Take your James Reason model and as one of the defences
Well I am no expert,like some posting, but I understand Reason is a model for finding cause of accident not prevention of same.
yet in the case of Norfolk all parties are willing to undertake a 20 second investigation and say 'its all Dom's fault'!
The 4 corners program said nearly three years for the ATSB investigation, or did I understand incorrectly?