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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

#111

Post by TeMPOraL »

rayiner wrote: post #27
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.

> But that doesn't mean the PPT slide is at fault. I think it's a bit of poetic license to say that the PPT is at fault. But didn't help. Many mistakes lead to an outcome like this one. But this PPT is one of those mistakes. The basic information is there for a very significant point--we know penetration can happen with a sufficiently large or sufficiently fast-moving piece of foam, and this piece of foam is 600 time…

> I think it's a bit of poetic license to say that the PPT is at fault. But didn't help.

Poetic license in journalism doesn't help either. What we got here is pure clickbait, literally accusing something of killing people, when it was just one among many things that were suboptimal and just "didn't help".

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

#112

Post by raducu »

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 sure they are not "idiots", but these are people who usually have done well in school/academia where saying "stop, don't do it!" is never the right answer; these are people who were never promoted to where they are now for saying "stop, don't do it!".

Recently I've seen a product owner trying to push us on a two week sprint where we needed to complete 100 story points worth of tasks while on the previous two sprints we only completed ~30 story points. To my protest, the SCRUM master sided with the product owner in saying we should go ahead and commit to the goal.

These are not stupid people, they were under pressure to deliver; unfortunately the incentives are not to listed to reasonable people, but to pushers; when the shit hits the fan, they make a big fuss and obtain even more resources to push even harder and they usually deliver -- whit 3X the costs.

Very rarely have I seen reasonable and smooth-sailing managers get to the top, usually it's the die-hard/hard-pushers/busy-appearing types that get to the top.

I think it's curse of modern society with its unlimited resources; this shit would never fly in the times of Sun Tzu or Caesar precisely because limited resources would prevent such smart "idiots" -- they'd succumb to the elements or their subordinates would do them in their sleep for being so detached from reality.

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

#113

Post by jplayer01 »

yitchelle wrote: post #101
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…

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.

I don't think he's that far off the mark. Take the seals. This wasn't a one-off decision. This was a problem that was known for years and repeatedly ignored at lower and lower temperatures (thus lowering the allowed limits far below the original specifications) until the disaster. The reasoning being "well, you warned us last time, but everything went fine, so let's just keep going, it'll keep being fine".

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

#114

Post by TeMPOraL »

kyberias wrote: post #107

Kinda weird to even hint that the tool used to communicate would be the cause of the disaster. The same words could have been written in LaTeX and presented with a PostScript viewer running in Linux.

They very much could. In terms of language, the whole slide deck in question is essentially a scientific paper in PPT form, and scientific papers tend to be typically written in LaTeX.

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

#115

Post by ovi256 »

darkpuma wrote: post #63
TheDong wrote: post #57

Earlier quoted context omitted.

> Not firing or disciplining these managers will cause similar disasters in future. I think the quote is something like "Why would I fire them, we just lost X lives and dollars training them?"

That doesn't seem to quite square with them being reassigned. In Ham's particular example: > "Ham's attitude, and her dismissal of dissenting points of view from engineers, was identified as part of a larger cultural problem at NASA.[2] After the report's release, Ham was demoted and transferred out of her management position in the space shuttle program. "

That's the best option if you want to be able to rebuild confidence in the chain of command. The people who have been ignored before will never trust her again anyway. In such situations, you either rebuild the chain of command or the whole troop if you want to have a functioning group.

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

#116

Post by philpem »

raducu wrote: post #112
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…

For sure they are not "idiots", but these are people who usually have done well in school/academia where saying "stop, don't do it!" is never the right answer; these are people who were never promoted to where they are now for saying "stop, don't do it!". Recently I've seen a product owner trying to push us on a two week sprint where we needed to complete 100 story points worth of tasks while on the previous two spri…

With the obvious warnings about limited sample size, anecdotal evidence and so on...

I've encountered a few people with this trait, and the general trend I've noticed is an excess of optimism and a hint of complacency.

"I have the utmost faith that my team can do 100 hours of work in 25!"

"We did 75 scheduled hours of work in 15. That means we can easily do 100 in 25." (completely overlooking that the team - by that point - had been working from 7am until 9pm for the entire week, ordered food in and had to take several days PTO to recover)

Curiously these are usually the same managers who demand crunch-time, but "have a prior engagement" when the team asks if they'll be helping too.

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

#117

Post by TeMPOraL »

noego wrote: post #54
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…

Your post reads like one of those classic "Guns don't kill people, people kill people" slogans. Sure, but guns make it a whole lot easier. No one is innocent here - there's plenty of blame to go around. One of the key skills in being a senior engineer, is knowing how to communicate clearly with managers and decision-makers who don't have the same level of technical knowledge that you do. Communication is an extremely…

No; what the article is doing is equivalent to blaming the whole World War II on MP 40 machine pistols. Sure, that SMG killed a lot of people, but it's not the only gun that killed people, it's not the gun that started the war, and it had almost nothing to do with the causes and the course of the conflict.

A PowerPoint presentation did not kill the astronauts. Hell, judging by the full slide deck (elsewhere in the comments), the presentation wasn't even that bad - it was detached, the way scientific papers are detached. Could it be better? Yes. Should it be blamed for this? Not really.

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

#118

Post by andreareina »

VeninVidiaVicii wrote: post #94
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…

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…

Not quite what you're talking about, but very much related is normalization of deviance:

What these disasters typically reveal is that the factors accounting for them usually had “long incubation periods, typified by rule violations, discrepant events that accumulated unnoticed, and cultural beliefs about hazards that together prevented interventions that might have staved off harmful outcomes”. Furthermore, it is especially striking how multiple rule violations and lapses can coalesce so as to enable a disaster's occurrence.

[1] https://danluu.com/wat/

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

#119

Post by bloak »

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…

Also on the roads. So many people drive round a blind corner at high speed because they do the journey every day and the road is always empty. Until one day it isn't.

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

#120

Post by maze-le »

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…

Actually, despite the headline the article states it clearly.

>> NASA managers listened to the engineers and their PowerPoint. The engineers felt they had communicated the potential risks. NASA felt the engineers didn’t know what would happen but that all data pointed to there not being enough damage to put the lives of the crew in danger. They rejected the other options and pushed ahead with Columbia re-entering Earth’s atmosphere as normal.

This is it. Not any slideshow or wrong communication of risks, but lack of responsibility.

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