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

Linked from Tufte’s article, I found this interesting comment from someone’s experience at Microsoft: [1]<p>&gt; 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 prove your point. PowerPoint is a terrible tool for making written documents, that&#x27;s what word processors are for.<p>I think that’s on point for many companies. A lot of the terrible slides you see in meetings are actually intended as documentation after the fact, and few people recognize (or care) that this makes for a terrible presentation.<p>Ironically, I think Powerpoint isn’t such a bad tool for creating handouts. If the intended reader reads the document on their screen instead of printing it, a nice PDF with screen-shaped pages might actually be close to optimal.<p>You just have to be 100% clear whether you’re creating a document or a presentation.<p>[1] <a href="http:&#x2F;&#x2F;mamamusings.net&#x2F;archives&#x2F;2005&#x2F;11&#x2F;19&#x2F;the_culture_of_the_deck.php" rel="nofollow">http:&#x2F;&#x2F;mamamusings.net&#x2F;archives&#x2F;2005&#x2F;11&#x2F;19&#x2F;the_culture_of_th...</a>

Another NASA screw-up that they&#x27;re trying to pin on the vendor engineers, just like Challenger.<p>The title is <i>not</i> 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, but that they didn&#x27;t know the extent.<p>&quot;NASA felt the engineers didn’t know what would happen but that all data pointed to there not being enough damage to put the lives of the crew in danger.&quot;<p>If you thought they didn&#x27;t know, then ask them what they do know! It&#x27;s right on the slide that flight conditions are outside of test parameters and that the mass of the projectile was much higher. How the F do you work at NASA and not understand the basic principles of mass, velocity, and energy well enough for that to stand out enough to ask questions or run your own calculations...<p>The reason the slide is laid out the way it is, is because it&#x27;s describing the thought process and creates a deductive argument for how they got to their concern. This is a presentation for a <i>briefing for other engineers</i>, not a conference or sales pitch. It&#x27;s supposed to be formal and contain the synopsis of technical points. Using projectors for technical briefings predates the use of PowerPoint. I see nothing wrong with the layout in that context.<p>Edit: why downvote without a reply? NASA has a history of blaming vendors when they screw up. This looks like another example to me. The presentation format does not have any issues given the setting and target audience.

Diane Vaughn&#x27;s <i>The Challenger Launch Decision</i> misattributes responsibility for the disaster to the meeting in which a similar slide was shown.<p>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!<p>The shuttle had hundreds of critical flaws and that &#x27;normalization of deviance&#x27; 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.<p>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 &quot;unsafe at any speed&quot;. When the first few shuttles were launched there was a huge amount of concern about tiles breaking and coming off. Once they&#x27;d dodged the bullet a few times they assumed it was alright but it wasn&#x27;t...<p>In the literature &quot;normalization of deviance&quot; 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.

The title presumed that the crew could have been rescued if NASA had recognized that reentry was impossible. But that&#x27;s far from clear. This article goes into fascinating detail about how difficult it would have been to prepare a rescue mission on time: <a href="https:&#x2F;&#x2F;arstechnica.com&#x2F;science&#x2F;2016&#x2F;02&#x2F;the-audacious-rescue-plan-that-might-have-saved-space-shuttle-columbia&#x2F;" rel="nofollow">https:&#x2F;&#x2F;arstechnica.com&#x2F;science&#x2F;2016&#x2F;02&#x2F;the-audacious-rescue...</a><p>One huge issue, beyond whether a rescue mission would&#x27;ve been possible, is whether it would&#x27;ve be ethical. If NASA knew that Columbia was stranded in orbit, then it would be knowingly sending a second crew up on a vehicle with the exact same potential problem, with no time to mitigate it. I&#x27;m sure a rescue crew would&#x27;ve volunteered despite the risks, but anyway the point is that &quot;the slide that killed seven people&quot; is erasing all of these questions.

&gt; 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.<p>That&#x27;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 there still wasn&#x27;t anything that could have been done. I think the main problem with launching a rescue mission was the time it took NASA to get a shuttle ready for launch.

Kinda pointless to show the slide without the audio of the presenter to go with it. Unless we&#x27;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&#x27;ve seen presenters actually do that, but the author didn&#x27;t provide any indication that that&#x27;s what happened here.

I&#x27;ve seen presentations with Powerpoint that suck the life out of you and also ones that inspire and excite. It&#x27;s not the tool, it&#x27;s the presenter and how they wield the tool.<p>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&#x2F;diagrams that back up my talking points. And I&#x27;ve seen image-heavy decks that really don&#x27;t convey anything either.

&gt; Imagine if the engineers had put up a slide with just: “foam strike more than 600 times bigger than test data.”<p>Then they would have been fired unceremoniously and replaced with engineers that knew better than to make their bosses look bad. (who themselves would then, of course, been held responsible for apparently preventable deaths).<p>Stop blaming the engineers for this stuff. This is the fault of the timeline chasers.

I don&#x27;t buy the title.<p>This is not just a normal, routine presentation. This is an all hands on deck emergency and discussion. And NASA isn&#x27;t just a bunch of MBA&#x27;s, but rather people who have spent their entire careers immersed in this kind of stuff.<p>No matter what is one the slide, I expect that the audience asks detailed questions. Even if the slide has just a big thumbs up emoji, I suspect you would still get a lot of really hard questions.<p>Think about presentations on programming, where someone in the audience points out that the example code on the slide is incorrect&#x2F;won&#x27;t compile&#x2F;undefined behavior<p>I would expect a bunch of geeks (which I think would be there at NASA) to scrutinize the slide and try to find any flaw in the logic. Especially when the lives of people they deeply care about are on the line.<p>If they are so cavalier about human life that they just skip the details of the slide while making literal life and death decisions, it speaks of a very deep culture rot that goes far beyond PowerPoint.

The first step they went wrong is using a slideshow in the first place. This was a time critical scenario, anyone who needed to be making decisions should have been part of the engineering discussions from the beginning. They should have been having interactive conversations going over what they knew and how they knew it. The engineers had no time to be making slides for a management and that wasn&#x27;t interested enough to be in the room with them in the first place.<p>Slides make sense as a way to introduce the outline of concept to a broad audience in a way that requires much less effort than 1-on-1 discussions. They are not a means for coming to decisions. If you need to make a critical, life- and business-shaping decision off the back of a side deck, you should instead delegate the decision to someone who knows more than you.

In general, we give people too much of a pass for not bothering to read what they are supposed to (and I myself am guilty of this as it seems like it preparedness for meetings is useless as nobody else reads even on the rare occasions I do speak).<p>That is part of the reason Powerpoint is everywhere. You cannot assume that people have read anything before the meeting, you cannot assume they will read during the meeting, so you need to read it out loud to have a decent chance of it being received.<p>I am also not thrilled accepting the use of titles and formatting as a excuse to skim 100 words. It is just the refusal to read&#x2F;comprehend on a smaller scale.

I give Tufte&#x27;s (admittedly imperfect) thoughts on this deck and David Foster Wallace&#x27;s This is Water (<a href="https:&#x2F;&#x2F;fs.blog&#x2F;david-foster-wallace-this-is-water&#x2F;" rel="nofollow">https:&#x2F;&#x2F;fs.blog&#x2F;david-foster-wallace-this-is-water&#x2F;</a>) to every new member of my team to read and make it apparent that I expect them to have command of each document&#x27;s implications.

The original article by Edward Tufte which is referenced by this blog post can be found here:<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>

The title is wrong - it didn&#x27;t kill 7 people. And it is stated in the article that it &quot;helped&quot; 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&#x27;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 ordered 24 minutes to late and in those 24 minutes it caused other companies to get foam orders in first and a really good mixture batch came out and the next was sub-par and that&#x27;s what the shuttle got. Basically chaos theory.

You don&#x27;t see the cultural assumptions in the slide. You don&#x27;t see why defensive phrasing is used. You don&#x27;t see the recriminations that people have gone through in the past.<p>One slide and bad culture killed seven people.

&gt; this foam, falling nine times faster than a fired bullet<p>Wouldn’t the foam initially be travelling as fast as the spacecraft? So it’s just the time between it’s release and hitting the wing to accelerate.

In my experience, it&#x27;s nearly impossible to convey information so accurately that the the receiver is likely to make the same decision you would make.<p>There is a simple low-effort high-information solution to this problem - have everyone vote (or bet) on the decision. This, more than anything else, will reveal whether or not you&#x27;ve reached understanding&#x2F;consensus&#x2F;alignment.<p>(This is not to say that the final decision should be made by voting, rather it&#x27;s to gauge the level of consensus)

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

A question I often ask myself (though I don&#x27;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.<p>My own personal experience is that it&#x27;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 &quot;it&#x27;ll probably work out&quot;.

Wow, 7 lifes at stake and still managers can decide to &quot;skip smaller text&quot; because if it is smaller it is definitely less important...<p>I agree: it&#x27;s an awful slide. But the information was there. And I can imagine that the engineers were asked to assemble that presentation in a couple days, so I&#x27;d be surprised if they could do anything better.<p>I agree: an outsider would not understand a word of that slide. So what? What was the audience of that presentation? Why did the audience not read the slide &#x2F; documentation beforehand? Why was it not understandable by them?<p>Again: the point here is the stakes. Would I read such a presentation for my day-to-day work? Probably not. Would I read it until I understand every single word if there were 7 lifes at stake? OF COURSE! Would I try to understand the engineers that had to assemble a comprehensive and credible document in a matter of days, and do my part of the work? If it was my day-to-day job, probably not. If there were 7 lifes at stake? OF COURSE.<p>So yeah, terrible slide. Don&#x27;t try to justify people not reading it, though.

Three kickass books I found very helpful in improving my slide-foo and hold the attention of my audience:<p><a href="https:&#x2F;&#x2F;www.amazon.com&#x2F;gp&#x2F;product&#x2F;0596522347&#x2F;ref=ppx_yo_dt_b_search_asin_title?ie=UTF8&amp;psc=1" rel="nofollow">https:&#x2F;&#x2F;www.amazon.com&#x2F;gp&#x2F;product&#x2F;0596522347&#x2F;ref=ppx_yo_dt_b...</a> <a href="https:&#x2F;&#x2F;www.amazon.com&#x2F;gp&#x2F;product&#x2F;0470632011&#x2F;ref=ppx_yo_dt_b_search_asin_title?ie=UTF8&amp;psc=1" rel="nofollow">https:&#x2F;&#x2F;www.amazon.com&#x2F;gp&#x2F;product&#x2F;0470632011&#x2F;ref=ppx_yo_dt_b...</a> <a href="https:&#x2F;&#x2F;www.amazon.com&#x2F;gp&#x2F;product&#x2F;1101980168&#x2F;ref=ppx_yo_dt_b_search_asin_title?ie=UTF8&amp;psc=1" rel="nofollow">https:&#x2F;&#x2F;www.amazon.com&#x2F;gp&#x2F;product&#x2F;1101980168&#x2F;ref=ppx_yo_dt_b...</a><p>If you only have time to go through 1 book, I would recommend Slide:ology.

Could it be that Boeing engineers made this presentation vague and confusing on purpose? I mean the article presumes that the engineers had poor PowerPoint skills, but it seems to me that this could have been cover-your-ass type of situation (also perhaps similar to Challenger disaster story).<p>I mean obviously Boeing engineers need to communicate to NASA their assessment of the situation, but they don&#x27;t want to be blamed for any technical difficulties (e.g. if second shuttle would have to be launched to save the crew). So they think Columbia will probably be fine, but let&#x27;s communicate our worries to NASA, but let&#x27;s do that in deliberately vague and conspicuous language, in hope that NASA managers won&#x27;t see the fine print.

Very interesting! I will start my future presentations with &#x27;The Board views the endemic use of PowerPoint...&#x27; :-)<p>But this &#x27;...has grown exponentially...&#x27; is just such BS. <i>sigh</i> I just cannot get used to this expression entering lay language.

Tufte isn&#x27;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.<p>Alternatives like Prezi exist, but are not really going to be accepted in formal presentations <a href="https:&#x2F;&#x2F;infovisu.com&#x2F;assets&#x2F;pubs&#x2F;linder2015beyond.pdf" rel="nofollow">https:&#x2F;&#x2F;infovisu.com&#x2F;assets&#x2F;pubs&#x2F;linder2015beyond.pdf</a> .<p>If you really bring me a physical piece of paper today, I doubt I would be able to keep track of it.

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.<p>We don&#x27;t need Tufte and his subtle points to see this was an abominable piece of communication. More important, would be the question &quot;is it safe to call out a bull shit slide in a corporate meeting&quot;. 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.

Related:<p><i>Death by PowerPoint: The slide that killed seven people</i> - <a href="https:&#x2F;&#x2F;news.ycombinator.com&#x2F;item?id=19668161" rel="nofollow">https:&#x2F;&#x2F;news.ycombinator.com&#x2F;item?id=19668161</a> - April 2019 (127 comments)<p><i>Death by PowerPoint: the slide that killed seven people</i> - <a href="https:&#x2F;&#x2F;news.ycombinator.com&#x2F;item?id=24115837" rel="nofollow">https:&#x2F;&#x2F;news.ycombinator.com&#x2F;item?id=24115837</a> - Aug 2020 (1 comment)

I just realized that more time has passed since the Columbia Shuttle disaster (19 years), then passed between the Columbia and Challenger disasters (17 years). That seems impossible to me.<p>I remember reading each of the astronaut&#x27;s bios after the Columbia disaster, and the same thought kept echoing in my head: what a tragedy, what a waste. Seven remarkably talented people. I had no idea until I read this article how easily their deaths could have been avoided.

I’ve seen a lot of management consulting decks, and they tend to be very information dense. But a lot of effort is put into making sure that the each slide conveys exactly the message that the consultant wants to convey. Also the slides are designed to be read and used outside of the actual presentation, often as reference material.

So what would have been a (realistic) alternative instead of trying to reenter the athmosphere with a broken tile?

&gt; <i>Imagine if the engineers had put up a slide with just: “foam strike more than 600 times bigger than test data.” Maybe NASA would have listened. Maybe they wouldn’t have attempted re-entry.</i><p>Yes. This proves PowerPoint isn&#x27;t to blame <i>per se</i>, but how it was used.

PowerPoint is not the problem, it&#x27;s poor presentation of information.<p>Yes, you can de-emphasize information in a powerpoint presentation, just like you could with a chalkboard, overhead slides, or any other way of presenting information to a group. So what?

Has nothing to do with PowerPoint or the language:<p>The shuttle is inherently dangerous. An endless # of things can go wrong. The Shuttle program should have been grounded anyway on the basis of cost and danger. Too bad it took a tragedy for that to happen.<p>hindsight bias

Is the implication that the slide was presented without discussion? You can&#x27;t judge a presentation based on the accompanying visual aids without considering the verbal content.

&gt; This allowed NASA managers to imply a hierarchy of importance in their head: the writing lower down and in smaller font was ignored<p>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&#x27;re too stupid to read one whole entire paragraph worth of text without ignoring subheadings because they &quot;don&#x27;t look important&quot;? I hope they&#x27;re happy with the result of their childish intellectual laziness.

PPT as it is used, or any similar software performing the same function, as used in the same way, is a cancer.

this is why whenever i write slides, each slide gets a title and a subheading. the subheading provides the implication of the slide and its contents.<p>done properly, one could read the heading and subtitle of each slide and never need to look at the contents, unless some specific detail is desired&#x2F;needed.

I would be peeved at the typos in the slide. That seems sloppy if youre dealing with this kind of work.

Fascinating, I&#x27;m familiar with the incident but never heard this aspect of it.

I still cannot get why was it a big deal to go outside and check the tile?

The article doesn&#x27;t do the slides nor the evidence justice. It might be more illustrative to study the original article by Edward Tufte, which the writer (and I) learned about the issue from, <a href="https:&#x2F;&#x2F;www.edwardtufte.com&#x2F;bboard&#x2F;images&#x2F;0001yB-2238.gif" rel="nofollow">https:&#x2F;&#x2F;www.edwardtufte.com&#x2F;bboard&#x2F;images&#x2F;0001yB-2238.gif</a><p><a href="https:&#x2F;&#x2F;www.edwardtufte.com&#x2F;bboard&#x2F;images&#x2F;0001yB-2239.gif" rel="nofollow">https:&#x2F;&#x2F;www.edwardtufte.com&#x2F;bboard&#x2F;images&#x2F;0001yB-2239.gif</a><p>I think it&#x27;s why I think teaching engineers how to draw and do good design is important. How big is a cubic inch? How big is the crater in the heat shield that we&#x27;re talking about?<p>It would have been better to draw comparisons and explore things. Here&#x27;s a simple sentence that could have done better;<p>&quot;Sir, our test database was for objects the size of an average icecube. The thing that hit the wing was the size of seven and a half footballs. It&#x27;s 640x larger!<p>[chart that shows just how much kinetic energy we&#x27;re talking about]<p>We&#x27;re looking at somewhere between 640x to 1000x more energy than we&#x27;ve ever seen. We have a problem.&quot;<p>A friend and I did an interview with Don Eyles a while ago and he said something that haunts me, &quot;if you see something, say something&quot; <a href="https:&#x2F;&#x2F;twitter.com&#x2F;_areoform&#x2F;status&#x2F;1501589762599112704" rel="nofollow">https:&#x2F;&#x2F;twitter.com&#x2F;_areoform&#x2F;status&#x2F;1501589762599112704</a><p>I&#x27;d like to go a bit further. If you see something, design and explain something. Challenger is a great example of this; Dr Tufte covers it extremely well, just laying out the boosters and the blowthrough they experienced from left to right on a chart that has temperature as the X axis, you can see clearly that it gets worse as the temperature drops. But no one at NASA or Thiokol thought about doing that.<p>No one thought about humanizing the data. They knew how important it was. They tried to say something. But they couldn&#x27;t express it.<p>It&#x27;s not enough to just show people the data. We need to get people to understand it. And that&#x27;s often social suicide.<p>It&#x27;s easy for people to want to remain stuck in their status quo, no one likes the &quot;negative person&quot;, but that&#x27;s what ends up getting people killed in safety critical environments. And that&#x27;s how we get messes like the ones we&#x27;re in today.<p>One particular one that comes to mind is climate change, I am unsure if most people are aware of this, but it&#x27;s very similar to the failure expressed here. Most of the scientists whose work is consumed by the IPCC and the models that are published by the IPCC know that the &quot;consensus&quot; is wrong. Except, it&#x27;s wrong in the opposite direction to what certain people want it to be.<p>The reality is <i>far worse</i> than what the models suggest. The models still don&#x27;t include the loss of permafrost - what&#x27;s worse is that they don&#x27;t model the non-linearity of permafrost loss, methane emission, that then sparks more warming and more permafrost loss etc, <a href="https:&#x2F;&#x2F;www.woodwellclimate.org&#x2F;review-of-permafrost-science-in-ipccs-ar6-wg1&#x2F;" rel="nofollow">https:&#x2F;&#x2F;www.woodwellclimate.org&#x2F;review-of-permafrost-science...</a> nor do they include effects of how the climate would change of ocean conveyor currents shut down (AMOC in particular is of significant interest, <a href="https:&#x2F;&#x2F;www.aljazeera.com&#x2F;news&#x2F;2021&#x2F;11&#x2F;12&#x2F;concern-grows-over-atlantic-ocean-conveyor-belt-shutdown" rel="nofollow">https:&#x2F;&#x2F;www.aljazeera.com&#x2F;news&#x2F;2021&#x2F;11&#x2F;12&#x2F;concern-grows-over...</a> ). They also don&#x27;t model the melting and release of clathrates from the ocean, or the effects of ocean acidification, and several other non-linear processes.<p>I had a very polite, but heated argument with one of the scientists involved and he told me that they aren&#x27;t going to include that, because if they do, the numbers will look much worse and they&#x27;ll be dismissed as apocalyptic loons.<p>Which brings us, elegantly, back to the point that Dr Feynman made in his remarks about the Challenger disaster,<p>&quot;For a successful technology, reality must take precedence over public relations, for nature cannot be fooled.&quot;

Powerpoint doesn&#x27;t communicate badly. People communicate badly.

If you are impressed by this, wait until you see Colin Powell&#x27;s Iraq slides

How about death by a tiny gray serif font?