In Para 86 he makes it quite clear that there was nothing that happened that could be prevented into the future therefore meeting his obligations under Part 2 of Section 28. IMHO there is more to the coroner's objection to the ATSB report than meets the eye. The coroner was basically saying that it was all an unfortunate accident (which it was) and that the pilot's employer had no role in what happened. The ATSB were simply stating that there could be improvements made to the companies SMS beyond just relying on incident reports. They were not blaming the company for anything. I remember after the Mt Hotham report that the Chief Pilot engaged the services of a high profile lawyer to trash that report. In an unusual step the ATSB released a supplementary report which provided even more information about what the accident pilot had done that day. The high profile lawyer didn't have a lot to say after that. I am not alleging anything about why the coroner felt the need to trash the ATSB report but it says more on what improvements could be made to improve the safety of operations to that part of Tasmania than the coroner does.