Causative factors of Asiana loss of life
These are the holes of the cheese that lined up:
1. Disabled landing aids at SFO requiring visual approach from tired long haul crew.
2. PF unfamiliarity with type, and PIC unfamiliarity with training role, not a standard crew distribution, leading to loss of situational awareness of airspeed and CFIT.
3. Passenger ejection during hard landing as result of CFIT.
4. Ground crew driving over passengers.
I really think that (1.) deserves looking at, because otherwise it is just a question of waiting for the next incident, as aircrew training and fatigue will clearly not improve substantially in the next few years. As for (4) ...
Last edited by edmundronald; 15th Jul 2013 at 11:50.