All the deficiencies and RCAs in the CASA report are symptomatic of an underlying problem. That problem was the culture at Pelair. The audit hints at this in several areas, but does not go far enough IMHO.
Since the accident. Pelair has claimed alternate fuel was not required for aerial work category. That may be strictly legal but it is hardly prudent in that part of the world.
The CASA report states it was not confirmed whether or not these flights were Aerial Work or Charter (page 12). Why not? Why could CASA not determine the category of operations being conducted under the AOC?
The pilots interviewed said they didn't know if they were Aerial Work or Charter (and therefore they could not know what regulations governed their flight planning). The pilots further said they planed as if they were Charter. It appears they did in general. However 3 flights in the 2 months prior to the crash arrived at Norfolk with less that alternate fuel, and so did not comply with Charter requirements. They would only be legal if Aerial Work. The PIC for one of these flights was the former CP and the then WW standards manager.
So what exactly was a junior Captain to make of all this? He screwed up big time. However the system let him down, and I believe most here recognise this. Dom may have a reputation for being too casual in his approach. However he operated in an environment that was equally casual and facilitated this behavior. What Dom really required was an old fashioned kick up the backside long before this flight. I can't see who at Pelair was going to do this.
A marginal fuel policy. Poor oversight of someone who perhaps needed to operate under a very tight system. No RVSM capability. Problems accessing Noumea. Sooner or later luck was going to run out. The only surprise here is that all lived.