Lookleft, I agree with the drift of your approach and it is clear that the ATSB has made important observations.
However that doesn’t explain why they have decided to leave out the fact that Airservices had been given a directive by the Minister – which if complied with, would have resulted in the airpace being Class E, or an approach radar facility being provided.
In each case, there is less likelihood that the plane would have crashed with the loss of the lives of two people.