Death by PowerPoint: The slide that killed seven people • Hacker News Board

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

#31

Post by mjevans » Mon, Apr 15, 2019, 10:18 PM UTC

jaabe wrote: post #16

PhasmaFelis wrote: post #12

Earlier quoted context omitted.

Yeah, it's clear that the slide was poorly written, but it seems very odd to put the lion's share of the blame on the people who presented accurate information poorly, instead of the people who thought it was okay to merely skim a Why on Earth did they veto even doing a spacewalk to inspect the damage, before concluding it was safe?

I don’t agree. I work in the Danish public sector, which means we handle healthcare related software that could potentially lead to deaths. Our managers aren’t technical wizards, and especially not in the field of healthcare. They are mostly doctors with a masters in management. Their job is to listen to what everyone has to say, and then make a decision based on that. Our job is to make sure they don’t miss importan…

I believe the logical reasoning to be: Powerpoint presentations facilitate filling in the blanks without prompting careful weight and consideration. As a tool it is more likely to influence poor thought and communications structure and muddle high level intake and review of data.

A more correct communications format might be the traditional longer-form report. A main document frames facts, possibly with graphs and other features used to reach the conclusions and explain why different points are salient. An executive summary preface presents the conclusions of skilled individuals and their core reasoning, which lets non-experts reference the larger report for a better understanding and/or ask questions if they are still unclear.

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

#32

Post by sopooneo » Mon, Apr 15, 2019, 10:19 PM UTC

I am not sure if the author and commenters here are specifically condemning Microsoft Powerpoint, or just computerized slide presentations, of which Powerpoint is by far the most common type. Because even if everyone used Apple's "Slides" tool, they could still make a lot of the same mistakes. Even if they drew things out on clear plastic sheets, they could still make the same mistakes.

So is it really Powerpoint specifically? Maybe. I'm open to that possibility. But I'm more sympathetic to the idea that Powerpoint has enabled many more people incapable of creating quality presentations to deliver them anyway.

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

#33

Post by rossdavidh » Mon, Apr 15, 2019, 10:20 PM UTC

everdev wrote: post #13

protomyth wrote: post #6

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.

I think the PPT slide is at fault for the fact that the most relevant piece of information (this is 600x bigger than we have tested) got lost. The decision, and even the way in which the meeting to make the decision was held, is not on PPT. But, it was the one and only purpose of a PPT slide to communicate information in a way that makes it easier to understand, otherwise we would just use plain txt files.

A plain txt file here, would have been better.

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

#34

Post by paultopia » Mon, Apr 15, 2019, 10:28 PM UTC

rayiner wrote: post #24

protomyth wrote: post #6

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 relativel…

Yeah, I agree. This is one of the worst slides I've ever seen. A few things I'd add to the above.

- The title is extremely unclear: are they supposed to be conservative in their beliefs about the risks (i.e., to not believe that the tile got penetrated), or are they supposed to be conservative in their behavior about the consequences (i.e., reduce risks by not re-entering the damn shuttle)?

- wtf does "overpredicted" mean? That's the second largest font, and it has no visible meaning?

- They don't even attempt to estimate the speed that the foam was traveling. They just said that it depends on speed and mass, but they make no suggestion of the speed.

- Nor do they attempt to draw boundaries on the possible speeds. Could they have fit a line on the test data and at least given a range of speeds that were clearly dangerous?

I don't think this is merely bad presentation design, however. This feels like someone was afraid to stick their necks out in a bureaucracy, and hence didn't give the managers enough information because there were some error bars around it.

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

#35

Post by paultopia » Mon, Apr 15, 2019, 10:29 PM UTC

davidmr wrote: post #8

As much as I appreciate the sentiment and I never like to miss a chance to pile on PowerPoint, this is really, really missing the point. As the CAIB report makes clear, the PowerPoint slide was a small symptom of the actual problem of a complex organization gradually accepting more and more risk as “in family” simply because unexplained phenomena hadn’t caused serious issues before (while remaining unexplained). The…

Yeah, I think this is right. Which doesn't detract from the slide being terrible, but just adds a bit more about why the slide was terrible.

Edit: from the summary of chapter 7 of the CAIB report [1]:

"organizational barriers which prevented effective communication of critical safety information and stifled professional differences of opinion;"

http://s3.amazonaws.com/akamai.netstorage/anon.nasa-global/C...

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

#36

Post by sailingparrot » Mon, Apr 15, 2019, 10:41 PM UTC

rossdavidh wrote: post #33

everdev wrote: post #13

Earlier quoted context omitted.

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.

I think the PPT slide is at fault for the fact that the most relevant piece of information (this is 600x bigger than we have tested) got lost. The decision, and even the way in which the meeting to make the decision was held, is not on PPT. But, it was the one and only purpose of a PPT slide to communicate information in a way that makes it easier to understand, otherwise we would just use plain txt files. A plain tx…

How would a plain txt file have helped? As the person writing the txt/ppt/whatever it's your job to put the emphasis on the important part: the 600x difference.

In text this means puting that at the beginning, in the title and in bold. The same is true in PPT, you have to outline the important stuff. It has to be visible at a glance.

File formats don't solve lack of communication and listening skills.

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

#37

Post by PhasmaFelis » Mon, Apr 15, 2019, 10:59 PM UTC

jaabe wrote: post #16

PhasmaFelis wrote: post #12

Earlier quoted context omitted.

Yeah, it's clear that the slide was poorly written, but it seems very odd to put the lion's share of the blame on the people who presented accurate information poorly, instead of the people who thought it was okay to merely skim a Why on Earth did they veto even doing a spacewalk to inspect the damage, before concluding it was safe?

I don’t agree. I work in the Danish public sector, which means we handle healthcare related software that could potentially lead to deaths. Our managers aren’t technical wizards, and especially not in the field of healthcare. They are mostly doctors with a masters in management. Their job is to listen to what everyone has to say, and then make a decision based on that. Our job is to make sure they don’t miss importan…

The engineers aren't blameless. They clearly fucked up as well. There is plenty of blame to go around.

But the managers should have carefully read every word that was placed in front of them. They should have asked questions if anything was at all unclear. This was, ultimately, their responsibility and their decision. They chose to rush it, and people died.

And I'm just baffled as to why they didn't send someone out to inspect the damage visually. The Columbia wasn't carrying a remote arm to quickly and safely maneuver an astronaut to the observation site, but the crew were trained and equipped for emergency EVA. It would have been a minor risk, but nothing compared to the danger of reentry failure.

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

#38

Post by ridgeguy » Mon, Apr 15, 2019, 11:01 PM UTC

>...nine times faster than a fired bullet... I don't think so.

A NASA publication [1] gives the SOFI piece impact velocity as about 800 feet/sec. Rifle bullets reach 2.5K - 3K fps muzzle velocity routinely.

[1] https://history.nasa.gov/columbia/Troxell/Columbia%20Web%20S...

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

#39

Post by Endy » Mon, Apr 15, 2019, 11:17 PM UTC

PopePompus wrote: post #29

js2 wrote: 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…

In my life up until now, I'd always believed the best of people and doubly so of NASA. Seeing that, and knowing it's true, makes me believe that there is evil in this world. And that man is part of it. Whoever and whatever forces allowed him to get where he was with opinions like that, needlessly sacrificing the lives of seven people and being satisfied that he'd made the right decision needs to be brought to account, publicly and with no means of secrecy.

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

#40

Post by scott_s » Mon, Apr 15, 2019, 11:25 PM UTC

Endy wrote: post #39

PopePompus wrote: post #29

Earlier quoted context omitted.

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…

In my life up until now, I'd always believed the best of people and doubly so of NASA. Seeing that, and knowing it's true, makes me believe that there is evil in this world. And that man is part of it. Whoever and whatever forces allowed him to get where he was with opinions like that, needlessly sacrificing the lives of seven people and being satisfied that he'd made the right decision needs to be brought to account…

> "After showing the astronauts in orbit a video of the foam strike and discussing with them what they thought they knew, mission managers concluded that it was a non-issue and posed no threat to the crew's safe return.

> ...

> "Although the circumstances of the tragedy have been well documented, and Hale insists there was "never any debate about what to tell the crew", his revelation brings new insight to the mindset of some Nasa employees at the time."

The crew knew.