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Death by PowerPoint: The slide that killed seven people

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

#41

Post by js2 »

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…

If he actually said that, it’s fucking unconscionable. It’s not his decision to make (or shouldn’t be), it’s the crews’.

What kind of morality underlies such thinking?

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

#42

Post by OnlyOneCannolo »

davidmr wrote: post #9
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…

There’s definitely audio from all those meetings. You can hear the mission manager plow right through the issues with bureaucratic ease. They’ve seen something similar before and even though it was unexplained, because they’ve seen it, they think it’s a known issue. You want to blame her for it and shake her out of it as you hear her say it, but it wasn’t malicious. I believe the mission manager even had a spouse who…

I don't think anyone is saying that it was malicious, but it was absolutely negligent. For people with decisional authority, organizational pressure is not an excuse. For people with responsibility, lapsed vigilance is not acceptable. They weren't forced to make a split-second decision, and they weren't fatigued. While there were contributing systemic factors, this was still a mistake to dismiss the information so quickly. They're professionals, not amateurs.

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

#43

Post by erobbins »

nyx_ wrote: 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=...

So if I'm reading this right, the previous testing was done with a 3 cubic inch foam block at 200 ft/sec impact velocity... and the foam ramp was 1900 cubic inches and going 900 feet/sec at impact.

This is like saying "shooting someone in the head with a BB gun doesn't kill them, so we think shooting them in the head with a shotgun slug should be fine."

What on earth were these people thinking?

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

#44

Post by PopePompus »

scott_s wrote: post #40
Endy wrote: post #39

Earlier quoted context omitted.

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 mindse…

Here is what NASA emailed to the crew about the foam strike:

--- begin quote ---

You guys are doing a fantastic job staying on the timeline and accomplishing great science. Keep up the good work and let us know if there is anything that we can do better from an MCC/POCC standpoint.

There is one item that I would like to make you aware of for the upcoming PAO event on Blue FD 10 and for future PAO events later in the mission. This item is not even worth mentioning other than wanting to make sure that you are not surprised by it in a question from a reporter.

During ascent at approximately 80 seconds, photo analysis shows that some debris from the area of the -Y ET Bipod Attach Point came loose and subsequently impacted the orbiter left wing, in the area of transition from Chine to Main Wing, creating a shower of smaller particles. The impact appears to be totally on the lower surface and no particles are seen to traverse over the upper surface of the wing. Experts have reviewed the high speed photography and there is no concern for RCC or tile damage. We have seen this same phenomenon on several other flights and there is absolutely no concern for entry.

That is all for now. It's a pleasure working with you every day.

--- end quote ---

Now does it sound to you like the crew was fully informed, or like NASA was minimizing the issue?

https://spaceflightnow.com/shuttle/sts107/030630emails/

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

#45

Post by RachelF »

davidmr wrote: post #9
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…

There’s definitely audio from all those meetings. You can hear the mission manager plow right through the issues with bureaucratic ease. They’ve seen something similar before and even though it was unexplained, because they’ve seen it, they think it’s a known issue. You want to blame her for it and shake her out of it as you hear her say it, but it wasn’t malicious. I believe the mission manager even had a spouse who…

True, it is easy to be wise after the event. However, the management culture at NASA, which was also responsible for the loss of Challenger, and something Richard Feynman also criticized, did not change.

This lead to managers ignoring engineers' warnings about the foam strikes on Columbia, and also rejecting requests for high resolution images.

This is exactly the same culture which ignored engineers' warnings about the O-rings on the SRBs.

Linda Ham, the mission manager who rejected these requests left the space shuttle program after the Columbia disaster and was moved to other positions at NASA. Not firing or disciplining these managers will cause similar disasters in future. https://en.wikipedia.org/wiki/Linda_Ham#Columbia_disaster_an...

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

#48

Post by vezycash »

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…

> "Review of Test Data Indicates Conservatism for Tile Penetration."

The title has nothing to do with power point. This is no different from how academics title papers. The use of unnecessarily big words & passive tenses (rather than active) increases with level of schooling.

"Don't bury the lede" - Journalists and writers are taught this. It means, save readers some mental clock cycles. Pore through your own news and figure out the most important fact. Then put it in the title and/or on top.

Highly schooled, intelligent and "honest" people don't do this. When journalists over simplify or make logic leaps in their writing, we call it clickbait. We also prefer the use of the words MAY, and COULD (probability isn't intuitive to most people) - which allows people to ignore the information.

Successful salesy types are intentional about their use of words. They'll use active phrases, avoid ambiguous words, use words that denote certainty to force action in choice areas, and vagueries to hide or down play others.

The officials were surely served papers before or after the meeting and made their decision despite the slideshow.

Summary: Engineers need copyrighting and sales training as well.

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

#49

Post by hughes »

The speed listed in the introduction is wildly wrong. The foam could not possibly have hit at 28968 km/h - that is the approximate orbital speed of the shuttle. At 82 seconds into flight, the speed is about 700m/s (2500 km/h).

Even using that figure would assume that the foam came to a dead stop instantaneously after detaching from the tank. I wouldn't be surprised if the relative speed was only 1/10th of that, putting the speed of the collision around 250km/h, less than 1% of the figure stated in the article.

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

#50

Post by dba7dba »

I heard one possible reason for underestimating the damage was due to the move of a NASA (or the contractor?) lab/facility that dealt with this kind of issues, from California to a cheaper place such as Alabama/Florida(?).

The move was done as a cost saving measure. Quite a few of the engineers chose not to relocate with the office. When the space shuttle launched and the image was being reviewed, many of the experienced engineers (who could possibly have predicted it correctly) were no long with the team.

I remember reading above bit years ago while reading about the incident.

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