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.
Edmund
Nice list!
I'll add some, perhaps less important, points:
5. General sense of unease in Flight Crew about visual ops. (Speculative, but should be tested. Perhaps by throwing visual approaches at this or other Asiana crew in the Sim or check flights. )
6. Failure of relief crew in drawing attention to the impending disaster forcibly enough or failure of flight crew to take notice of relief crew's warning calls. Bad CRM?
7. Failure of the other relief crew member to remain present on flight deck during landing. (Who can say if that one extra set of eyes might have caused an earlier go around)
8. PF mixing manual and automated landing modes without realizing the precise nature of control logic.
9. Boeing allowing combinations in control logic that are potentially dangerous or easily misunderstood or not widely understood.