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

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

#131

Post by rayiner » Tue, Apr 16, 2019, 8:45 PM UTC

caconym_ wrote: post #123

peteradio wrote: post #75

Earlier quoted context omitted.

So what exactly is technically dense/ambiguous in this summary presentation (remember this isn't the only information provided). Perhaps you'd like to review the full deck of slides rather than the single one picked by the asshole author, I'm particularly interested in the one titled "Damage Results From “Crater” Equations Show Significant Tile Damage" . https://www.nasa.gov/pdf/2203main_COL_debris_boeing_030123.p...

The title, "Review of Test Data Indicates Conservatism for Tile Penetration" is completely ambiguous to the point of being nonsensical. It is impossible to know in which direction the author of the slides thinks we should be conservative. Ironically the slide you point out ("Damage Results From 'Crater' Equations Show Significant Tile Damage") seems to skew our interpretation of the next slide's title and content in…

This is a great point. The beginning of the disputed slide continues to build up a point—Crater (the prediction software) is overly conservative. The major caveat that the test data is far afield from the actual situation is buried at the bottom of all that.

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

#132

Post by aeternus » Tue, Apr 16, 2019, 9:03 PM UTC

OnlyOneCannolo wrote: post #42

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…

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 qu…

It's easy for us to past judgement in hindsight, but what is an acceptable failure rate? For Apollo, I believe it was around 7-8%. There's always going to be some risk, what you don't see is all the times those administrators correctly identified a risk as acceptable, or scrubbed a mission due to inaccurate risk assessment.

A space program that demands better than six-sigma risk for example is unlikely to ever get off the ground.

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

#133

Post by OnlyOneCannolo » Wed, Apr 17, 2019, 12:13 AM UTC

aeternus wrote: post #132

OnlyOneCannolo wrote: post #42

Earlier quoted context omitted.

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 qu…

It's easy for us to past judgement in hindsight, but what is an acceptable failure rate? For Apollo, I believe it was around 7-8%. There's always going to be some risk, what you don't see is all the times those administrators correctly identified a risk as acceptable, or scrubbed a mission due to inaccurate risk assessment. A space program that demands better than six-sigma risk for example is unlikely to ever get of…

Although I'm technically judging in hindsight since I wasn't there, I don't think I'm being unfair in my judgement. I have experience in safety and I've seen better and worse safety reviews than this one. Although there were plenty of external factors that pushed people to act the way they did, the people we're talking about were the responsible authority for vetting these issues. It was their job to take ownership of the issues and their inquiries, and they failed to conduct themselves appropriately.

Just because their mistake didn't push the failure rate past the acceptable limit doesn't absolve them of anything.

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

#134

Post by sytelus » Wed, Apr 17, 2019, 3:50 AM UTC

TLDR; Engineers had found that there was risk of foam detachment, NASA managers thought that risk was not flagged significant to halt the mission.

In retrospect, it's easy to blame decision makers but here's the thing: If I told you that risk of you dying is 1 in 103 if you drive the car today, would you still drive? Relatively risk of fatal accident in Space Shuttle program was 1 in 62.

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

#135

Post by Schwolop » Thu, Apr 18, 2019, 4:50 AM UTC

utborin wrote: post #103

VeninVidiaVicii wrote: post #94

Earlier quoted context omitted.

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, a…

A very similar phenomenon happens in aviation—we call it complacency. Thousands of successful takeoffs in a row make it hard sometimes to remember that each one is a completely independent event. The way I fight it is by explicitly reminding myself that just because something worked yesterday, that doesn't mean I can skip a step today or let my guard down at any point. It really does take deliberate thought though. F…

Sometimes there are comparatively simple lifehacks you can establish to prevent complacency from leading to problems.

A little example from my life is forgetting to secure the buckle of my motorcycle helmet. Once I've done everything else and gotten my gloves on, it's a pain to take them off again to buckle it up if I forget, and a few times I just shrugged it off and rode anyway.

Then an instructor suggested he always follows exactly the same procedure each time, to the point that he always even puts the same glove on first. It made me wonder if I should do that, and in thinking it through I realised if I changed my order to always buckle up before putting my glasses back on, I'd never forget. There's no way I'd ride off without the glasses (because I can't see without them!), so if that step can only come _after_ buckling up, then there's now no way I'd ever not buckle it up either.