of those - son of Andrew and Pauline and brother of Nick. He was in the rear of the helicopter with Stevin Creeggan early that Anzac Day morning when it slammed into hills just north of Wellington.
Stevin survived but Ben was killed, as were pilots Hayden Madsen and Dan Gregory. They died for nothing, and did so in an accident that was entirely preventable.
Usually when young men die for no good cause there is culpability. History has not been kind to the generals who led the Gallipoli campaign, especially down under.
When young men die for no good cause, it is good to know who contrived the circumstances which led to their death so that it might not happen again.
The Anzac Day 2010 deaths have had no such individual accountability, and with the coroner now closing the file, there will be no warnings to the future of the cost of casual disregard.
The only inquiry into the deaths of those three men has been by the Air Force. The formal military Court of Inquiry found bad weather and an unhealthy culture of risk-taking was behind the deaths of the men.
The inquiry was tightly focused on 3 Squadron, the Ohakea-based air force base from which the Iroquois departed. For all its narrow focus, it drew on a much wider body of evidence not reflected in the Court of Inquiry report.
The Herald has obtained and reported on some of that evidence. One example is the emails exchanged between senior officers in 3 Squadron months before the crash in which concerns were raised about the culture blamed for the crash. The Herald's reporting on those emails showed concerns had been raised before the crash. With tragic consequences, they were ignored.
More significantly, the Herald obtained the Accident Analysis Report. It was written by the air force's most experienced crash investigator, Squadron Leader Russell Kennedy.
Kennedy's keen observations extend well beyond the Manawatu-based squadron. It considers the air force's history of safety and found it wanting - recommendations from other Court of Inquiry investigations made for safety reasons had not been carried out. This was the case even though the "recommendations" had the force of an order from the Chief of Air Force.
In two of those cases, the failure to make changes had links to the failures which led to the deaths of the three who died on Anzac Day 2010. Kennedy's scope was not only deep but broad, examining the entire air force. "The RNZAF does not have the appropriate and effective processes to adequately and reliably ensure safe and effective military air operations."
The problems were not limited to a poor culture, but the poor culture was "to some extent", wrote Kennedy, "pervasive throughout the whole air force". He found that command knew of these culture issues and had known "for some time".
The officer who oversaw the assembly of the Court of Inquiry - one of the air force's most senior commanders - wrote that the scrapping of the air combat wing in 2001 had removed a layer of command and control which partly contributed to the crash.
"This was done for what we thought were good reasons but nobody at the time realised the real impact the changes would make," he said.
For all that, there is no sign that at any stage concerns were raised about safety gaps, contradictory orders or the poor culture other than by the brave squadron leader who attempted to speak out and was ignored.
The limited and focused military inquiry aimed to identify and fix problems without apportioning blame. In doing so, it managed to avoid naming names, just as it managed to avoid broadening the inquiry beyond 3 Squadron.
In this sorry saga, the three men who died were let down by the military and were then let down by the government when it emerged the Civil Aviation Authority and then-Department of Labour bungled their jobs, thinking the other was going to investigate the crash. Neither did and the time frame lapsed, meaning the agencies' own independent inquiry would never happen. This dismal failure saw the survivor of the crash, Stevin Creeggan, take a private prosecution against the air force for its failures. Critically injured and permanently affected by the crash, Creeggan did the government's job for it.
When NZDF pleaded guilty to failing the men, it cut short a full court hearing.
Again, an independent inquiry into the fatal crash did not happen.
There was one final possibility - the coroner. Charged by law to find the cause of death, the office of the coroner has the power to conduct broad inquiries into fatal incidents. The Herald revealed yesterday the coroner had accepted the air force's original Court of Inquiry as sufficient. Again, no independent inquiry.
Ben Carson's dad Andrew has fought for years to have the crash of 2010 investigated by someone other than the agency which employed his son. He told the Herald in 2012: "I don't blame the pilots who died. It's the guy who gave them the keys and told them to go there."
When young men die for no good cause, it's important to know the names of the men who sent them. This is the burden of command.
With no full and independent inquiry, it is a burden not fully shouldered. Those whose responsibility it is to command did so from as far behind the front line as the generals of Gallipoli, and they have done so anonymously.