When the Columbia space shuttle broke up upon re-entry to earth in 2003, the President appointed the Columbia Accident Investigation Board(CAIB) to look into the causes.
As part of the investigation, the Board looked into how engineers and contractors at the National Aeronautical and Space Agency (NASA) transmit their technical information to their management. When NASA discovered that a piece of foam had fallen off the shuttle during take off and had impacted its wing, a team of engineers and scientists began a series of analyses to assess any risk that such impact would have upon re-entry. The concern was that the damage done to the wing during take off might impair its ability to withstand the tremendous heat that would be generated when the shuttle began its re-entry into the Earth’s atmosphere. That turned out to the fatal cause of the incident.
On Day Nine of the mission, the engineering team presented the results of its risk assessment findings to NASA management in a PowerPoint presentation while the shuttle was still in space. One of the critical slides used in the presentation contained six levels of hierarchy. The Board hired Dr. Edward Tufte – a Yale Professor who is an expert in information presentation – to analyze that particular PowerPoint slide (shown on the right).
According to the Board, important engineering information was either “filtered out or lost in the small prints within the bullet points.”
The CAIB further concluded as follows: “When engineering analyses and risk assessments are condensed to fit on a standard form or overhead slide, information is inevitably lost. In the process, the priority assigned to information can be easily misrepresented by its placement on a chart and the language that is used. . . . As information gets passed up an organization hierarchy, from people who do analyses to mid-level managers to high-level managers, key explanations and supporting information is filtered out. In this context, it is easy to understand how a senior manager might read this PowerPoint slide and not realize that it addresses a life-threatening situation. . . . The Board views the endemic use of PowerPoint briefing slides instead of technical reports as an illustration of the problematic methods of technical communication at NASA.”
The Board also observed that “generally, the higher information is transmitted in the hierarchy, the more it gets ‘rolled up,’ abbreviated, and simplified. Sometimes information gets lost altogether, signals drop from memos, problem identification systems, and formal presentations. The same conclusions, repeated over time, can result in problems eventually being deemed non-problems”.
One avenue by which information gets “rolled up” and confused – according to the Board – was through the technology of PowerPoint presentations.