AerocatS2A,
I was probably a bit less clear than I should have been.
In the Norfolk Island case, CASA and the ATSB blamed the pilot and then used that as the reason to look no further at the systemic issues.
I agree that fuel policy wasn't the headline act at Mildura.
My point was supposed to be that any decent investigation looks at all elements of the system and may well identify related issues that had no real influence on that particular event but in slightly different circumstances may well have become critical. They are the things you write on the white board for future consideration or clarification - or you make comment in the report about potential issues that readers might wish to contemplate in other contexts
