Challenge accepted Oleo
Owen you really need to a little more research. The Reason model is used to discover the trajectory of an accident or incident through the absence or failure of defences that should have prevented it. Once these are identified then the job at hand is to bolster and sometimes place those defences to prevent similar accidents or incidents from reoccurring.
Dig a little deeper to our regulator's actions over the last 20 or so years. Trumpeting their achievements in recognising the need for employing specialist inspectors to conduct through audits and investigations then white-anting them by not putting their specialist skills and expertise into practice, not promoting them to positions where they can influence change and frustrating them out of a job, thus allowing the system to revert to where it was 20 years ago and maintaining the status quo.
Come to think of it, the Coles theme song should be adopted by CASA because they are hell bent on keeping the quality of its service as a regulator "Down, Down, Deeper and Downer".
Only a root and branch removal of this gnarled old weed will bring any improvement to the regulation of the aviation industry in this country.