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

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

#61

Post by thrwy_918 »

whartung wrote: post #39
gmiller123456 wrote: post #22

Kinda pointless to show the slide without the audio of the presenter to go with it. Unless we're thinking the presenter just read the slide verbatim with no extra context, and no questions were asked, which would essentially defeat the purpose of having a presenter and audience present at the same time. I know I've seen presenters actually do that, but the author didn't provide any indication that that's what happene…

Well, that's kind of the point. The people making the decisions, whether they listened to the presentation or not, perhaps gave too much credence to what was on the slide. The audio portion is temporal, even if recorded. You're there in the moment listening, but it doesn't necessarily last. But the slide is "eternal". Always there to be referenced, or passed along. The slide was going to be viewed repeatedly over a l…

> Similarly for technical papers. Read the intro, the summary, skip to the end, read the conclusion.

This isn't an appropriate comparison. The purpose of the conclusion is to present the findings of the paper, whereas the purpose of presentation slides is not (or at least, should not be) to summarize the content of the presentation.

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

#62

Post by lostcolony »

TobTobXX wrote: post #56
giantg2 wrote: post #50

Earlier quoted context omitted.

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.

Yep; this slide was worse than useless in that to the given audience it could instead read as an endorsement that launching is fine.

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

#63

Post by giantg2 »

Iolaum wrote: post #53
giantg2 wrote: 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…

True, there are better ways to word it. That does leave out some detail that the original one had, like test velocity and not showing the thought process as well (like a formula on a math slide or deductive argument in philosophy).

My main point is that the title claims thus slide is what killed 7 people and basically blames the creator, but leaves out all the other failures. Slide formatting and wording (which ignores the actual discussion that should have gone with it) is really inconsequential compared to the rest of the process in a briefing.

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

#64

Post by mannykannot »

gmiller123456 wrote: post #22

Kinda pointless to show the slide without the audio of the presenter to go with it. Unless we're thinking the presenter just read the slide verbatim with no extra context, and no questions were asked, which would essentially defeat the purpose of having a presenter and audience present at the same time. I know I've seen presenters actually do that, but the author didn't provide any indication that that's what happene…

Indeed, and the article leaves out other relevant issues, such as where else the question was discussed, and also when - the article rather glibly suggests a rescue mission could have been launched, but that would have been a very risky action in its own right, even if it had been started on the day of the launch; it remains uncertain whether Columbia's oxygen could have been stretched out long enough even then. There were no other alternatives.

This led to a certain realistic fatalism:

"Then [Linda Ham] delivered the sentence that would define the rest of the tragedy; a sentence that was repeated as common wisdom by almost every senior manager that I talked to over the next two weeks: ‘You know, if there was any real damage done to the wing, there is nothing we can do about it.’ As unsettling as that was, I had to agree; going back to the first shuttle flight it had been well known that there was no way to repair the heat shield in flight. Nobody, not even me, thought about a rescue mission. Why would we?" - Wayne Hale, https://waynehale.wordpress.com/2013/01/07/after-ten-years-d...

Once it became clear, during the investigation, that the foam impact had created a hole in the reinforced carbon-carbon leading edge of the wing, the board's chairman, Admiral Hal Gehman, insisted that a test should be performed to demonstrate that this was likely. As this meant destroying one of the few spare parts, and it had not been decided at this point to retire the shuttles, he was unsure whether this was worth doing, but what convinced him to go ahead was the number of engineers and managers who still doubted this could have happened, despite all the evidence.

It is never just one thing.

The whole of Wayne Hale's retrospective starts here: https://waynehale.wordpress.com/2012/08/14/after-ten-years-w...

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

#65

Post by rhema »

Tufte isn't exactly wrong, but the way he writes has so much certainty in it. In reality, the design choices people make in the media they use has as much to do with social norms and culture as what really works.

Alternatives like Prezi exist, but are not really going to be accepted in formal presentations https://infovisu.com/assets/pubs/linder2015beyond.pdf .

If you really bring me a physical piece of paper today, I doubt I would be able to keep track of it.

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

#66

Post by giantg2 »

lostcolony wrote: post #60
Iolaum wrote: post #53

Earlier quoted context omitted.

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"

The damage happened during launch. Unless you're talking about how the insulation was old and NASA knew that insulation can, and had in the past, struck shuttles.

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

#67

Post by bumby »

giantg2 wrote: 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…

>The title is saying we need to be careful because a tile was likely penetrated.

To the point of the article, I think this is the wrong takeaway, meaning the slides were not communicating effectively.

The second point illustrates this. It says the models were overpredicting the penetration. Meaning the models were conservative and the the actual penetration was likely less than what models show. They were setting the table for an optimistic outlook.

The real issue, IMO, is highlighted later in the article where there isn't sufficient fidelity in the tests to back up those claims. Tests after the incident showed the foam acted very differently at the delta-v that actually occurred.

And regarding your point about blaming contractors, the vast majority of work done by NASA is done by contractors. NASA is, to some extent, a pass-through organization that funds other organizations like Boeing, Lockheed, Honeywell, Jacobs, etc.

>If you thought they didn't know, then ask them what they do know!

This gets to the same cognitive biases that led to Challenger, EVA 23 and a host of smaller incidents nobody hears about. Data is not objectively weighed in these situations because of schedule pressure, optimism bias, etc. In this case, most launches were showing foam shedding with no issue, so it lead to a false belief that it wasn't dangerous even though it was out-of-spec. Add to that a slide that says the models are too conservative and you can see where cognitive biases may influence the decision. Lastly, most people like to think they're self-aware enough to identify these biases in real-time, but they aren't. It's also why the incident lead to a separate organization within NASA focused on safety, quality, and risk that has a segregated chain of command.

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

#68

Post by raverbashing »

giantg2 wrote: 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…

No, even for an engineering slide this is apalling

I'm not so sure how many people are familiar with the term "conservatism" as used here. I'm not. Some might be aware, those who are not aware will just skip over

I read this slide a couple of times. There's no thought order, no connection between the topics (even if we assume people are familiar with the subject) and several typos.

It is not a Powerpoint fault it is a fault of whoever wrote this.

This is an issue with information hierarchy. If this is a risk (and I can't imagine what might have been a bigger risk at that mission) it needs to be brought into attention. Not added to line 4 of slide 7 and be done with it.

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

#69

Post by Chris2048 »

einpoklum wrote: post #49
jimmaswell wrote: post #25

> This allowed NASA managers to imply a hierarchy of importance in their head: the writing lower down and in smaller font was ignored These managers were REALLY that braindead? These are NASA managers in charge of life-or-death decisions, and their dull eyes glaze over as spittle puddles underneath them because they're too stupid to read one whole entire paragraph worth of text without ignoring subheadings because th…

> These managers were REALLY that braindead? These are NASA managers in charge of life-or-death decisions If you're in charge of 10000 life-or-death decisions, and are on a tight schedule, you are unlikely to give each of them its proper attention.

This doesn't sound like a normal decision, but a rather big one. Also, after 9,999 decisions, I'd expect you to be pretty good at picking out what's important.

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

#70

Post by bumby »

zelos wrote: post #44
giantg2 wrote: 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…

Maybe, but I don't think anyone can deny that it is an appalling slide. I count 3 spelling and grammatical errors alone. It looks like the bad "before" example in a presentation skills workshop. This was created by engineers working on life and death issues involving billions of dollars of hardware.

I agree with you, but to be charitable, this was a real-time and evolving situation where I'm willing to bet the slide was expected to be finished "yesterday"
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