It appears to me that whilst PA Operations manual was found to be inadequate in procedures for fuel planning, Dom was not compliant with the written procedure that was in the manual.
Sorry Blackie I don't believe there would be many that would disagree with your statement, however Dom was hung, strung and quartered back in about Act 2 Scene 3 'The Aftermath' and then further reinforced by the Final Report.
However a good investigator wouldn't stop there they should be asking questions like:
1) Prior to Dom's employment with PA did he display cowboy, risk taking, non-compliant behaviour? Y/N
2) How did Dom perform in previous checks/CRM courses etc i.e. within TCS system?
Then if there were no serious issues/aberrations/non-compliance then one would start to suspect what is called a 'normalised deficiency', which points towards Company operational support.
A good investigator would then start to focus on all the cogs and sprockets that make up the guts or engine room of the operational support team of an operator.
With PA (at the time) this appears to be particularly blurred by previous audit reports, reasonably well written COMs and generally a history of compliance i.e. 'all the boxes were ticked'!
So Blackie what would a good investigator do then?? Yeah you guessed it dig and dig a bit more till you find the nuggets....sadly in this case that hasn't happened, in fact there appears to be some serious 'negligence of duty' with some pretty elementary facts missed!