For those that haven’t read the NASA Columbia space shuttle accident reports, it has some great discussions around organisational factors in modern, complex environments.
One element relates to the communication of safety-critical information (images below from chapter 7 of the CAIB report, pg.191). According to Edward Tufte, the PowerPoint slides prepared to report on the threat of debris impact to the shuttle tiles contained “quite optimistic” high-level executive summaries and big-bullet items, whereas the lower-level bullets contained doubts and uncertainties.
The slide title was overly optimistic, suggesting conservatism of the damage threat, and said by Tufte to provide an “unmerited reassurance”.
A number of potential issues communicating critical information was highlighted. Importantly, information gets filtered and interpreted at different hierarchical levels and by different specialists (with their own lens and worldviews) as it moves up the organisation (no different to incidents or hazard comms, evidently).
Diane Vaughan covered this “interpretive flexibility” in her work, saying that groups typically search out more optimistic information and interpretations, while not putting as much effort into actively searching out unfavourable information. At an organisational level, this has been called a disqualification heuristic.
There’s a bit of text in the below images from the CAIB reports, but the images and the main reports are interesting reads.
Richard Feynman had an equal disdain regarding bullet points and communication. He noted as part of the NASA Challenger commission that NASA seemingly communicated all information via bullets – which he believed to be a flawed and potentially dangerous form of communication.
He put it nicely in his book “What do you care what people think” with:
“Then we learned about ―bullets – little black circles in front of phrases that were supposed to summarize things. There was one after another of these little goddamn bullets in our briefing books and on the slides”.
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SafetyInsights.org 