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Death by PowerPoint: The slide that killed seven people

387 pointsby newzisgudabout 6 years ago

26 comments

protomythabout 6 years ago
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&#x27;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.<p>On a side note, the whole first paragraph is just plain insulting to anyone who is making a life or death decision. If that is the attitude of anyone in the meeting, then they shouldn&#x27;t have that job.
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nyx_about 6 years ago
The slide in the article has the same text, but is a recreation of the original (The Calibri typeface used wasn&#x27;t part of PowerPoint until 2007).<p>The original slide can be seen in the full report linked in the article:<p><a href="https:&#x2F;&#x2F;www.edwardtufte.com&#x2F;bboard&#x2F;q-and-a-fetch-msg?msg_id=0001yB" rel="nofollow">https:&#x2F;&#x2F;www.edwardtufte.com&#x2F;bboard&#x2F;q-and-a-fetch-msg?msg_id=...</a>
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davidmrabout 6 years ago
As much as I appreciate the sentiment and I never like to miss a chance to pile on PowerPoint, this is really, really missing the point.<p>As the CAIB report makes clear, the PowerPoint slide was a small symptom of the actual problem of a complex organization gradually accepting more and more risk as “in family” simply because unexplained phenomena hadn’t caused serious issues before (while remaining unexplained). The CAIB report really is a masterpiece (as is Feynman’s appendix to the Challenger report) of understanding how the understanding of risk can be subjugated to organizational pressures over time.
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kangnkodosabout 6 years ago
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.<p>I remember being concerned, but confident that NASA would figure it out.<p>Then when I saw the headline that Columbia didn&#x27;t land, I remember immediately thinking, &quot;On no! The foam!&quot;. I also remember being puzzled that none of the news stories after the crash mentioned the foam for a long time.<p>I&#x27;ve tried to go back and find that news story, but I have never been able to find it.
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mannykannotabout 6 years ago
This is a rehash of the claim Edward Tufte.made about the Challenger crash, and it is doing the same thing: take something that was, at most, one of the many contributing factors (but the one of most interest to the person making the claim) and exaggerate its significance out of all proportion. It is not a helpful way to present data if the goal is to understand what went wrong in the hope of avoiding making the same mistake in future.
supahfly_remixabout 6 years ago
We weren&#x27;t at the briefing. Surely the briefer could have emphasized these points, rather than just relying on the slide itself to convey the seriousness of the situation. Or, the judgement of the audience to pick up that they hadn&#x27;t tested for this situation.<p>I like Tufte as much as anyone else, but he&#x27;s in the business of selling courses.
hughesabout 6 years ago
The speed listed in the introduction is wildly wrong. The foam could not possibly have hit at 28968 km&#x2F;h - that is the approximate orbital speed of the shuttle. At 82 seconds into flight, the speed is about 700m&#x2F;s (2500 km&#x2F;h).<p>Even using <i>that</i> figure would assume that the foam came to a dead stop instantaneously after detaching from the tank. I wouldn&#x27;t be surprised if the relative speed was only 1&#x2F;10th of that, putting the speed of the collision around 250km&#x2F;h, less than 1% of the figure stated in the article.
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peteradioabout 6 years ago
Actual slide deck. Personally I think the author of this blog is an a-hole to highlight a single slide.<p><a href="https:&#x2F;&#x2F;www.nasa.gov&#x2F;pdf&#x2F;2203main_COL_debris_boeing_030123.pdf" rel="nofollow">https:&#x2F;&#x2F;www.nasa.gov&#x2F;pdf&#x2F;2203main_COL_debris_boeing_030123.p...</a><p>Particularly interesting is the slide titled &quot;Damage Results From “Crater” Equations Show Significant Tile Damage&quot;
js2about 6 years ago
&gt; They rejected the other options<p>I didn’t think there were any options. Indeed the managers didn’t think so.<p>From <a href="https:&#x2F;&#x2F;en.wikipedia.org&#x2F;wiki&#x2F;Space_Shuttle_Columbia_disaster" rel="nofollow">https:&#x2F;&#x2F;en.wikipedia.org&#x2F;wiki&#x2F;Space_Shuttle_Columbia_disaste...</a><p>&gt; Throughout the risk assessment process, senior NASA managers were influenced by their belief that nothing could be done even if damage were detected.<p>However the CAIB determined Atlantis could have been used as a rescue vehicle had NASA acted quickly enough. It also put forth a high risk repair procedure:<p><a href="https:&#x2F;&#x2F;en.wikipedia.org&#x2F;wiki&#x2F;Space_Shuttle_Columbia_disaster#Possible_emergency_procedures" rel="nofollow">https:&#x2F;&#x2F;en.wikipedia.org&#x2F;wiki&#x2F;Space_Shuttle_Columbia_disaste...</a>
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ridgeguyabout 6 years ago
&gt;...nine times faster than a fired bullet... I don&#x27;t think so.<p>A NASA publication [1] gives the SOFI piece impact velocity as about 800 feet&#x2F;sec. Rifle bullets reach 2.5K - 3K fps muzzle velocity routinely.<p>[1] <a href="https:&#x2F;&#x2F;history.nasa.gov&#x2F;columbia&#x2F;Troxell&#x2F;Columbia%20Web%20Site&#x2F;CAIB&#x2F;CAIB%20Website&#x2F;news&#x2F;FOAMIM~1.PDF" rel="nofollow">https:&#x2F;&#x2F;history.nasa.gov&#x2F;columbia&#x2F;Troxell&#x2F;Columbia%20Web%20S...</a>
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unreal37about 6 years ago
&quot;Death by PowerPoint is a real thing. Sometimes literally.&quot;<p>So tacky. Treating human deaths as a punchline to a joke.
_cs2017_about 6 years ago
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.<p>Which of these is the more likely explanation?<p>I&#x27;ve seen experienced engineers incapable of expressing their thoughts clearly. But I&#x27;ve also seen well-established organizations that encourage hiding your opinions behind a wall of bullshit.
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outworlderabout 6 years ago
Powerpoint was one of the problems.<p>A much worse problem was NASA&#x27;s management stepping in to block multiple requests for imaging the orbiter.<p><a href="https:&#x2F;&#x2F;en.wikipedia.org&#x2F;wiki&#x2F;Space_Shuttle_Columbia_disaster" rel="nofollow">https:&#x2F;&#x2F;en.wikipedia.org&#x2F;wiki&#x2F;Space_Shuttle_Columbia_disaste...</a>
dba7dbaabout 6 years ago
I heard one possible reason for underestimating the damage was due to the move of a NASA (or the contractor?) lab&#x2F;facility that dealt with this kind of issues, from California to a cheaper place such as Alabama&#x2F;Florida(?).<p>The move was done as a cost saving measure. Quite a few of the engineers chose not to relocate with the office. When the space shuttle launched and the image was being reviewed, many of the experienced engineers (who could possibly have predicted it correctly) were no long with the team.<p>I remember reading above bit years ago while reading about the incident.
kyberiasabout 6 years ago
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.
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pjtrabout 6 years ago
&quot;there is a huge amount of text, more than 100 words&quot;<p>&quot;PowerPoint briefing slides instead of technical papers&quot;<p>Would technical papers have fewer than 100 words?<p>If people can&#x27;t be bothered to read 13 slides, what would they do with a technical paper?<p>If people can&#x27;t be bothered to make their message clear in slides, how would they create a readable technical paper?<p>I don&#x27;t like presentations that consist of &quot;monotonously reading [bullets] as we read along&quot; either. But what does PowerPoint have to do with this? I&#x27;ve seen such presentations done with trendy web tools instead; they don&#x27;t change anything. I&#x27;ve also read full technical papers written in LaTeX that didn&#x27;t manage to get their point through the unclear writing (and vaguely misused technical jargon buzzwords).
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sopooneoabout 6 years ago
I am not sure if the author and commenters here are specifically condemning Microsoft Powerpoint, or just computerized slide presentations, of which Powerpoint is by far the most common type. Because even if everyone used Apple&#x27;s &quot;Slides&quot; tool, they could still make a lot of the same mistakes. Even if they drew things out on clear plastic sheets, they could still make the same mistakes.<p>So is it really Powerpoint specifically? Maybe. I&#x27;m open to that possibility. But I&#x27;m more sympathetic to the idea that Powerpoint has enabled many more people incapable of creating quality presentations to deliver them anyway.
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Isamuabout 6 years ago
Tufte makes a good point that the critical information could have been conveyed so much more effectively.<p>If only the managers had been given a better summary! But I think this is a vast over-simplification.<p>Even with a crystal-clear summary of the issues, it doesn&#x27;t always add up to a clear disaster on your hands. Only in hindsight. The shuttle was an incredibly complex system and there were always issues to examine, to fix, to prioritize, to defer. There is just a lot to regularly weigh.
runciblespoonabout 6 years ago
I seem to remember it differently, what killed seven people was senior management choosing to ignore warnings about ice debris strikes on the wing during launches. On this one, they know ice had struck the wing, they choose not to have ground placed telescopes survey the shuttle, choose to not have the crew do an EVA and choose not have have a rescue shuttle sent up. The title has a nice ring to it all the same.
what-the-grumpabout 6 years ago
Not the person that made the powerpoint? Not the team that reviewed it? Was this done by an 10 man team in some tiny start up? I mean seriously.
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nablaoperatorabout 6 years ago
Ironic, the woman responsible for the catastrophe: &quot;...rather than spending the day just listening to keynotes...&quot; <a href="https:&#x2F;&#x2F;www.youtube.com&#x2F;watch?v=E2Pruxom9-8" rel="nofollow">https:&#x2F;&#x2F;www.youtube.com&#x2F;watch?v=E2Pruxom9-8</a>
darkpumaabout 6 years ago
&gt; <i>&quot;It was impossible to tell how much damage this foam had caused hitting the wing nine times faster than a fired bullet.&quot;</i><p>This figure is GROSSLY inaccurate.<p>From: <a href="https:&#x2F;&#x2F;history.nasa.gov&#x2F;columbia&#x2F;Troxell&#x2F;Columbia%20Web%20Site&#x2F;CAIB&#x2F;CAIB%20Website&#x2F;news&#x2F;FOAMIM~1.PDF" rel="nofollow">https:&#x2F;&#x2F;history.nasa.gov&#x2F;columbia&#x2F;Troxell&#x2F;Columbia%20Web%20S...</a><p>&gt;<i>Eighty-two seconds into STS 107, a sizeable piece of debris struck the left wing of the Columbia. Visual evidence and other sensor data established that the debris came from the bipod ramp area and impacted the wing on the wing leading edge. At this time Columbia was traveling at a speed of about 2300 feet&#x2F;second (fps) through an altitude of about 65,900 feet. Based on a combination of image analysis and advanced computational methods, the Board determined that a foam projectile with a total weight of 1.67 lb and impact velocity of 775 fps would best represent the debris strike.</i><p>So somewhere between 775fps and 2300 fps. For reference, slow and heavy 45 ACP bullets start at around 800fps and up. 7.62x39mm (AK-47) bullets are in the neighborhood of 2300fps. The shuttle was moving as fast as a moderately fast rifle bullet, and the foam likely hit at much less than that; something probably a bit under a subsonic pistol bullet.<p>The author is incorrectly assuming that the foam hit the shuttle at orbital velocity, which obviously couldn&#x27;t be the case because the shuttle was <i>nowhere even close</i> to orbital velocity at the time.
therealmarvabout 6 years ago
So do they still use PowerPoint like this?
veryworriedabout 6 years ago
I thought this was going to be a more direct kill, as in maybe a slide that flashed bright colors very quickly and killed people who got seizures from it.
sytelusabout 6 years ago
TLDR; Engineers had found that there was risk of foam detachment, NASA managers thought that risk was not flagged significant to halt the mission.<p>In retrospect, it&#x27;s easy to blame decision makers but here&#x27;s the thing: If I told you that risk of you dying is 1 in 103 if you drive the car today, would you still drive? Relatively risk of fatal accident in Space Shuttle program was 1 in 62.
pontifierabout 6 years ago
What a surprise that it was from Boeing. I don&#x27;t like them at all.