Brian those of us who are airline pilots have read through similar papers on the causes of human error and understand fully the Reason model and have the "Swiss cheese" analogy dangled in front of us every time we do a CRM refresher course. We get it, we understand it, we look for ways to avoid the holes lining up.
In addition to all the theory those of us who carry the responsibility of jet command also understand the responsibilities of been given that command. The company I work for has recently issued a FSO that restates the responsibility of the PIC. Nowhere in that document does it say that at the end of the day organisational issues and human factors will be held liable for any adverse outcome to the flight!
Your defense of Dom has never addressed the decisions he and his F/O made once they realised that they did not have the fuel to divert and the weather was below minimums. There was no attempt to buy time with the remaining FOB just blast on in, do four approaches to minima that was above the cloud base then go "oh well we've done our best lets ditch". As I have repeatedly stated and you have repeatedly ignored where was the leadership. Even when the ditching was conducted,where was the Mayday? Where was the radio call to the Unicom to say "We are ditching to the west of the island"? Where was the duty of care to his F/O when he left her unconscious in the cockpit?
So instead of plaigiarising someone elses thoughts on human factors put your own words here and explain to us why the decisions the crew made from ToD were the responsibility of CASA,Pelair and the ATSB.