Something missed by CASA in their surveillance of the operator would appear to be that they had a 'standard' flap setting for all takeoffs that was certainly not optimum for obstacle clearance. A bit of industry education would not have gone astray, as it is probable that neither the chief pilot or pilot on the day had specific understanding of the implications of using flap for takeoff with obstacles limiting. OK, so the info was in the AFM, but apparently the operator ignored it - possibly due lack of education. Yeah, I know, CASA is there to regulate, not educate.
In my short time operating the C404, I went to pains to educate pilots about the advantages of zero flap takeoffs whenever runway length permitted. This met with some resistance from the owner who thought it would wear the tyres out or damage the props or somesuch crap, and from some pilots "because it had never been done that way in the past and what would an ex-airline pilot know about light twins anyway?" Further, from the ATSB report :
"The investigation concluded that the pilot experienced an emergency situation, at a critical phase of flight, for which training in the aircraft had not been provided."
With no simulator, any engine-out training was likely done at light weights and with generous safety margins. This in itself gives pilots an unduly optimistic understanding of light twin capabilities. So how in all conscience can our so-called justice system lay blame on the unfortunate pilot faced with an impossible task not of his making?