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grenbys | 4 years ago

I think blaming the slide/presentation is severely affected by the hindsight bias - of course, knowing the outcomes, we can find loads of issues with the slide. More importantly, it is always easy to declare a "human factor" incident and blame the human for "bad slides". But the very fact that such an important decision (re-entry) was (presumably) made as a result of Boeing engineers presenting to NASA officials/managers is eyebrow raising. The fact that this type of an issue (foam hitting the tiles) was well know in advance and yet not properly addressed indicates a systemic organizational problems. It would be great to study those organizational factors and processes that resulted in both tragedies: how the risk was managed? how NASA "drifted" into failure? I believe focusing on a slide completely misses the point.

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