If you read the coroners report it outlines what he is looking at with reference to the coroners act. His comments WRT the ATSB is more about the evidence the ATSB had to make such accusations, more so the lack of any evidence provided regarding such things. Cause of death is straight forward what killed the person, from a medical point of view.
In short the ATSB made a statement to the effect that Par Avion "encouraged" pilots to depart in marginal weather conditions. This would have peaked the Coroners interest given the lack of evidence provided as it becomes an accusation of possible workplace issues, that is, was the pilot in that location due to being pushed beyond their will by their employer. The other issue identified was the lack of operational information given to pilots, however the coroner suggested that the pilot was reasonably familiar with the route so the lack of printed material was not relevant.
I'm well aware of what organisational factors are, but it muddies the waters in an 'accident' investigation. Possibly it should have been investigated separately.
Last edited by 43Inches; 30th Aug 2022 at 05:46.