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

mcdreeamiemusings.com

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

#51
I have an issue with the title of this piece. PowerPoint did not kill anyone. There are good people out there writing PowerPoint, and they should never be made to feel like their presentation software is responsible for seven people dying tragically. This was an engineering failure and a communication failure, but cannot and should not be laid at the feet of PowerPoint.

Alternative title: death by ears, how failing to listen and communicate killed seven people.

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

#52
A question I often ask myself (though I don't work with anything with actual human risk) - when are my concerns valid and when am I coming off as just having a bleak outlook.

My own personal experience is that it's easier to be concerned with the small things (we have to have naming conventions), than with big things (are we building the right thing). I think there is a tendency to think "it'll probably work out".

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

#53
post #13

Another NASA screw-up that they're trying to pin on the vendor engineers, just like Challenger. The title is not reassuring. Conservatism in engineering is essentially about creating safety margins through conservative estimation. The title is saying we need to be careful because a tile was likely penetrated. Hell, if I remember correctly they were reporting that there was known tile damage on the news before reentry…

I tried to read the powerpoint and it was not an easy task. The main point of the powerpoint is not supposed to be an answer to a riddle of fonts and words.

A quick and dirty re-writing of the title (and slide):

_______________

Review of Test data indicates incident is well outside of safety margins.

- Volume of ramp is 1920 cu in vs 3 cu in for test

- Once tile is penetrated SOFI can cause significant damage.

- Flight condition significantly outside of test database

_______________

Now that should get a reader's attention.

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

#54
post #42
post #13

Another NASA screw-up that they're trying to pin on the vendor engineers, just like Challenger. The title is not reassuring. Conservatism in engineering is essentially about creating safety margins through conservative estimation. The title is saying we need to be careful because a tile was likely penetrated. Hell, if I remember correctly they were reporting that there was known tile damage on the news before reentry…

You're being downvoted because the entire process that lead to this decision has been massively analyzed and the root causes were determined.

And was it determined that this slide killed 7 people, as claimed in the title? That seems overly dramatic and ignores the other root causes.

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

#55
post #13

Another NASA screw-up that they're trying to pin on the vendor engineers, just like Challenger. The title is not reassuring. Conservatism in engineering is essentially about creating safety margins through conservative estimation. The title is saying we need to be careful because a tile was likely penetrated. Hell, if I remember correctly they were reporting that there was known tile damage on the news before reentry…

> Another NASA screw-up that they're trying to pin on the vendor engineers, just like Challenger.

And, for context, Edward Tufte, whose review of the slides is being referenced in this article, is the same one who misunderstood and misrepresented what the actual issue was during the briefing the night before the Challenger launch, in his paper reviewing the presentation the engineers made then.

Edit: previous HN discussions of Tufte's Challenger review here:

https://news.ycombinator.com/item?id=10989358

https://news.ycombinator.com/item?id=19034783

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

#56
post #50

Earlier quoted context omitted.

I came in knowing the outcome, and roughly the point being made, but still found the conclusion of the slide hard to suss out. There were other failures in the chain as well for sure, but I don't think this is just a hit job on NASA vendors.

The title of this post is claiming this slide killed 7 people. That's a pretty bold and accusatory claim that seems to leave out the other failures, right?

From the article (emphasis mine):

> This, however, is the story of a PowerPoint slide that actually _helped_ kill seven people.

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

#57
post #27

> There were a number of options. The astronauts could perform a spacewalk and visually inspect the hull. NASA could launch another Space Shuttle to pick the crew up. Or they could risk re-entry. That's not how I remember it being presented to the public. The official word at the time was that there were no feasible rescue options. Yes, they could have done a spacewalk to inspect the damage but if it had been bad the…

https://spaceflightnow.com/columbia/report/rescue.html

Atlantis was already scheduled for launch 41 days after Columbia. Columbia had ~30 days of air. NASA believed that Atlantis prep could have been accelerated and launched in time to attempt a rescue.

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

#58
post #19

I've seen presentations with Powerpoint that suck the life out of you and also ones that inspire and excite. It's not the tool, it's the presenter and how they wield the tool. Reading word for word off a text-heavy deck in a monotone with no images or diagrams is a recipe for disaster. I tend to have my decks (back when I was doing presentations) be relatively text-lite and involve images/diagrams that back up my tal…

PowerPoint decks for the upper tiers of an organization can take on a whole different character. I shit you not that it's common to pass them around in email as if they were a document format, even for information that is never intended or expected to be presented. As if they were PDFs or something. It's crazy. [EDIT] There's also a kind of horrendous, illegible house style some places, that's expected to be how thes…

It's not unusual for the management/BOD decks I work on to be 30 slides + 100 slides of appendix material. Everything in the 30 slides is heavily footnoted and supplemental/support information is in the appendix. It's kind of bonkers but pretty much standard practice at certain sized companies.

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

#59
post #13

Another NASA screw-up that they're trying to pin on the vendor engineers, just like Challenger. The title is not reassuring. Conservatism in engineering is essentially about creating safety margins through conservative estimation. The title is saying we need to be careful because a tile was likely penetrated. Hell, if I remember correctly they were reporting that there was known tile damage on the news before reentry…

In this case the vendor engineers were from Boeing - Ya know, the same company that brought us the 737MAX MCAS fiasco. I mean sure, hindsight is a wonderful thing but given the history of Boeing engineering culture since their merger with McDonnell Douglas I can see the possibility of someone gliding over something inconvenient

(not the one that downvoted your comment btw)

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

#60
post #53
post #13

Another NASA screw-up that they're trying to pin on the vendor engineers, just like Challenger. The title is not reassuring. Conservatism in engineering is essentially about creating safety margins through conservative estimation. The title is saying we need to be careful because a tile was likely penetrated. Hell, if I remember correctly they were reporting that there was known tile damage on the news before reentry…

I tried to read the powerpoint and it was not an easy task. The main point of the powerpoint is not supposed to be an answer to a riddle of fonts and words. A quick and dirty re-writing of the title (and slide): _______________ Review of Test data indicates incident is well outside of safety margins. - Volume of ramp is 1920 cu in vs 3 cu in for test - Once tile is penetrated SOFI can cause significant damage. - Flig…

Hell, it's even probably fair to make an editorial conclusion at the end -

"Given this, we strongly recommend against launch"

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