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Death by PowerPoint: the slide that killed seven people (2019)

mcdreeamiemusings.com

131–140 of 204 posts

Re: Death by PowerPoint: the slide that killed seven people (2019)

#131
Diane Vaughn's The Challenger Launch Decision misattributes responsibility for the disaster to the meeting in which a similar slide was shown.

When the shuttle design was finalized in the late 1970s they knew it had a 2-3% chance of a hull loss per launch. They were still planning to launch it 50 times a year so that would have meant losing a shuttle and crew every year!

The shuttle had hundreds of critical flaws and that 'normalization of deviance' meeting at which slides like this were shown at was a routine part of each shuttle launch. For each of these unacceptable situations they had to convince themselves that, with some mitigation (or not), they could accept it. It was inevitable that something like this was going to happen and then there would be recriminations about the details of that meeting.

Every other crewed space vehicle had an escape system to get the crew away from a failed rocket. The Challenger crew survived the explosion but were killed when the reinforced crew section hit the ocean. Similarly the Colombia astronauts were killed by a thermal protection system that was "unsafe at any speed". When the first few shuttles were launched there was a huge amount of concern about tiles breaking and coming off. Once they'd dodged the bullet a few times they assumed it was alright but it wasn't...

In the literature "normalization of deviance" has turned from a formal process used in managing dangerous technology to incidents such as: surgeon takes a crap and goes to work without washing his hands, forklift operator smokes pot and operates, etc.

Re: Death by PowerPoint: the slide that killed seven people (2019)

#132
That powerpoint is truly opaque. The culture of work that resulted in that powerpoint being used hopefully is no more. I wonder if one can connect that to the Boeing Max disaster.

We don't need Tufte and his subtle points to see this was an abominable piece of communication. More important, would be the question "is it safe to call out a bull shit slide in a corporate meeting". We hear of how Bezos or Jobs would be rude and obnoxious to their employees when something was not laid out clearly. This, on the other hand is where politeness takes us.

Re: Death by PowerPoint: the slide that killed seven people (2019)

#134
post #29

Linked from Tufte’s article, I found this interesting comment from someone’s experience at Microsoft: [1] > Attempting to have slides serve both as projected visuals and as stand-alone handouts makes for bad visuals and bad documentation. Yet, this is a typical, acceptable approach. PowerPoint (or Keynote) is a tool for displaying visual information, information that helps you tell your story, make your case, or prov…

I don't know. Over time, I've learned to appreciate the kind of slides physicists make, which follow all the "worst practices". They are very dense, with lots of plots and text. They are like, I imagine in the olden days, when people would draw things on blackboards or print out their plots, and sit around them and interpret them. They are the material, and what the presenter does is walking the audience through the material. Compared with a scientific paper, they lack all the prose and weird formal phrases that make papers hard to read. You basically just show what your colleagues need to work with, not less or more. Most importantly, you are not trying to persuade anybody.

My experience outside of academia is that people use PowerPoint exactly for persuasion. Even to the degree that when I wanted to prepare a presentation internally, one of my bosses got angry because he thought I was going to bullshit him. (PowerPoint is something you do to a customer or to the board, not to your colleagues.)

Re: Death by PowerPoint: the slide that killed seven people (2019)

#135
post #29

Linked from Tufte’s article, I found this interesting comment from someone’s experience at Microsoft: [1] > Attempting to have slides serve both as projected visuals and as stand-alone handouts makes for bad visuals and bad documentation. Yet, this is a typical, acceptable approach. PowerPoint (or Keynote) is a tool for displaying visual information, information that helps you tell your story, make your case, or prov…

Powerpoint even has a special mode for creating handouts, by printing a non-displayed notes section. There's no need to put the outline on the slides... other than being less effort.

Re: Death by PowerPoint: the slide that killed seven people (2019)

#136
post #29

Linked from Tufte’s article, I found this interesting comment from someone’s experience at Microsoft: [1] > Attempting to have slides serve both as projected visuals and as stand-alone handouts makes for bad visuals and bad documentation. Yet, this is a typical, acceptable approach. PowerPoint (or Keynote) is a tool for displaying visual information, information that helps you tell your story, make your case, or prov…

What's are "screen-shaped pages"? My screens are all kinds of ratios and orientations.

I wish pdf would die. It's a left over vestage of a paper world. It's also left over from a non-connected, non-international world A4 vs US Letter.

PDF really has no place in this smartphone first world

Re: Death by PowerPoint: the slide that killed seven people (2019)

#137
post #130
post #126

Earlier quoted context omitted.

That points to a far more fundamental problem. Related to information processing higher up in the organisation. Just making better slides is unlikely to solve that problem.

Probably correct, and I have doubts that those types of problems are easily fixed because they're rooted in human psychology. It's interesting to me that the "big" incidents seem to occur every 15-20 years, almost as if there is a new professional cohort who has to learn the hard way. I do think clear communication is a necessary, but insufficient, element of fixing that problem.

One thing I wonder about with these kinds of accidents: to what extend does operational experience work its way back to requirements of components.

For example, if regularly pieces of foam are hitting the tiles after launch, was that part of the specs for the tiles to handle that? Did anybody go back, take a worst case scenario of a piece foam hitting a tile (size, speed, etc.) and verify that the tiles could handle such an impact?

Re: Death by PowerPoint: the slide that killed seven people (2019)

#138
post #95

The title is wrong - it didn't kill 7 people. And it is stated in the article that it "helped" kill 7 people, but even that is a leap. For all we know the slide actually reduced the percentage chance of this happening by .0001%. We can't actually know. We might as well blame it on the guy that was in charge of the foam order but had an extra extra long poop in the morning that reduced his work hours that day and he o…

Yeah. So why not walk off a cliff? Who knows what will happen when you walk off a cliff? It's impossible to know. Chaos theory and all that.

Re: Death by PowerPoint: the slide that killed seven people (2019)

#139
post #123

Earlier quoted context omitted.

Unbelievable, I've never copied text from a PDF without some error. It's baffling how broken that system is compared to say, text selection in web browsers. If you start doing fancy CSS tricks you can break that too, of course.

In a PDF, every single glyph could be independently positioned. Most aren’t quite that pathological, but frequently every text run is independent.

A PDF can contain metadata that correctly sequences the characters which is great for cut-n-paste, accessibility and reflowing the text. That metadata is frequently absent and the mechanism for incorporating it is by no means simple.
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