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Death by PowerPoint: The slide that killed seven people

mcdreeamiemusings.com

101–110 of 135 posts

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

#101
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…

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…

I hear what you are saying and agree with the danger fatigue observation, but it is different to the managers at NASA and Boeing that are reviewing the slides.

By default of your situation, you are facing these life and death decisions on a constant basis. The NASA and Boeing managers do not. I can't imagine they are part life and death scenarios very often, if at all.

Critical thinking failed them that day.

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

#103
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…

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. Funny how the brain works.

(The upside is that every successful takeoff becomes a delightful surprise!)

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

#104
post #24

Earlier quoted context omitted.

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 an…

> Summary: Engineers need copyrighting and sales training as well.

Waaait. Your comment essentially established two things: that journalists receive training on how to write properly, and that successful salesy type know how to bullshit their audience to get what their want. I think the conclusion doesn't follow.

Observe that journalists universally don't apply their writing training - in fact, modern news reporting is one of the worst kind of writing out there, with the lede buried under 30 meters of gravel, and spread on a hectare of land (we call it clickbait only when headline is manipulative). So this shows your training matters little if incentives on the job are in total opposition to it.

As for the sales angle, commercial copywriting isn't exactly a paragon of clarity either. Effectiveness in sales isn't measured in how clearly you communicated costs and benefits, but how excitingly you communicated the benefits, and how effectively you've hidden the drawbacks. Engineering communication shouldn't be manipulative like this.

The way I see it, many engineers could use some communication training, but it should be focused at presenting things clearly and truthfully, and on effectively ELI5-ing things to managers. But beyond that, incentives within organization needs to be adjusted, because it's hard to get an engineer to explain things clearly when their job depends on them not doing it.

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

#105

Earlier quoted context omitted.

> "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 an…

> Summary: Engineers need copyrighting and sales training as well. Waaait. Your comment essentially established two things: that journalists receive training on how to write properly, and that successful salesy type know how to bullshit their audience to get what their want. I think the conclusion doesn't follow. Observe that journalists universally don't apply their writing training - in fact, modern news reporting…

> The way I see it, many engineers could use some communication training, but it should be focused at presenting things clearly and truthfully

There are technical communications courses, in fact, it's a required course at Cornell Engineering. Agreed, it's not at all the same as copyrighting or journalism, but the general level of technical communication is so poor, that even courses in those would be an improvement.

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

#106
post #62

Earlier quoted context omitted.

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"…

> wtf does "overpredicted" mean? That's the second largest font, and it has no visible meaning? Honestly, it reads to me as being along the lines of "overestimated" - and in this sentence would mean "reality wasn't as bad as our predictions, so we have a lot more leeway than we thought".

A mathematical model (here, the crater equations) predicts something. If the prediction turned to be larger than reality, you could say that the model overpredicted.

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

#108
post #82

Earlier quoted context omitted.

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

Thank you for posting the full deck. The conclusion is pretty clearly stated that the engineers thought the shuttle would return safely, even with missing tiles. The focus on this one slide out of context seems totally wrong.

"Contingent on multiple tile loss thermal analysis", i.e. "we're running that model now and until we're done we're not sure, but the tests we did so far suggest that a tile loss should not prevent safe return".

It isn't really that unclear. There are formal words, but - unlike typical managerial presentations - there's also content behind them.

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

#109

Earlier quoted context omitted.

Spacewalks are neither free nor totally safe either. It is possible they calculated that the risk of a spacewalk and the time it would take to do that was worse than attempting re-entry. They were probably wrong, but it's not a free operation.

With hindsight, we can say they were definitely wrong.

Only if you look at things deterministically, which is usually the incorrect approach. It was almost certainly wrong. But you are working with incomplete information.

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

#110

Earlier quoted context omitted.

Yes, and my experience doing so only cements the opinion(s) expressed in my previous comment—to which I'm inclined to say your reply is not terribly relevant. Ambiguous, poorly presented, and technically dense are three different things, though they can all be present in the same place. Only two of them are necessarily bad.

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...

Seconding your comment. The presentation isn't ambiguous, it's just written in a detached, conservative style typical to scientific papers.
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