
Death by PowerPoint: The slide that killed seven people - newzisgud
https://mcdreeamiemusings.com/new-blog/2019/4/13/gsux1h6bnt8lqjd7w2t2mtvfg81uhx
======
protomyth
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 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't have that job.

~~~
davidmr
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
was an astronaut, so it’s obviously not like they don’t care. I’ve always
found it fascinating how organizational structure and pressure can take really
brilliant and motivated people and beat them into making such poor decisions.

It’s really important to remember that these people are not idiots. It’s
literally a room of rocket scientists and space shuttle mission managers. It’s
so easy for us all to say here that it was so easy to see it happening and
that anyone who didn’t ask the right question was a moron, but these
structures take on a life of their own. If I had it to start all over again,
studying that would make a fascinating and potentially rewarding career.

~~~
VeninVidiaVicii
For the past two years I have worked in the local emergency room as a
technician working on getting some clinical experience. Let me tell you, in
the constant face of life and death, you really just develop a kind of "danger
fatigue" and even the most critical moments become somewhat prosaic.

You begin to develop a false sense of security after nobody really does from a
gunshot wound. Then, someone septic comes in, and "seems" fine, and they're
dead in a few hours.

I'm not sure what this kind of logical fallacy is, but I suspect it's similar
in a government environment, where you're constantly at RED ALERT. The risk of
danger just seems overstated, even when it isn't.

~~~
danaliv
A very similar phenomenon happens in aviation—we call it complacency.
Thousands of successful takeoffs in a row make it hard sometimes to remember
that each one is a completely independent event.

The way I fight it is by explicitly reminding myself that just because
something worked yesterday, that doesn't mean I can skip a step today or let
my guard down at any point.

It really does take deliberate thought though. Funny how the brain works.

(The upside is that every successful takeoff becomes a delightful surprise!)

~~~
brazzy
Same thing for rock climbing, and complacency born from routine is exactly the
problem: you tie knots that your life will depend on every day, thousands of
times, and then stuff like this happens to some of the most skilled and
experienced people:

\- get distracted while tying the rope to your harness and leave the knot
unfinished, fall 20 meters from the top of the climb (Lynn Hill, by sheer luck
only broke her foot and elbow)

\- use a slightly unusual rope setup and when preparing to be lowered, tie in
on the wrong side of the anchor, fall 14 meters onto rock (Rannveig Aamodt,
broke her spine, pelvis and ankles)

\- have your partner point out damage on your harness, shrug it off because
there's plenty of safety margin, continue climbing for 3 days in a manner that
puts repetitive abrasion on exactly that part of the harness, have it snap
while rapelling and fall 150 meters to your death (Tood Skinner)

------
nyx_
The slide in the article has the same text, but is a recreation of the
original (The Calibri typeface used wasn't part of PowerPoint until 2007).

The original slide can be seen in the full report linked in the article:

[https://www.edwardtufte.com/bboard/q-and-a-fetch-
msg?msg_id=...](https://www.edwardtufte.com/bboard/q-and-a-fetch-
msg?msg_id=0001yB)

~~~
jrochkind1
Why would someone recreate that slide instead of just using the original? Gah,
that's sloppy reporting. Makes me suspect the entire story told, now that you
pointed that out.

~~~
bumby
There's other sloppiness here as well, like treating the orbiter velocity as
the determining factor (nine times the speed of a bullet...) when the delta-V
between the foam and the orbiter is the more pertinent information.

The author comes across like they have an axe to grind (maybe rightly so) but
should make better efforts at getting technical details right in an article
about the perils of miscommunicating technical details

------
davidmr
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.

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.

~~~
icelancer
> 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.

Agreed. It is a useful document to read for anyone who plans meetings and
heavily relies on consensus to see where the problems lay. You need outsiders
and first principles thinkers (physicists are good options, as Feynman always
demonstrates) to disrupt bureaucratic agreement.

------
kangnkodos
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 foam!". I also remember being puzzled that none of the
news stories after the crash mentioned the foam for a long time.

I've tried to go back and find that news story, but I have never been able to
find it.

~~~
foobarbecue
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.

------
mannykannot
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_remix
We weren'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't tested for this situation.

I like Tufte as much as anyone else, but he's in the business of selling
courses.

------
hughes
The speed listed in the introduction is wildly wrong. The foam could not
possibly have hit at 28968 km/h - that is the approximate orbital speed of the
shuttle. At 82 seconds into flight, the speed is about 700m/s (2500 km/h).

Even using _that_ figure would assume that the foam came to a dead stop
instantaneously after detaching from the tank. I wouldn't be surprised if the
relative speed was only 1/10th of that, putting the speed of the collision
around 250km/h, less than 1% of the figure stated in the article.

~~~
speedplane
> The speed listed in the introduction is wildly wrong. The foam could not
> possibly have hit at 28968 km/h

The article said "[a]s the crew rose at 28,968 kilometres per hour the piece
of foam collided with one of the tiles". It did not say that it collided with
the tiles at 28k km/hr, just that it collided with it during it's acceleration
to that speed. So technically it's correct, but I definitely agree that it
it's a false implication, likely added for dramatic effect.

~~~
hughes
In the next sentence the author also says the damage was caused by foam
"hitting the wing nine times faster than a fired bullet." A bullet goes about
900m/s, and the "nine times" figure often symbolizes orbital velocity. It's
clear that the reference is to the speed of the collision.

------
peteradio
Actual slide deck. Personally I think the author of this blog is an a-hole to
highlight a single slide.

[https://www.nasa.gov/pdf/2203main_COL_debris_boeing_030123.p...](https://www.nasa.gov/pdf/2203main_COL_debris_boeing_030123.pdf)

Particularly interesting is the slide titled "Damage Results From “Crater”
Equations Show Significant Tile Damage"

------
js2
> They rejected the other options

I didn’t think there were any options. Indeed the managers didn’t think so.

From
[https://en.wikipedia.org/wiki/Space_Shuttle_Columbia_disaste...](https://en.wikipedia.org/wiki/Space_Shuttle_Columbia_disaster)

> Throughout the risk assessment process, senior NASA managers were influenced
> by their belief that nothing could be done even if damage were detected.

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:

[https://en.wikipedia.org/wiki/Space_Shuttle_Columbia_disaste...](https://en.wikipedia.org/wiki/Space_Shuttle_Columbia_disaster#Possible_emergency_procedures)

~~~
PopePompus
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 been damaged it's probably better not to know. I think the
crew would rather not know. Don't you think it would be better for them to
have a happy successful flight and die unexpectedly during entry than to stay
on orbit, knowing that there was nothing to be done, until the air ran out?"

[https://www.theguardian.com/world/2013/feb/01/columbia-
space...](https://www.theguardian.com/world/2013/feb/01/columbia-space-
shuttle-anniversary-nasa)

~~~
Endy
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, publicly and with no means of
secrecy.

~~~
scott_s
> "After showing the astronauts in orbit a video of the foam strike and
> discussing with them what they thought they knew, mission managers concluded
> that it was a non-issue and posed no threat to the crew's safe return.

> ...

> "Although the circumstances of the tragedy have been well documented, and
> Hale insists there was "never any debate about what to tell the crew", his
> revelation brings new insight to the mindset of some Nasa employees at the
> time."

The crew knew.

~~~
PopePompus
Here is what NASA emailed to the crew about the foam strike:

\--- begin quote ---

You guys are doing a fantastic job staying on the timeline and accomplishing
great science. Keep up the good work and let us know if there is anything that
we can do better from an MCC/POCC standpoint.

There is one item that I would like to make you aware of for the upcoming PAO
event on Blue FD 10 and for future PAO events later in the mission. This item
is not even worth mentioning other than wanting to make sure that you are not
surprised by it in a question from a reporter.

During ascent at approximately 80 seconds, photo analysis shows that some
debris from the area of the -Y ET Bipod Attach Point came loose and
subsequently impacted the orbiter left wing, in the area of transition from
Chine to Main Wing, creating a shower of smaller particles. The impact appears
to be totally on the lower surface and no particles are seen to traverse over
the upper surface of the wing. Experts have reviewed the high speed
photography and there is no concern for RCC or tile damage. We have seen this
same phenomenon on several other flights and there is absolutely no concern
for entry.

That is all for now. It's a pleasure working with you every day.

\--- end quote ---

Now does it sound to you like the crew was fully informed, or like NASA was
minimizing the issue?

[https://spaceflightnow.com/shuttle/sts107/030630emails/](https://spaceflightnow.com/shuttle/sts107/030630emails/)

------
ridgeguy
>...nine times faster than a fired bullet... I don't think so.

A NASA publication [1] gives the SOFI piece impact velocity as about 800
feet/sec. Rifle bullets reach 2.5K - 3K fps muzzle velocity routinely.

[1]
[https://history.nasa.gov/columbia/Troxell/Columbia%20Web%20S...](https://history.nasa.gov/columbia/Troxell/Columbia%20Web%20Site/CAIB/CAIB%20Website/news/FOAMIM~1.PDF)

~~~
bumby
I assume the author mistakenly took the orbital velocity instead of the
delta-V at impact

------
unreal37
"Death by PowerPoint is a real thing. Sometimes literally."

So tacky. Treating human deaths as a punchline to a joke.

------
_cs2017_
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.

~~~
peteradio
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.

~~~
_cs2017_
Yes, that's what I meant under "intentionally obscuring their opinions" (for
example because of the organizational culture, etc).

------
outworlder
Powerpoint was one of the problems.

A much worse problem was NASA's management stepping in to block multiple
requests for imaging the orbiter.

[https://en.wikipedia.org/wiki/Space_Shuttle_Columbia_disaste...](https://en.wikipedia.org/wiki/Space_Shuttle_Columbia_disaster)

------
dba7dba
I heard one possible reason for underestimating the damage was due to the move
of a NASA (or the contractor?) lab/facility that dealt with this kind of
issues, from California to a cheaper place such as Alabama/Florida(?).

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.

I remember reading above bit years ago while reading about the incident.

------
kyberias
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.

~~~
TeMPOraL
They very much could. In terms of language, the whole slide deck in question
is essentially a scientific paper in PPT form, and scientific papers tend to
be typically written in LaTeX.

------
pjtr
"there is a huge amount of text, more than 100 words"

"PowerPoint briefing slides instead of technical papers"

Would technical papers have fewer than 100 words?

If people can't be bothered to read 13 slides, what would they do with a
technical paper?

If people can't be bothered to make their message clear in slides, how would
they create a readable technical paper?

I don't like presentations that consist of "monotonously reading [bullets] as
we read along" either. But what does PowerPoint have to do with this? I've
seen such presentations done with trendy web tools instead; they don't change
anything. I've also read full technical papers written in LaTeX that didn't
manage to get their point through the unclear writing (and vaguely misused
technical jargon buzzwords).

~~~
speedplane
> If people can't be bothered to make their message clear in slides, how would
> they create a readable technical paper?

Slides are not the same as or replacements for technical papers. Even by
comparing them, you're making the same mistake as these engineers did.
Compared to a paper, the downsides of a presentation are that they are
typically constrained to just 30-60 minutes, in front of a group of people who
may be checking their phones and only be half-engaged. Also, by its very
nature, the presenter is speaking, so it's difficult to simultaneously read
the slides while listen to the presenter.

The upside of a presentation however, is that you can give it to many people
at once, and solicit feedback in real-time.

Accordingly, presentations like this need to be far tighter than technical
papers. There needs to be much more work invested in prioritizing the issues
that you discuss, they should take advantage of the advantages of the form
(e.g., utilizing the skills of the audience), and minimize the disadvantages
(short time-frame, and no monopoly on attention).

As a starter, you should never put a single word on a slide that you do not
say out-loud. There's nothing worse than putting a block of text on a screen
and talking about it. The astute audience members will listen to you while
reading the text, and in the process not internalizing either. Most audience
members will just have their eyes glaze over and then check their phones.

Sadly, engineers are often taught how to write technical papers, but not how
to give effective technical presentations.

~~~
pjtr
> you're making the same mistake

I assume you mean the "generic you", as it was the article quoting the NASA
report that suggested the comparison.

------
sopooneo
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's "Slides" 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.

So is it really Powerpoint specifically? Maybe. I'm open to that possibility.
But I'm more sympathetic to the idea that Powerpoint has enabled many more
people incapable of creating quality presentations to deliver them anyway.

~~~
ericsoderstrom
No, this article is not a criticism of PowerPoint specifically.

------
Isamu
Tufte makes a good point that the critical information could have been
conveyed so much more effectively.

If only the managers had been given a better summary! But I think this is a
vast over-simplification.

Even with a crystal-clear summary of the issues, it doesn'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.

------
runciblespoon
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-grump
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.

~~~
system2
Exactly. This article is like one of those BusinessInsider click-baits.

------
nablaoperator
Ironic, the woman responsible for the catastrophe: "...rather than spending
the day just listening to keynotes..."
[https://www.youtube.com/watch?v=E2Pruxom9-8](https://www.youtube.com/watch?v=E2Pruxom9-8)

------
darkpuma
> _" It was impossible to tell how much damage this foam had caused hitting
> the wing nine times faster than a fired bullet."_

This figure is GROSSLY inaccurate.

From:
[https://history.nasa.gov/columbia/Troxell/Columbia%20Web%20S...](https://history.nasa.gov/columbia/Troxell/Columbia%20Web%20Site/CAIB/CAIB%20Website/news/FOAMIM~1.PDF)

> _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 /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._

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.

The author is incorrectly assuming that the foam hit the shuttle at orbital
velocity, which obviously couldn't be the case because the shuttle was
_nowhere even close_ to orbital velocity at the time.

------
therealmarv
So do they still use PowerPoint like this?

------
veryworried
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.

------
sytelus
TLDR; Engineers had found that there was risk of foam detachment, NASA
managers thought that risk was not flagged significant to halt the mission.

In retrospect, it's easy to blame decision makers but here'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.

------
pontifier
What a surprise that it was from Boeing. I don't like them at all.

