Did we let it happen? - YES. (Sandilands).
The thing gets me cranky is that the CASA are supposed to iron out the deficiencies they noted
before operational approval is issued. The audited deficiencies are not the ATSB fault they are admitted, signed confessions of CASA acceptance /approval of the 'suddenly' now noted deficiencies. The audit damns the CASA: not the operator; if CASA is happy, all is well and the operator is not going to go looking for more grief. The Safety Authority accepted it, must be good.
The ATSB would have been, let's say 'guided' by whoever was in charge of the audit. It is NOT the job of the ATSB to raise noted operational problems until after the event. Sure they were influenced, but who persuaded them to slide around CASA accepted/ approved time bombs left laying about in a company operations manual ????. We know, don't we children.
Steam off - Confirmed.