A scary list of mistakes in a multiple protection environment.
I suspect that some of these are not human error but rather continuous fails over multiple flights.
I've seen three layers of protection not work in preventing an accident because
one layer was hidden from any in-service checks and only worked in the eyes of the board designer
one layer could not be relied on because the crew were not adequately trained in its use
and the last layer was just a common flaw with a known failure rate of one in a 1000 flights