An official accident report into the drowning of a soldier during a kayak session in Cyprus uncovered flawed and unsafe training procedures, an inquest has heard.
Private Jamie Lee Sawyer died after bad weather struck his group on the Army-run course, swamping the novices with 2.5-metre (8ft) high waves on March 12, 2015.
An inquest into the 20-year-old's death heard how a joint services Land Accident Investigation Team (LAIT) report into the incident found faults and poor practice in the way the course was run.
Previously, Louise Hunt, senior coroner for Birmingham and Solihull, was told how experienced civilian kayak instructor David Hughes took the group out to sea despite a weather forecast warning of wind gusts.
A soldier who survived the ordeal on Tuesday said:
"It could have been any of us that day."
Two Met Office weather warnings of thunderstorms in the area had also not been passed on to Mr Hughes or the Army officer overseeing training.
The court also heard that it took 25 minutes for a Greek Cypriot rescue launch to be alerted and that the kayak instructor had no mobile phone signal.
In the event, the alarm was raised by a group of civilians on the coastline.
Royal Logistic Corps chef Pte Sawyer, from Birmingham, was serving with the 2nd Battalion The Mercian Regiment battle group, deployed as part of the United Nations' peace-keeping operation.
Birmingham Coroner's Court was told that the joint services investigation identified the "unexpected weather" as the chief cause of the tragedy.
However, it found two occasions of "unsafe practice" leading up to the incident and several areas where best practice had not been followed.
Its report concluded that the "unanticipated weather change" and the "inexperience" of the kayakers, had made the 4km route "unsafe" in all but "benign weather".
Investigators found the course taken, which took the group about 100 metres off the island's south-eastern coast, was:
"potentially extremely hostile in anything other than good weather".
The report added:
"The apparent failure to appreciate the effect of the forecast of weather might have had on conditions likely to be encountered is considered to be unsafe practice."
There was also "no system in place" for the local Army training team to receive and act on thunderstorms.
"Their inability to react in timely fashion to a thunderstorm warning is considered unsafe practice."
The report repeatedly concluded that parts of the course's safety measures and risk assessments were also flawed.
It was critical of military oversight of the instructing staff, adding "such a lack of oversight cannot be considered best practice."
Another report, carried out by the Army unit's own investigation team, also raised a concern about "the capability of the rescue boat" sent out by Greek police.
The accident investigators found there were "no control measures" to make sure the island's civilian phone network, upon which the kayak training team relied for communications, worked on the route.
Training teams now have both mobile phones and marine radios, and course audits are carried out.
Other improvements including whistles for all kayakers, formal buoyancy aid testing, co-ordination with Cypriot air-sea rescue, and improvements in passing on weather forecasts, the coroner heard.
Civil servant Andrew Gee, the Army's chief environmental safety officer, said the rules around adventure training had been "reviewed and re-written" after the tragedy.
Mrs Hunt asked: "Are you as satisfied as you can be the changes you've made would avoid a similar incident?"
Mr Gee replied: "I'm content that is the case."
Mrs Hunt concluded that she would not be sending a report to the authorities, as she was convinced the Army and joint services had taken steps to improve safety practices.
She also addressed Pte Sawyer's mother:
"I hope that at last you have an understanding of what happened finally".
"It can't help your pain or grief, but I hope you can somehow remember the Jamie we heard about - that loving, caring son and brother."
Andrew Buckham, military injuries lawyer at Irwin Mitchell solicitors - who represented Pte Sawyer's family - said:
"Obviously military training needs to be robust and realistic to prepare our troops for conflict, but it is vital that there is adequate protection for soldiers to prevent tragedy".
Miranda Ching, Associate, Peters & Peters and representative of Mr Hughes commented:
Key questions concerning the final moments of Private Sawyer could not be examined by the Coroner because she did not receive information from the local Cypriot authorities who carried out the rescue operation.
It is hoped that the inquest has provided all concerned with a greater understanding of what happened.