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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

#81

Post by philwelch »

Endy wrote: post #39
PopePompus wrote: post #29

Earlier quoted context omitted.

There were a number of things they could have tried. No one of the alternatives (except launching a rescue shuttle) could possibly have turned out worse than the course they chose. Instead of an Apollo-13 style "Failure is not an option" effort, Jon Harpold, then the director of Mission Operations, is reported to have said "You know, there is nothing we can do about damage to the thermal protection system. If it has…

In my life up until now, I'd always believed the best of people and doubly so of NASA. Seeing that, and knowing it's true, makes me believe that there is evil in this world. And that man is part of it. Whoever and whatever forces allowed him to get where he was with opinions like that, needlessly sacrificing the lives of seven people and being satisfied that he'd made the right decision needs to be brought to account…

It's not evil, not per se. Evil would be murdering people deliberately. This is incompetence, complacency, and apathy. It's negligence. But it's exactly what we should expect from an agency that knowingly ran an unsurvivable death trap of a launch vehicle for thirty years.

During the early stages of a shuttle launch, prior to SRB separation, the only abort mode available was RTLS--"return to launch site". Unlike Apollo, Soyuz, Dragon, or any other capsule-based spacecraft, which had a launch escape system that could immediately separate the crew capsule from the rest of the launch vehicle and place it in a safe vector to parachute back to the surface, the Shuttle was expected to pitch end-over-end, with the external fuel tank still attached, in an attempt to return to a runway near the launch pad. John Young, the pilot of the first Space Shuttle mission, declined the suggestion to perform a manned test of the RTLS abort mode, stating, "let's not practice Russian roulette." He also noted, "RTLS requires continuous miracles interspersed with acts of God to be successful".

It's not as though a LES would have necessarily saved Challenger, mind you. The explosion was too fast. But if the craft were mounted vertically with the booster stage rather than tandem, and if the abort mode didn't require having a fully intact orbiter and external fuel tank that could perform aerobatic maneuvers at the edge of possibility, there would have at least been a chance. Likewise, such a vertical-stacked design would have completely eliminated the risk of anything like the Columbia disaster.

This isn't to minimize the real, compounding negligence in how the program was executed over the years. But the program was damned to begin with.

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

#82

Post by zaroth »

peteradio wrote: post #79
bumby wrote: post #77

Earlier quoted context omitted.

Use of jargon is a huge impediment to communication in organizations like NASA and DoD. There's even a glib saying that you won't get your project funded unless you give it a cutesy/cool acronym. This ends up stifling communication because each group has its own pet vernacular that obfuscates meaning unless you are inside the circle. They could benefit from clear, concise communication that gets to the point

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.

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

#83

Post by [deleted] »

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…

[deleted]

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

#84

Post by InclinedPlane »

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…

It's important to remember that it was their job to be mindful of the risks. These weren't folks working at a bake sale or something, these were trained professionals who had been entrusted with significant and weighty responsibilities, and they did not take those responsibilities seriously enough. No, they weren't idiots, and that makes it far worse. Negligence is a common human failing, we should remember what it looks like and how it happens, we shouldn't pretend that it doesn't exist or that it should be excused.

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

#85

Post by WillPostForFood »

icelancer wrote: post #17
PhasmaFelis wrote: post #12

Earlier quoted context omitted.

Yeah, it's clear that the slide was poorly written, but it seems very odd to put the lion's share of the blame on the people who presented accurate information poorly, instead of the people who thought it was okay to merely skim a Why on Earth did they veto even doing a spacewalk to inspect the damage, before concluding it was safe?

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.

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

#86

Post by zipperhead »

peteradio wrote: post #79
bumby wrote: post #77

Earlier quoted context omitted.

Use of jargon is a huge impediment to communication in organizations like NASA and DoD. There's even a glib saying that you won't get your project funded unless you give it a cutesy/cool acronym. This ends up stifling communication because each group has its own pet vernacular that obfuscates meaning unless you are inside the circle. They could benefit from clear, concise communication that gets to the point

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

Indeed. The conclusion is:

```` Contingent on multiple tile loss thermal analysis showing no violation of M/OD criteria, safe return indicated even with significant tile damage ````

That's going to be difficult for management to push back against.

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

#87

Post by _cs2017_ »

peteradio wrote: post #60
_cs2017_ wrote: post #26

The authors of the slide either lacked the ability to analyze problems, or lacked the ability to communicate their opinions, or were intentionally obscuring their opinions. Which of these is the more likely explanation? I've seen experienced engineers incapable of expressing their thoughts clearly. But I've also seen well-established organizations that encourage hiding your opinions behind a wall of bullshit.

Have you considered the possibility that in some cases it is basically forbidden from expressing opinions. These guys were tasked to conduct and summarize their studies not opine on the decision to be made, that violates separation of duties and an expressed opinion leads to questions of diligence.

Yes, that's what I meant under "intentionally obscuring their opinions" (for example because of the organizational culture, etc).

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

#88

Post by kiwijamo »

vezycash wrote: post #48
rayiner wrote: 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…

Did you mean copywriting?

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

#89

Post by foobarbecue »

kangnkodos wrote: post #21

During that final Columbia flight, I remember reading a short news story on the internet on the foam falling off. It even had a short video of the foam falling off. (Somewhat of a novelty way back in 2003.) I watched that video several times. I remember being concerned, but confident that NASA would figure it out. Then when I saw the headline that Columbia didn't land, I remember immediately thinking, "On no! The foa…

This sort of thing seems to be standard in journalism. For some reason, the articles never seem to ask the obvious questions or make the obvious connections. I've always been so puzzled by this but I guess it's because there's no incentive to speculate.

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

#90

Post by henvic »

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…

They acted irresponsibly. They should respond for their actions. They had a responsibility and failed miserably.

I have no pity for such lack of professionalism. You are correct in saying that it is not so easy and that these structures take a life of their own but this shouldn't be an excuse and we see disasters happening over and over because people don't act as professional.

Anyone on the room seeing such mistakes and who was capable of standing up, should have, even if it meant they could end up jeopardizing their careers by doing so.

* I'm not asking for a hero and I understand that failure is part of the human nature but we should have [professional] respect where it is due.

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