VH-MLE you are spot on.
ATSB blaming the operator's ops manual is bull****: For the purposes of the operation, CASA was the operator AND they had accepted those procedures in Rossair's manual.
SG should never have been in that seat and should never have put himself, or those pilots, in that situation. He was the pilot in command.
We have been doing Conquest endorsements in Australia since the first airframes were imported (ironically, by Rossair I think) in the 1970s. This is the first fatality. It speaks to the dwindling experience and judgement available in CASA, and the dwindling experience and judgement available in General Aviation at that time in particular, but across the last 20 years generally.
I have been doing Conquest endorsements for 6 years now and piston twin endorsements for 5 years before that. I am fortunate to have had Flying Bear as a resource and a mentor as I have learnt to teach Turboprop handling; but as a Chief Pilot and CFI most of my learning has been by trial and error. Some days I wonder if my survival to this point has been pure good luck.
CASA lacks the expertise, currency and testicular fortitude to provide industry development, preferring to pass the buck. It's time to ask Ben Cook, Tony Kern and other respected training leaders to lead a program to build industry capability.