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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

#91

Post by pjtr »

peteradio wrote: post #79
bumby wrote: post #77

Earlier quoted context omitted.

Use of jargon is a huge impediment to communication in organizations like NASA and DoD. There's even a glib saying that you won't get your project funded unless you give it a cutesy/cool acronym. This ends up stifling communication because each group has its own pet vernacular that obfuscates meaning unless you are inside the circle. They could benefit from clear, concise communication that gets to the point

Read the full deck and tell me what is hard to understand: https://www.nasa.gov/pdf/2203main_COL_debris_boeing_030123.p...

So the real slide was actually quite different from the one presented in the article. The article shows various errors not present in the real slide (vaires, e.?g., Ln, hanrd). The real slide also use different font weights and bullet symbols. Was that intentional to give a bad impression, or just really sloppy? Or were those slides cleaned up?

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

#92

Post by speedplane »

henvic wrote: post #90
davidmr wrote: post #9

Earlier quoted context omitted.

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…

They acted irresponsibly. They should respond for their actions. They had a responsibility and failed miserably. I have no pity for such lack of professionalism. You are correct in saying that it is not so easy and that these structures take a life of their own but this shouldn't be an excuse and we see disasters happening over and over because people don't act as professional. Anyone on the room seeing such mistakes…

> They acted irresponsibly. They should respond for their actions.

It's satisfying to point to a handful of people to place blame, but it isn't terribly scientific. We should be asking why they asked irresponsibly. The folks making these decisions didn't just act in a vacuum, they were a product of NASA, systems engineering at large, a bureaucratic institution, and our own societal norms.

It's likely that others who went through similar training and operated in a similar environment would have made the same decision. But even if the bad call was due to a few bad apples that inserted themselves into the decision making process, we should ask how we allowed them to get there.

Punishing an individual may or may not be warranted in this case, I suspect that the guilt they must live with is punishment enough. However, what's clear is that punishment won't be enough to prevent similar problems from arising again.

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

#93

Post by pjtr »

"there is a huge amount of text, more than 100 words"

"PowerPoint briefing slides instead of technical papers"

Would technical papers have fewer than 100 words?

If people can't be bothered to read 13 slides, what would they do with a technical paper?

If people can't be bothered to make their message clear in slides, how would they create a readable technical paper?

I don't like presentations that consist of "monotonously reading [bullets] as we read along" either. But what does PowerPoint have to do with this? I've seen such presentations done with trendy web tools instead; they don't change anything. I've also read full technical papers written in LaTeX that didn't manage to get their point through the unclear writing (and vaguely misused technical jargon buzzwords).

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

#94

Post by VeninVidiaVicii »

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…

For the past two years I have worked in the local emergency room as a technician working on getting some clinical experience. Let me tell you, in the constant face of life and death, you really just develop a kind of "danger fatigue" and even the most critical moments become somewhat prosaic.

You begin to develop a false sense of security after nobody really does from a gunshot wound. Then, someone septic comes in, and "seems" fine, and they're dead in a few hours.

I'm not sure what this kind of logical fallacy is, but I suspect it's similar in a government environment, where you're constantly at RED ALERT. The risk of danger just seems overstated, even when it isn't.

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

#95

Post by ApolloFortyNine »

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…

Actually there was a similar situation during Apollo 13 having to do with possible damage to the heat shield. They had no way to know if the heat shield had been damaged or not by the explosion, and even if they did find out they couldn't have fixed it.

My readings of the Colombia disaster have yielded similar results, unless someone can tell me of a way to repair the tiles on the shuttle. Launching Atlantis early was, as far as I know, determined to be possible only afterwards. At the time they had no idea it could be done, and honestly it sounds like a chance to risk 14 lives instead of 7. Or at least 8, I'm not aware of how many people were actually required to fly the shuttle.

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

#96

Post by henvic »

speedplane wrote: post #92
henvic wrote: post #90

Earlier quoted context omitted.

They acted irresponsibly. They should respond for their actions. They had a responsibility and failed miserably. I have no pity for such lack of professionalism. You are correct in saying that it is not so easy and that these structures take a life of their own but this shouldn't be an excuse and we see disasters happening over and over because people don't act as professional. Anyone on the room seeing such mistakes…

> They acted irresponsibly. They should respond for their actions. It's satisfying to point to a handful of people to place blame, but it isn't terribly scientific. We should be asking why they asked irresponsibly. The folks making these decisions didn't just act in a vacuum, they were a product of NASA, systems engineering at large, a bureaucratic institution, and our own societal norms. It's likely that others who…

> We should be asking why they asked irresponsibly. > I suspect that the guilt they must live with is punishment enough. We should ask this for the sake of science. However, it is not only accident prevention here that should be at stake here. They signed off and should be held responsible. I'm not even talking about punishment here but about repairing the damages done.

This is a question of justice first of all. Punishing for the sake of punishment is not the way forward. It is true that people will think twice [before dismissing such kind of complains] if they see that you can't get away with [unintended] murder but this should be a secondary, positive side-effect only. If you try to punish to send a message it might be unjust, send the wrong message (like, silencing whistleblowers that have doubts or people from fixing their own mistakes), or both.

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

#97

Post by speedplane »

pjtr wrote: post #93

"there is a huge amount of text, more than 100 words" "PowerPoint briefing slides instead of technical papers" Would technical papers have fewer than 100 words? If people can't be bothered to read 13 slides, what would they do with a technical paper? If people can't be bothered to make their message clear in slides, how would they create a readable technical paper? I don't like presentations that consist of "monotono…

> If people can't be bothered to make their message clear in slides, how would they create a readable technical paper?

Slides are not the same as or replacements for technical papers. Even by comparing them, you're making the same mistake as these engineers did. Compared to a paper, the downsides of a presentation are that they are typically constrained to just 30-60 minutes, in front of a group of people who may be checking their phones and only be half-engaged. Also, by its very nature, the presenter is speaking, so it's difficult to simultaneously read the slides while listen to the presenter.

The upside of a presentation however, is that you can give it to many people at once, and solicit feedback in real-time.

Accordingly, presentations like this need to be far tighter than technical papers. There needs to be much more work invested in prioritizing the issues that you discuss, they should take advantage of the advantages of the form (e.g., utilizing the skills of the audience), and minimize the disadvantages (short time-frame, and no monopoly on attention).

As a starter, you should never put a single word on a slide that you do not say out-loud. There's nothing worse than putting a block of text on a screen and talking about it. The astute audience members will listen to you while reading the text, and in the process not internalizing either. Most audience members will just have their eyes glaze over and then check their phones.

Sadly, engineers are often taught how to write technical papers, but not how to give effective technical presentations.

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

#98

Post by speedplane »

hughes wrote: post #49

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, putti…

> The speed listed in the introduction is wildly wrong. The foam could not possibly have hit at 28968 km/h

The article said "[a]s the crew rose at 28,968 kilometres per hour the piece of foam collided with one of the tiles". It did not say that it collided with the tiles at 28k km/hr, just that it collided with it during it's acceleration to that speed. So technically it's correct, but I definitely agree that it it's a false implication, likely added for dramatic effect.

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

#99

Post by hodgesrm »

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…

I wonder if they would really would have been any clearer without PowerPoint. The person who wrote that slide seemed fully capable of obscuring the message in any medium.

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

#100

Post by speedplane »

henvic wrote: post #96
speedplane wrote: post #92

Earlier quoted context omitted.

> They acted irresponsibly. They should respond for their actions. It's satisfying to point to a handful of people to place blame, but it isn't terribly scientific. We should be asking why they asked irresponsibly. The folks making these decisions didn't just act in a vacuum, they were a product of NASA, systems engineering at large, a bureaucratic institution, and our own societal norms. It's likely that others who…

> We should be asking why they asked irresponsibly. > I suspect that the guilt they must live with is punishment enough. We should ask this for the sake of science. However, it is not only accident prevention here that should be at stake here. They signed off and should be held responsible. I'm not even talking about punishment here but about repairing the damages done. This is a question of justice first of all. Pun…

> This is a question of justice first of all.

No it's not. This is a question of optimizing spaceflight for safety.

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