There is enough dirt in this report to besmirch the pilot, Operator, ATSB (for their original report) and, of course CASA.
My opinion of the whole episode is best summarised by the Reason model - swiss cheese slices:
1. The operators sloppy planning and operating practices.
2. The operators training and checking procedures.
3. A pilot who tended to take the easy way out by not paying attention to detail - with the approval of 1. This wasn't detected by 2.
4. The result of 1. 2. and 3. was a flight plan that had no backup alternatives.
5. A weather event that scuttled 4.
6. A system of aviation regulation that, despite its draconian penalties, capricious, unfair and vicious enforcement techniques, failed totally to detect and correct 1., 2., 3. and 4. in time for corrective action to be taken. Relying on fear is not a very good safety regulation method.
7. Compounding all this was an allegedly "independent" ATSB that tried their very best to hide the whole sorry episode under the carpet and was complicit in CASA's persecution of the poor pilot, who, as far as I can tell, was only doing what others had done before him with the full approval of the operator and CASA. This action by ATSB prevented early safety action being taken.
Questions:
Is it possible for the current aviation regulation system to prevent such accidents in future? The answer has to be "No" because the current system goes against every safety mitigation principle, starting with "just culture".
To put that another way, there will be commercial pilots right now, today, who are faced with the double bind - accepting sloppy practices forced on them by their employer in order to keep their job and hoping to God that nothing happens or a merciless CASA finds out.
Is it possible to recover from the current state? Yes, but there is no political will to do so. The only glimmer of hope is that the ATSB produced a comprehensive and cogent report albeit at the direction of the Australian Senate.