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Death by PowerPoint: The slide that killed seven people

mcdreeamiemusings.com

21–30 of 135 posts

Re: Death by PowerPoint: The slide that killed seven people

#21
During that final Columbia flight, I remember reading a short news story on the internet on the foam falling off. It even had a short video of the foam falling off. (Somewhat of a novelty way back in 2003.) I watched that video several times.

I remember being concerned, but confident that NASA would figure it out.

Then when I saw the headline that Columbia didn't land, I remember immediately thinking, "On no! The foam!". I also remember being puzzled that none of the news stories after the crash mentioned the foam for a long time.

I've tried to go back and find that news story, but I have never been able to find it.

Re: Death by PowerPoint: The slide that killed seven people

#23

No, the NASA officials are the ones that killed seven people. Is there audio from the presentation? If you are meeting with some group about something that is life or death, you sit your butt down and ask questions until you get the actual situation. They didn't do it for Challenger and they failed to do it for Columbia. You are in charge, the decision is yours and you are responsible. On a side note, the whole first…

I completely agree. Powerpoint may cause information to be lost, or encourage sloppy speaking skills. But the deaths regarding "NASA's powerpoint that kills" is squarely on the chuckleheads who didn't sit down and get to brass tacks and ask the hard questions. Powerpoint didn't stop NASA employees from asking "What are the chances of a catastrophic result?" In times of critical issues, you ask plain and direct questi…

> Powerpoint didn't stop NASA employees from asking "What are the chances of a catastrophic result?"

How so? The whole practice of using Powerpoint, whether in business, other enterprises, education or elsewhere is literally designed around its nature as a persuasion technology that makes true shared deliberation impossible, by ensuring that everyone in the audience has to expend their mental effort to focus on what the Powerpoint slides purport to say. Even Tufte is rather clear about this, and consistently critical about Powerpoint use. There is a very real sense in which Powerpoint stopped the audience from asking the right question.

Re: Death by PowerPoint: The slide that killed seven people

#24

No, the NASA officials are the ones that killed seven people. Is there audio from the presentation? If you are meeting with some group about something that is life or death, you sit your butt down and ask questions until you get the actual situation. They didn't do it for Challenger and they failed to do it for Columbia. You are in charge, the decision is yours and you are responsible. On a side note, the whole first…

Clearly the mission controllers bear some responsibility, but I disagree with diverting blame from the creators of the PowerPoint.

The PowerPoint displays extremely clouded thinking. The title is: "Review of Test Data Indicates Conservatism for Tile Penetration." What the heck does that even mean? An unclear title is a very strong indicator of unclear thinking about the point being made. Further, there is a relatively precise estimate of the size of the foam, and its orders of magnitude larger than the size used for the tests. The slide clearly states that the penetration velocity depends on "volume/mass of the projectile"--i.e. one would expect a much larger projectile to penetrate at a lower speed. So why is the lead message not "we have to try the tests with bigger foam, because we don't have the data we need to reach a proper conclusion?"

Remember, while this is happening, a million other things are going on. The officials have other risks and trade-offs to deal with. In that scenario, one of your jobs as an engineer is to clearly convey your point, and perhaps more importantly, the limitations of your analysis. It's not the job of the decisionmakers to tease that information out of you. Ideally, of course, a decisionmaker faced with unclear messaging will try and get to the bottom. But in a high-pressure scenario, that doesn't always happen. For one thing, how does the official even know which issues need to be run to the ground and which do not? Who was the person who best knew how significant this slide was? The official reading it (who probably saw a hundred other slides in the same meeting), or the person who wrote it?

Re: Death by PowerPoint: The slide that killed seven people

#25

No, the NASA officials are the ones that killed seven people. Is there audio from the presentation? If you are meeting with some group about something that is life or death, you sit your butt down and ask questions until you get the actual situation. They didn't do it for Challenger and they failed to do it for Columbia. You are in charge, the decision is yours and you are responsible. On a side note, the whole first…

[deleted]

Re: Death by PowerPoint: The slide that killed seven people

#26
The authors of the slide either lacked the ability to analyze problems, or lacked the ability to communicate their opinions, or were intentionally obscuring their opinions.

Which of these is the more likely explanation?

I've seen experienced engineers incapable of expressing their thoughts clearly. But I've also seen well-established organizations that encourage hiding your opinions behind a wall of bullshit.

Re: Death by PowerPoint: The slide that killed seven people

#27
post #13

No, the NASA officials are the ones that killed seven people. Is there audio from the presentation? If you are meeting with some group about something that is life or death, you sit your butt down and ask questions until you get the actual situation. They didn't do it for Challenger and they failed to do it for Columbia. You are in charge, the decision is yours and you are responsible. On a side note, the whole first…

It is a little far fetched to think the audience didn't listen or ask questions about any potential risks. It's easy to go back after an accident and find multiple points of failure and find things that could have been done better. My guess is that most people thought it was a minor or acceptable risk. Unfortunately, they were very wrong. But that doesn't mean the PPT slide is at fault.

> But that doesn't mean the PPT slide is at fault.

I think it's a bit of poetic license to say that the PPT is at fault. But didn't help. Many mistakes lead to an outcome like this one. But this PPT is one of those mistakes. The basic information is there for a very significant point--we know penetration can happen with a sufficiently large or sufficiently fast-moving piece of foam, and this piece of foam is 600 times bigger than anything we tested before. Had this PPT clearly conveyed that point, the chances would have been higher that some decisionmaker would have realized its significance.

Re: Death by PowerPoint: The slide that killed seven people

#29
post #20

> They rejected the other options I didn’t think there were any options. Indeed the managers didn’t think so. From https://en.wikipedia.org/wiki/Space_Shuttle_Columbia_disaste... > Throughout the risk assessment process, senior NASA managers were influenced by their belief that nothing could be done even if damage were detected. However the CAIB determined Atlantis could have been used as a rescue vehicle had NASA ac…

There were a number of things they could have tried. No one of the alternatives (except launching a rescue shuttle) could possibly have turned out worse than the course they chose. Instead of an Apollo-13 style "Failure is not an option" effort, Jon Harpold, then the director of Mission Operations, is reported to have said

"You know, there is nothing we can do about damage to the thermal protection system. If it has been damaged it's probably better not to know. I think the crew would rather not know. Don't you think it would be better for them to have a happy successful flight and die unexpectedly during entry than to stay on orbit, knowing that there was nothing to be done, until the air ran out?"

https://www.theguardian.com/world/2013/feb/01/columbia-space...

Re: Death by PowerPoint: The slide that killed seven people

#30
post #3
post #2

The slide in the article has the same text, but is a recreation of the original (The Calibri typeface used wasn't part of PowerPoint until 2007). The original slide can be seen in the full report linked in the article: https://www.edwardtufte.com/bboard/q-and-a-fetch-msg?msg_id=...

Thanks for pointing this out. I noticed the typo of "hanrd" ("hard") on the re-creation and drew the further conclusion that they weren't even taking the issue seriously enough to pay attention to their slide content. Even though it doesn't change what ultimately happened, it's nice to know that someone was paying at least cursory attention.

Indeed. I missed "hanrd" on my first read through, but "Vaires" and the stray "?" jumped out at me. The original slide is much more readable, and "Flight condition is significantly outside of test database" stands out as almost the conclusion rather than being buried in noise. Talk about a strawman. (Still a bad slide, though.)
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