Information School

Dissertation COVER SHEET (TURNITIN)

Module Code: INF6000 Dissertation (GRADUATE YEAR 2014~15)

Registration Number 140135310

Family Name Angoura First Name Stavroula

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The Challenger and Columbia space shuttle accidents: a comparative

research on the impact of information behaviour on information failure.

A study submitted in partial fulfilment

of the requirements for the degree of

Information Management.

at

THE UNIVERSITY OF SHEFFIELD

by

Stavroula Angoura

September 2015

3

Abstract

Background: Research in information behaviour has focused on the information-

seeking processes, whereas research concerning information failure has focused on

information systems. Less attention, however, has been paid to the relationship

between information behaviours and organisational culture and its impact on

information failure

Aims: This dissertation aims at investigating the impact that information behaviours

have on information failure and the extent to which organisational culture influences

the development of such behaviours. Τhe Challenger and Columbia space shuttles’

disasters are used as cases studies and NASA constitutes the organisational context

in which the above aims are examined.

Methods: The methodology employed in this research is qualitative interpretive and

the approach inductive using thematic analysis. Due to travel and access limitations

desk research was conducted. NASA’s official reports on the Challenger and

Columbia space shuttles’ disasters were chosen to be analysed as they provide

diverse aspects of a complex organisation during a 17-year time frame.

Results: Through the analysis of the official reports three different themes were

developed, namely NASA’s culture, pressures and communication and decision-

making. The findings revealed that the agency’s culture was so strong and resistant

to change that during the years the image and a myth of an invincible organisation

had been established. This led to the development of political and production

pressures, which in turn affected the communication and decision-making. As a

consequence behaviours of information avoidance and escalation of the commitment

to launching were evolved allowing concerns about safety to be overlooked. These

behaviours were detected during both disasters. This indicates an interrelationship

between organisational culture and information behaviours which leads to

information failure.

Conclusions: It is concluded that information behaviours were a major factor in both

disasters. These behaviours, influenced by the agency’s strong culture as well as

political and production pressures, created by an escalation of commitment to the

image and myth surrounding NASA and its resistance to change, resulted in flawed

communication and decision-making and eventually in information failure. Further

research, could lead to a more comprehensive understanding of the relationship

between organisational culture and information behaviours and the impact it has on

information failure.

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Contents

Abstract…………………………………………………………………………….....3

Acknowledgements.......................................................................................................5

1. Introduction...............................................................................................................6

1.1. Aims.......................................................................................................................6

1.2. Objectives..............................................................................................................6

1.3. The disasters of Challenger and Columbia............................................................7

2. Literature review…………………………………………………...........................8

2.1. Background............................................................................................................8

2.2. Information behaviour…………………………………………………………...9

2.3. Information behaviour theories …………...........................................................10

2.3.1. Affective Load Theory......................................................................................10

2.3.2. Face Threat Theory...........................................................................................12

2.3.3. Escalation Theory.............................................................................................13

2.4. Information failure.................................................…………………..................15

2.5. Decision-making and organisational learning.……......…..................................16

2.6. Organisational culture..........................................................................................16

2.7. Conclusion...........................................................................................................17

3. Methodology………..……………………….....................……………................19

3.1. Research methodology…………………………….............................................19

3.2. Research design…………………………………………..........….....................20

3.3. Data analysis…………………………………………………........………........21

3.4. Ethical aspects......................................................................................................24

4. Findings………………………......................................................……................25

4.1. NASA’s culture ……………….………………..................................................25

4.2. Pressures..............................................................................................................32

4.3 Decision-making...................................................................................................38

4.4. Conclusion...........................................................................................................43

5. Discussion……………………………………………………...............................45

5.1. Framework...........................................................................................................45

6. Conclusion…………………………………………………..................................51

6.1. Contribution to knowledge.......………….....……………..................................51

6.2. Limitations of the study.......................................................................................52

6.3. Further research...................................................................................................53

7. References………………………………………………………………………...54

8. Appendices ……………………………………………………………………….61

Appendix 1 Themes....................................................................................................61

Appendix 2 Research classification............................................................................62

Appendix 3 Definitions of foam-loss events classification........................................63

Appendix 4 Missed opportunities...............................................................................64

Access to Dissertation.................................................................................................65

Address & first employment destination details.........................................................66

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Acknowledgements

I would like to thank Dr Ana CristinaVasconcelos for her support and guidance as

well as all the staff at the Information School for the excellent services and help they

provided throughout the course.

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1. Introduction

1.1. Aims

The aim of this research is to address the impact that information behaviour has on

information failure, using the Challenger and Columbia space shuttle’s disasters as

cases studies. Those two events were chosen because they represent significant

organisational failures, which marked NASA’s history and became the subject of

several debates concerning the agency’s culture and the way in which it operates and

treats vital information. Rudestam and Newton (2015), suggest that the term case

study indicates a focus on a specific incident, organisational body or activity that

took place. Similarly, Punch (2005) states that a case study can be defined as ″a

research strategy which focuses on the in-depth, holistic and in-context study of one

or more cases″ (p. 289).

Furthermore, this research seeks to investigate and reveal potential patterns and

similarities between the information behaviours that were adopted during the two

incidents and the impact they had on the final outcomes. There is a great deal of

literature concerning the Challenger and Columbia’s disasters. Past research has

focused on different aspects of both the agency and those incidents. Several authors

investigated them in detail and highlighted their causes (McConnell’s, 1987; Trento,

1987; Jensen, 1996; Vaughan, 1996; Cabbage & Harwood, 2004), whereas others

dwelled on the political consequences they had as well as on the agency’s strengths

and weaknesses (Sietzen & Cowling, 2004; McCurdy, 1990).

1.2. Objectives

In addition to the above aims, the research has several objectives, which are:

To identify the actors that were involved in the Challenger and Columbia

space shuttles disasters as well as the role they played in them.

To identify the information behaviours that were adopted by the actors of the

two incidents and indicate potential similarities and differences.

To address the relationship between the information behaviours and the

culture of the organisation.

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To address the extent to which such information behaviours led to a decision-

making trajectory that affected the outcome of the disasters.

1.3. The disasters of Challenger and Columbia

In 1986, January 28th

at 11:39:13 EST, the flight 51-L of Challenger ended suddenly

entraining its crew in death; it exploded just 73 seconds after launch. The cause of

this disaster was ″a failure in the joint between the two lower segments of the right

Solid Rocket Motor. The specific failure was the destruction of the seals that are

intended to prevent hot gases from leaking through the joint during the propellant

burn of the rocket motor″ (Presidential Commission Report, 1986, p.40). Several

concerns regarding the low temperature and its impact on the O-rings as well as

objections against launching were raised by Thiokol’s engineers, NASA’s contractor

However, those were all overruled and Challenger was launched. In its aftermath, a

Presidential Commission was created so as to investigate the reasons it happened and

made recommendations for changes in order for future accidents to be avoided.

Nevertheless, in 2003, February 1st, fifteen years later, NASA experienced another

tragic accident; the Columbia space shuttle, disintegrated while re-entering earth.

During its launch, a piece of foam insulation debris hit and damaged the orbiter’s left

wing. This ″allowed superheated air to penetrate the leading-edge insulation and

progressively melt the aluminium structure of the left wing, resulting in a weakening

of the structure until increasing aerodynamic forces caused loss of control, failure of

the wing, and breakup of the orbiter″ (CAIB, 2003, p.49). The Columbia Accident

Investigation Board was brought together to investigate the cause of the disaster and

concluded that although several of the Presidential Commission’s recommendations

were followed, the two incidents bare similarities in terms of information

communication and processing.

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2. Literature review

2.1. Background

Given the aims of the study and research questions cited above, this chapter reviews

the literature in this topic area and identifies the most relevant sources. Past research

in information behaviour tends to focus on the information-seeking processes

followed by individuals, so as to satisfy the need for information acquisition in

regard to certain information tasks, and on how the acquired information fulfils the

emerged needs (Wilson, 2000). Conversely, research concerning information failure

usually focuses on information systems in order to identify the reasons that led to an

adverse outcome (Gauld, 2007). Less attention, however, has been paid to the

correlation between information behaviours and information failure at an

organisational level in terms of its impact on significant events (Thatcher,

Vasconcelos & Ellis, 2014).

Weick (1998) claims that after a disaster has occurred certain information behaviours

have been identified as contributing factors to the information failure of the incident.

Subsequently, several researchers have cited information failure as having an impact

on organisational disasters (Vaughan, 1996; Turner & Pigeon, 1997). More

specifically, studies have shown that although vital information was available to

decision-makers prior and during the course of a disaster, it was not properly utilised

or acted upon (Lei & Bui, 2000; Mahler & Hogan-Casamayou, 2009). Others suggest

that information behaviours are ingrained in the organisational culture and therefore

in the behavioural patterns, perceptions and beliefs of the individuals interacting with

it (Deltor, Choo, Bergeron & Heaton, 2006; Brown, 1998). Political and financial

barriers and pressures have also been found to affect information behaviour and

information failure within an organisation (Vaughan, 1996; Mahler & Hogan-

Casamayou, 2009).

Moreover, culture is considered to be a significant influencing factor of the way in

which an organisation operates and manages its information flow (Alvesson, 2002;

Brown, 1998). Relevant literature highlights the complexity and interrelation of

organisational culture with internal and external environments, and stresses the

importance of coherence and consistency of culture in order for an organisation to be

9

efficient and able to achieve its goals. It is also considered to affect the way

individuals think and act and denotes that a person’s decisions and actions may have

an effect on the organisation as a whole (Brown, 1992)

There are, however, different perspectives on how culture is treated (Alvesson, 2002;

Brown, 1998). Organisational culture could be viewed as a metaphor. According to

this position, an organisation is seen as if it is a culture; it manifests individuals’

consciousness and permeates every aspect of an organisation, which can be

understood and represented in terms of its symbolic and ideal aspects (Alvesson,

2002). Subsequently, culture is viewed as the intellectual device that enables a

coherent understanding of an organisation in terms of its elements (Brown, 1998).

From another perspective, culture is seen as a variable, an objective reality measured

by certain phenomena and a set of behavioural and cognitive elements (Schein,

1985). It is viewed as a functional part of an organisation that holds all segments of

an organisation together. Accordingly, an organisation has rather than is a culture

(Alvesson, 2002).

2.2. Information behaviour

According to Wilson (2000), information behaviour is ″the totality of human

behaviour in relation to sources and channels of information, including both active

and passive information seeking, and information use″ (p. 49). Information seeking is

considered as an action that is prompted by a conscious purpose to aggregate

information from specific sources (Johnson, 2009). By active information-seeking,

Wilson (1997) refers to the occasions where a person proactively seeks information,

whereas passive information-seeking is the outcome of a search that results in the

retrieval of the relevant information by the seeker. Similarly, information use refers

to the acts, both physical and mental, intended to incorporate the acquired

information into an individual’s existing knowledge (Spink & Cole, 2006). Three

types of information behaviour have been identified: information-seeking,

information searching and information use. These behaviours are viewed as the result

of a secondary need, which is driven by the primary one to fulfil an activity or goal

(Wilson, 1997). It could be, thus, argued that this differentiation concedes the need

for information as a secondary and not as a basic one (Case, 2012).

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Grunig (1989) defines need as an inmost motivational state that facilitates actions

and thoughts. Atkin (1973), on the other hand, argues that a need is the outcome of a

perceived discrepancy between a person’s confidence about a certain situation and a

desirable goal. It is also suggested that a need may vary depending on its nature; it

may be contestable, in that it is different from a person’s ″wants″ and therefore

debatable; alternatively it may have a sense of necessity, in that individuals tend to

stress the degree of a need so as to ensure that everyone accepts a certain goal state

(Case, 2012). In addition, Wilson (1981) has acknowledged three types of

information needs; the physiological, cognitive and affective.

An individual’s information behaviour is affected by several barriers within their

environment. These might be personal, social and interpersonal, work related,

technology related, political or financial (Wilson, 1997). Personality and personal

attributes may affect information-seeking behaviour in terms of motivation. During

stressful circumstances, in their attempt to decrease the uncertainty that derives from

such situations individuals are likely to make use of strategies that affect their

information behaviour (Wilson, 1999). Similarly, the concept of cognitive

dissonance suggests that ″the existence of non-fitting relations among cognitions″

(Festinger, 1957, p. 3) has a significant impact on information-seeking. More

specifically, cognitions, that is any knowledge, opinion or belief about oneself and

one’s environment which are opposed to an individual’s knowing, lead to the

commencement of actions aiming at reducing dissonance (Festinger, 1957).

2.3. Information behaviour theories

Information behaviour is considered to be a major factor in information failures. The

motivational state that is created as a result of the desire to reduce uncertainty may

prompt the individual to avoid information (Johnson, 2009), or be selectively

exposed to it (Case, 2012). Such behaviours are predominant in information

behaviour theories, namely Affective Load, Face Threat and Escalation Theories.

2.3.1 Affective Load Theory

The theory of Affective Load suggests that ″through membership of cultural groups

people inherently develop learned affective norms which influence cognitive

strategies employed for information use″ (Thatcher, Vasconcelos & Ellis, 2014,

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p. 58). It provides a social-behavioural point of view in the context of information

behaviour. According to Nahl (2001), information searching behaviour can be

classified as an ordered sequence, in that a motive arises (affective behaviour); an

interpretation related to the motive is chosen (cognitive behaviour); and a decision

about the action to be taken is made (sensorimotor behaviour). More specifically,

individuals are motivated by a goal-directed behaviour to create and follow a strategy

towards reaching the desirable outcome (Nahl, 2004).

Affect can be viewed as the conscious or subconscious judging of situations or the

process of experiencing feelings (Norman, 2004). It is, also, inextricably connected

with emotions, the conscious realisation of affect (Norman, 2004), which in turn

have a significant impact on information use. Consequently, the affective

motivations that are produced through the individual’s perception of their needs, and

the context in which they interpret them, result in the creation of cognitive processes

(Julien & McKechnie, 2005).

The affective behaviour of an individual can begin, continue and terminate a

cognitive process depending on whether their affective state is negative or positive

and the affective motivation high or low. Thus, it is can be argued that if an

individual’s information behaviour is not supported by an affect of goal oriented

feeling, the behaviour cease and is replaced by a new one. Maintaining an ongoing

affective motivation is the key factor towards completing a task (Nahl, 2004).

Based on their affective motivations, it is observed that individuals tend to create

their unique norms and attributes regarding their information behaviour so as to

achieve a goal. This process results in the development of certain learned affective

norms (Julien & McKechnie, 2005). These norms are created in a social context to

which values can be added at any stage of the cognitive process. As a result, certain

information behaviours are strengthened and new norms are created. According to

Nahl (2005), when the levels of the affective load are high, individuals tend to

present disruptive emotional states such as frustration and pessimism. Conversely,

when affective load is low, individuals tend to employ better coping strategies and

develop positive emotional states as they are not faced with uncertainty and the

negative consequences it may have.

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Moreover, affect has an impact on organisational behaviour, as it influences the

whole cognitive process of those who work within it. Past research has shown that it

plays an important role in organisational decision-making as it influences

information sharing among individuals within an organisation, thereby affecting their

information behaviour and the organisation as a whole (Forgas & George, 2001).

2.3.2 Face Threat Theory

Face Threat Theory posits that people create a sense of self, a public image based on

the accepted social roles and attributes. An individual’s public image or ″face″ is,

then, developed in a social context and influenced by the perceptions of all members

within a social group. Information-seeking and sharing are also regarded as social

activities that take place through interaction, and during which all participants have a

socially defined role or face. The interaction itself is, in turn, framed by the

expectations, socially accepted attributes and roles of the participants. Any

information that disturbs that public image is treated as a threat and as a result is

either avoided, or ignored (Mon, 2005). Face Threat Theory also seems to bare

similarities with Goffman’s Face Theory, which focuses on the social interaction

through which individuals present themselves to the members of the society they are

part of. It also seeks to address the way in which experiences and actions are

organised based on the socially accepted attributes and norms (Goffman, 1974).

Furthermore, individuals have different expectations and they may change their point

of view in different occasions; the interactions might be observed in a different way

and this might result in the creation of certain behaviours and barriers (Thatcher,

Vasconcelos & Ellis, 2014). The consequence of these may be information

avoidance and selective exposure by ignoring or rejecting certain information

(Johnson, 2009).

Information avoidance can be defined as the behaviour that aims at preventing or

obstructing the acquisition of available and potentially discomforting information. As

an information activity, it may be either passive, in that individuals might fail to

complete the information seeking process at any stage, or active, in that a person

acknowledges the unwanted information and chooses to reject it. This behaviour may

also be temporary or permanent, in that one might decide to be engaged with the

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information at a later stage, or avoid it by all means (Sweeny, Melnyk, Miller &

Shepperd, 2010).

The loss of autonomy is an important motivation for avoiding information as well.

Being able to decide and act upon issues based on personal motivations and desires

rather than external variables and pressures, is considered to be an explicit form of

autonomy. Information may jeopardise autonomy, when individuals are forced to

adopt a behaviour which they object to. Consequently, if the acquisition of

information leads to unwanted and unpleasant behaviours, it is most likely to be

avoided or rejected (Howell & Shepperd, 2012).

Conversely, the selective exposure to information suggests that individuals seek what

is congruent with their existing knowledge, opinions and beliefs and choose to

dispose of information that is inconsistent (Smith, Fabrigar & Norris, 2008). When

information is inconsistent with existing beliefs or knowledge, it is likely that it will

be ignored and new information will be introduced. According to Case, Andrews,

Johnson and Allard (2005), if acquiring new information is seen as a cause of

experiencing extra mental or affective discomfort or dissonance, then this will be

avoided or ignored. It is not the information itself that individuals are threatened by,

but the ″cognitive, affective and behavioural consequences of learning the

information″ (Howell & Shepperd, 2012, p. 258).

2.3.3 Escalation Theory

Information behaviours such as information avoidance and selective exposure are

major factors of information failure and are considered to be closely related to

escalation theory (Thacher, 2013).

Escalation Theory is concerned with the escalation of commitment to a course of

action, and to what motivates the stakeholders who are involved in decision making

to persist on such a course, even if it is obvious that the outcome would be negative

(Drummond, 1999; Staw & Fox, 1997). Past research has found two pertinent points

of view related to the theory of escalation. One refers to the perspectives of the

decision-dilemma theorists and the other supports the social-psychological theorists.

The former group claims that escalation is a result of ″information poverty″ and

inadequate data and suggests that it is not possible to predict the outcome of a

14

planned project, especially if the feedback is ambiguous and insufficient. They also

state that in some cases persistence on a course of action is sensible so as to give time

to the project to overcome difficulties (Goltz, 1992).

On the other hand, social-psychological theorists argue that escalation is a result of a

desire to avoid the consequences of a failure. More specifically, it is suggested that

personal responsibility for an adverse outcome is highly instrumental to escalation

(Brockner, 1992). In order to defend decisions previously made, decision-makers

tend to seek information that supports them. Conversely, if its acquisition forces

them to admit wrongdoing, it is ignored. Such inherent biased information processing

would result in developing a false view of the situation, in that the issues the

organisation is facing are temporary and the positive outcome is imminent

(Drummond, 1999).

When escalation occurs, it is observed that the process of decision-making is unlikely

to remain rational and objective. In situations, where an individual or organisations

escalate their commitment to a course of action, when the right decision would be to

abandon it, the result is a continuous cycle of escalation, in order to keep on the

course, increasing commitment of both resources and effort is required (Staw, 1981).

In many cases of escalation, the acquisition of information tends to be oriented

towards decreasing the negative outcomes of a situation as much as possible rather

than altering it (Thatcher, Vasconcelos & Ellis, 2014; Staw, 1981). The key

motivations behind the intensification of persistence in such occasions are self-

justification and refusal to recognise that a decision was the false one to make. ″Once

started, self-justification can lead to a self-perpetuating sequence of escalation

activities″ (Chakravorty, 2009, p.45). Accordingly, in order to justify their position,

the decision-makers seek information that supports their position and avoid others.

Consequently, any information that is not congruent with prior decisions would be

discarded or avoided. In addition, they would cognitively distort any adverse results

and would attempt to put the blame on external factors, instead of altering course

(Staw & Fox, 1978).

Furthermore, commitment may be escalated as a result of external pressures for

success, when failure is not an option (Staw, 1981). Therefore, outcome expectancy,

15

which refers to the extent to which a desirable outcome can be controlled and

predicted, is seen as an influencing factor of escalation (Wong, 2005). In addition to

the expectations concerning the outcome of a situation, a culture in which risk

oriented behaviours are ingrained could also lead to intensification of commitment.

The level of risk related to a decision is likely to influence in a negative way the

outcome of a situation and lead to information failure (Thatcher, Vasconcelos &

Ellis, 2014).

2.4. Information failure

Information failure has been identified as contributing to organisational disasters and

accidents. Deficiency in capturing and interpreting information that could have

prevented an incident is seen as a reason for information failure and therefore a

disaster or accident (Maclntosh-Murray & Choo, 2002).

Shared thinking and practices within an organisation may obstruct the dissemination

of information concerning possible failures and hinder their effective deterrence. Its

absence or inefficient communication is also identified as a cause of information

failure (Westrum, 1992). Information disjunction may also hamper sense-making and

lead to the development of diverse interpretations of a set of information and thus

complicate an existing situation (Turner & Pigeon, 1997).

Furthermore, the tendency to make decisions based on inadequate or pre-existing

information, and to interpret it in a simplified way, creates collective erroneous

perceptions, which lead to negative outcomes (Weick, 1998). Similarly, collective

sense-making is influenced by an organisation’s culture and has an impact on

information failures, as they occur due to inefficient dissemination and

communication of information (Turner & Pigeon, 1997).

Nevertheless, there are several organisational features that contribute to failures. A

rigid organisational culture and its ingrained beliefs and norms bias members’ sense-

making. Organisational exclusivity also results in rejecting warnings about a

potential incident coming from ″outsiders″ (Turner & Pigeon, 1997). Furthermore,

difficulties in interpreting information may result in failure; the organisation may not

be able to retrieve the information needed, individuals might employ a negative

attitude when responding to issues; or fail in attending the information (Maclntosh-

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Murray & Choo, 2002). Moreover, individuals might not comply with rules or not be

able to cope with emergent hazard due to the lack of sufficient information

(Vaughan, 1996).

Weick (1998) suggests that a persistent effort to comprehend a situation might result

in ignoring distinctive information and in adopting a solution accepted by the

majority. In many occasions, such an activity creates ″blind-spots″ and leads to

information failure. Collective actions require simplified assumptions, which in turn

confine precautions and allow the accumulation of anomalies. Consequently, the

possibilities of undesired outcomes are gradually increasing.

2.5. Decision-making and organisational learning

Decision-making is a process that results in the activity of choosing and is subject to

various influences. It could be said that the information behaviour of escalation is a

prime example. When decision-makers are responsible for a choice that is likely to

fail, they stay on course by altering their beliefs and changing practices. Hence, they

escalate commitment to the decision due to biased updating of beliefs aiming at

supporting it (Biyalogorsky, Boulding & Staelin, 2006). It is argued that decision-

making is closely related to and affects the way in which organisational learning

takes place, as past mistakes become guides for future success. If a decision is

harmful, although it may lead to failure, organisations strive to identify and record

faults in order not to repeat them, and thus go through a learning process (Bettis-

Outland, 2012). Accordingly, organisational learning refers to the change in an

organisation’s behaviour; the acquisition and further processing of new knowledge

and experiences which in turn have an impact on individuals (Argote & Miron-

Spektor, 2011).

2.6. Organisational culture

Organisational culture is an important yet complex segment of an organisation. The

structure of an organisation in conjunction with its culture are considered to be

influencing factors of information sharing and use, and consequently of information

behaviours (Markoulides & Heck, 1993). Similarly, cultural and social norms have

an impact on how individuals act and interact with information (Chatman, 2000).

Therefore, a strictly hierarchical structure obscures the efficient flow of information

17

and smooth communication among the different parts of an organisation (Daft,

2003).

Several researchers view organisational culture differently. For example, Sun (2008)

describes it as the right way in which issues are understood and dealt with, whereas

Ogbonna (1992) argues that it is a set of ingrained values and beliefs shared by all

members of an organisation. Likewise, Brown (1998) defines culture as a set of

beliefs, values and norms developed throughout an organisation’s history and

identifiable in the behaviour of its members. Conversely, Schein (1985) deems

organisational culture to be a learned entity; ″a pattern of shared basic assumptions″

(p. 9) that is learned, is efficient and can be taught to new members.

Moreover, organisational culture can either be strong, in that a diffusible

commitment is present and the consistency of its elements guides information

behaviour and establishes solid compliance (Deninson, 1990), or have several sub-

cultures, in that a subset of individuals interact with each other and build distinctive

groups, which share a different understanding from the one of the predominant

culture (Bell, 2013).

The former occurs due to a long history or important shared experiences; it is highly

resistant in change and although it fortifies an organisation from external influences,

it hinders internal change. Contrariwise, sub-cultures which are developed within

different units due to the existence of more than one set of beliefs, enable deviant

groups to grow and result in a paralysed organisation (Sinclair, 1993; Schein, 1990).

2.7. Conclusion

Information behaviours, such as information avoidance, selective exposure and

escalation, are considered to have an impact on information failures. Similarly,

information failure is viewed as contributing to organisational disasters and

accidents. In situations where discomfort or information inconsistent with current

beliefs and knowledge exist, information behaviours may result in its dismissal or

rejection. This would result in ineffective communication and dissemination of

information and thus lead to failure.

18

Decision-making would also be affected by the existence of certain information

behaviours. More specifically, escalation is viewed as a strong influencing factor.

Responsibility for a decision ignites escalation of bias and compels decision-makers

to modify their original beliefs in accordance with the requirements of the decision.

Furthermore, organisational learning is likely to be interrupted on minimised, since it

is intertwined with the decision-making process.

Organisational culture provides a shared set of values which manifests the way in

which an organisation operates. It both influences and is influenced by information

behaviours and in turn affects decision-making and organisational learning. Culture

underpins how information is treated and utilised in regard to the desirable outcome.

If information is viewed to be opposed to existing rationale or have undesirable

consequences, it is unlikely to be sought out. Instead, it will be avoided and replaced.

Such activity reveals ingrained perceptions and respective behaviours, which inform

decision-making and shape organisational learning. Consequently, misinformation

takes place, threats are underrated or not fully acknowledged and hence organisations

are unable to react properly; as a result failure occurs.

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3. Methodology

3.1 Research methodology

The methodology employed in this research is qualitative interpretive and the

approach inductive. According to Flick (2007), qualitative research is considered to

be subjective. Its purpose is to capture the image of the world as it is and interpret,

delineate and disclose inner social norms. It emphasizes on understanding the

meaning, experiences and perspectives of the individuals over the social

construction. Similarly, Silverman (2013) deems that qualitative research seeks to

explain the social phenomena and cultures that underpin different communities and

the thinking as well as the social structure behind it. It makes use of empirical

material, in that everything that can be observed with broad and variant

interpretations (Punch, 2005), such as textual or discursive, documents and

transcriptions of interviews.

Rudestam and Newton (2015) suggest that qualitative research ″begins with specific

observations and moves toward the identification of general patterns that emerge

from the cases under study″ (p. 39). The reason for employing a qualitative

methodology is the purpose of the project itself, which is to identify the impact that

information behaviour has on information failure during disastrous events within a

complex organisational context, which is open to different interpretations. To that

end, NASA was chosen as it constitutes a prime instance of a convoluted

organisation. Subsequently, the cases of Challenger and Columbia space shuttles’

disasters were selected as case studies in order to provide a longitudinal perspective

on the cultural remaining commonalities and ingrained information behaviours of the

organisation; the time-frame between these two incidents is 17 years. According to

Rudestam and Newton (2015), the use of case studies is closely affiliated with

qualitative research, where an endeavour to discern the complex context of an

individual unit is postulated.

NASA is a federal agency and a highly matrixed organization, meaning that there are

several lines of authority. ″At the simplest level, there are three major types of

entities involved in the Human Space Flight Program: NASA field centres, NASA

programs carried out at those centres, and industrial and academic contractors. The

20

centres provide the buildings, facilities, and support services for the various

programs ″ (CAIB, 2003, p. 16).

3.2 Research design

The approach taken is inductive as the project deals with two specific cases in order

to conclude and provide an answer to the research question through the analysis of

the official related reports, which constitute the data set of the research. The idea of

conducting an inductive research is to step aside and become an observer so as to

take a closer look to the situation in question (Silverman, 2013).

Additionally, since the goal of the research is to identify, analyse and record patterns

that derive from the data, thematic analysis was employed (Braun and Clarke, 2006).

According to Fereday and Muir-Cochrane (2006), thematic analysis ″is a search for

themes that emerge as being important to the description of the phenomenon...a form

of pattern recognition within the data, where emerging themes become the

categories. Braun and Clarke (2006) suggest that thematic analysis or thematic

synthesis, as Thomas and Harden (2008) name it, is characterised by its flexibility.

They posit that it can be either an essentialist or realist method, in that it records the

experiences and reality of the participants as they understand it, or constructionist

method, in that it explains how these experiences and meanings have an effect on the

discourses created within a community. Boyatzis (1998), however, argues that

thematic analysis can be either theory-driven or data-driven. Moreover, a hybrid

model of this analysis that incorporates both a deductive, theory-driven and a data-

driven, inductive approach can be adopted. For the purposes of this research the

inductive data-driven approach to thematic analysis was chosen as the most

appropriate.

Conducting thematic analysis requires ″reading and re-reading of the data″ (Rice &

Ezzy, 1999, p. 258), coding them and then creating themes. Coding constitutes

prerequisite for the identification and development of themes. A useful code captures

the deep meaning of the data and leads to coherent themes (Fereday &Muir-

Cochrane, 2006). According to Boyatzis (1998), a theme can be defined as “a pattern

in the information that at minimum describes and organises the possible observations

and at maximum interprets aspects of the phenomenon (p. 161). Thematic analysis

21

may have several steps and stages through which codes are created depending on the

approach that is followed (Boyatzis, 1998; Braun & Clarke, 2006). Moreover,

Boyatzis (1998) suggests that in order for a theme to be robust and valid it must

contain three elements: a label or name for the theme, its definition and a description

of how to identify when the theme occurs.

3.3 Data analysis

For the purposes of this research, NASA’s official reports on the Challenger and

Columbia space shuttles’ disasters were chosen to be analysed. These reports were

selected because they provide diverse dimensions and different perspectives of a

complex organisation during a time-frame of more than a decade. Furthermore, the

analysis of the reports aims at disclosing the information behaviours that are rooted

within the organisation’s culture as a phenomenon, and at identifying the way in

which they affect NASA’s interpretation of a situation of hazard. The two reports

are:

The Roger’s Commission official report on the Space Shuttle Challenger

Accident: This report, which is also known as the Presidential Commission

Report, was created by a Commission appointed by the President of the USA so

as to conduct an investigation regarding the Challenger’s destruction just

seconds after its launch. (http://history.nasa.gov/rogersrep/genindex.htm)

The official report of the Columbia Accident Investigation Board (CAIB): This

report was created by the Investigation Board, which was assembled by NASA

so as to investigate the disintegration of the Columbia space shuttle during its re-

entry into the earth’s atmosphere.

(http://s3.amazonaws.com/akamai.netstorage/anon.nasa-

global/CAIB/CAIB_lowres_full.pdf)

Furthermore, since the reports are the source of the data, quotations were used so as

to support the findings of the research. To that end, a referencing system based on the

reports was employed. More specifically, for the Roger’s Commission official report

on the Space Shuttle Challenger Accident the abbreviated title “Presidential

Commission Report” is used, whereas for the official report of the Columbia

22

Accident Investigation Board the acronym “CAIB” is adopted. The publication date

follows and then goes the page and the volume or chapter number. For example, the

reference for a quotation from the Presidential Commission Report would be:

“Presidential Commission Report, 1986, p. 15, Vol. I, Ch. III”, while for the CAIB

would be “CAIB, 2003, p. 15, Ch. 3”. The difference between the two reports is that

the former is divided in volumes, from which the first is the full report and the rest

are the appendices, and then in chapters, whereas the latter is divided only in

chapters.

Nevertheless, a problem was encountered in terms of format. The Presidential

Commission Report is available in a different type of format than the CAIB, that is

XML and pdf respectively. In order to conduct the analysis the documents had to be

downloaded and printed. In the case of the Presidential Commission Report that was

problematic and time consuming as each volume of the report had to be converted

into pdf and then be printed and studied.

The data analysis was conducted in four phases. Firstly, the documents were read and

re-read several times with the aim to become familiarised with the material. During

this process, notes and initial ideas were written down and hence a list of premature

and broad codes was created. These ideas were then processed and narrowed down,

reviewed and organised into meaningful groups. Each group consisted of codes with

similar context. As a result, several mind-maps of codes were created. At a later

stage, these codes were analysed and sorted into potential themes and sub-themes.

Relationships between codes were identified, combinations for overarching

categories were tested and candidate themes were formed. Subsequently, some of

them were collapsed into others due to several similarities or repetitions. As a result

of this process three final themes were generated.

The fourth phase of the analysis was divided into two stages. During the first stage,

all candidate themes were reviewed at the level of the coded data extracts. If there

was a pattern formation, the process moved on to the second stage. If themes did not

fit, they were either processed again or dismissed. At the second stage the validity of

each theme was examined in relation to the data set and the extent to which they

reflected its meaning. Thereafter, according to Boyatsis (1998), the themes were

23

given a label, definition and indicators. An example of the final presentation of the

themes is provided below whereas a full list can be found in the appendices1.

Theme 1:

Label: NASA’s culture

Definition: The basic values, norms, beliefs and practices that define an

organisation’s functioning and its employees’ assumptions.

Indicators: Coded when the report states “cultural traits”, “program culture”

or “organisational culture”.

Differentiation: Occasionally “history” is treated as intertwined with

“culture”.

1 See appendix 1

24

3.4 Ethical aspects

Both reports are publically available and easily accessible. No further access to or

contact with the organisation was required. Thus, the research was based on desk

rather than on primary research. According to Woolley (1992), ″desk research is used

to describe the process of gathering information available in published form, rather

than obtaining the data directly″ (p. 227). Furthermore, no human participants were

engaged with the research at any stage. Consequently, the research was classified as

“no risk” and no ethical approval was required2.

2 See appendix 2

25

4. Findings

The analysis of the official reports on the Challenger and Columbia space shuttles’

disasters revealed that apart from the technical causes there were additional elements

and respective information behaviours that contributed to the outcome, which are

rooted in NASA’s history and the way in which it operates. These are grouped into

three themes; NASA’s culture, political and production pressures and decision-

making. Each will be discussed in the following chapter.

4.1 NASA’s culture

It became clear that the disasters occurred not only due to the technical issues but

also because of the existence of certain elements that are ingrained in the agency’s

culture.

″The Board recognized early on that the accident was probably not an

anomalous, random event, but rather likely rooted to some degree in

NASAʼs history and the human space flight program’s culture″. (CAIB,

2003, p. 9)

NASA was considered to be the most important political underpinning and was

surrounded by the perception of a strong and safe organisation. Since its inception,

the human space shuttle program generated high expectations and created a myth

around the agency concerning the ease of travelling to space and completing its

missions.

″...the Shuttle emerged from a series of political compromises that produced

unreasonable expectations – even myths – about its performance. ″ (CAIB,

2003, p. 9, Ch. 1)

The successes of the Apollo mission also contributed to the enrichment and

enhancement of this myth as well as the cultivation and promotion of an image,

presenting NASA as the “perfect organisation” that can achieve everything.

″Apollo successes created the powerful image of the space agency as a

“perfect place,” as “the best organization that human beings could create to

accomplish selected goals.” During Apollo, NASA was in many respects a

26

highly successful organization capable of achieving seemingly impossible

feats. ″ (CAIB, 2003, p. 102, Ch. 5)

Subsequently, this image was promoted not only within the organisation itself but

also to the public.

″... NASA promised it could develop a Shuttle that would be launched almost on

demand and would fly many missions each year. Throughout the history of the

program, a gap has persisted between the rhetoric NASA has used to market the

Space Shuttle and operational reality, leading to an enduring image of the

Shuttle as capable of safely and routinely carrying out missions with little

risk″ (CAIB, 2003, p. 23, Ch. 1)

″From the inception of the Shuttle, NASA had been advertising a vehicle

that would make space operations routine and economical″. (Presidential

Commission Report, 1986, p. 15, Vol. I, Ch. VIII)

The “Apollo era” signalled the consolidation of the idea of NASA as an organisation

capable of achieving anything and as such it was viewed by the public and those who

worked within it. As a result, over the years certain cultural attitudes were developed

that strengthened the agency’s “can-do” culture, accepted risk and ignored signals of

potential danger.

″The Apollo era created at NASA an exceptional “can-do” culture marked

by tenacity in the face of seemingly impossible challenges. The culture also

accepted risk and failure as inevitable aspects of operating in space″. (CAIB,

2003, p. 101-102, Ch. 5)

Reliance on past success and ambitions for future developments lead managers to

overlook the developmental condition of the shuttle and go ahead with an increasing

flight-rate schedule in order to maintain the image of the successful organisation.

″NASA managers “may have forgotten–partly because of past success,

partly because of their own well-nurtured image of the program– that the

Shuttle was still in a research and development phase″. (CAIB, 2003, p.

100, Ch. 5; Presidential Commission Report, 1986, p. 165, Vol. I, Ch. VIII)

27

Both Challenger and Columbia were nodal points in achieving important goals. A

potential failure of attaining these goals meant loss of funding from the government

and significant damage in NASA’s reliability and image. For that reason, information

opposed to or seen as threat to the desirable outcome was avoided or ignored.

More specifically, in the case of Challenger, indications of O-ring erosion and hence

strong signals of danger were present yet avoided or rejected. Concerns regarding the

low temperature were raised from the Thiokol’s engineers who suggested delaying

the launch. Accepting, however, such suggestion meant that the flight schedule

would not be met; a choice that was unacceptable. Consequently, managers made use

of information that was congruent with their intension of launching and ignored

those that opposed in any way to the goal. Such decision shows that behaviours of

information avoidance took place.

Despite the engineers’ objections about launching and indications for the potential

results of low temperature, managers decided that because erosion had occurred

before it did not constitute a discriminating factor, and hence to go ahead as planned.

During the teleconference, where the Thiokol engineers’ recommendation was not to

launch, information avoidance was clear.

″The conclusion was we should not fly outside of our data base, which was

53 degrees...Listeners on the telecon were not pleased with the conclusions

and the recommendations″. (Presidential Commission Report, 1986, p. 90,

Vol. I, Ch. V)

Even though the recommendation was not to launch and despite engineers’

continuous efforts to stress the potential danger, managers rejected the information

opposed to launching and acted upon those in favour.

″I [Boisjoly] tried to make the point that it was my opinion from actual

observations that temperature was indeed a discriminator and we should not

ignore the physical evidence that we had observed...After Arnie and I had

our last say, Mr. Mason said we have to make a management decision.″

(Presidential Commission Report, 1986, p. 92-93, Vol. I, Ch. V)

28

″...we just don't know how much further we can go below the 51 or 53

degrees or whatever it was. So we were concerned with the unknown. And

we presented that to Marshall, and that rationale was rejected. They said that

they didn't accept that rationale...Mr. Hardy said he was appalled that we

would make such a recommendation″. (Presidential Commission Report,

1986, p. 94, Vol. I, Ch. V)

The avoidance and rejection of information that would delay the launch is closely

related to the “can-do” attitude that is prevalent to the organisation. Even after the

Challenger’s accident, NASA strived to maintain its image of the “best organisation”

by avoiding information that threatened to disturb it. As a result, information

avoidance and selective exposure continued to occur as they were ingrained within

the agency’s culture.

″In the aftermath of the Challenger accident, these contradictory forces [the

trend toward bureaucracy and the associated increased reliance on

contracting] prompted a resistance to externally imposed changes and an

attempt to maintain the internal belief that NASA was still a “perfect

place...Within NASA centres, as Human Space Flight Program managers

strove to maintain their view of the organization, they lost their ability to

accept criticism, leading them to reject the recommendations of many

boards and blue-ribbon panels, the Rogers Commission among them″.

(CAIB, 2003, p. 102, Ch. 5)

It could be argued that the behaviours that took place in Challenger’s mission, also

occurred during the course of Columbia flight, which in conjunction with the self-

confidence and the sense of invisibility that had been cultivated led to the disaster.

″NASAʼs safety culture has become reactive, complacent, and dominated by

unjustified optimism″. (CAIB, 2003, p. 180, Ch. 7)

″NASA appeared to be immersed in a culture of invincibility, in stark

contradiction to post-accident reality. The Rogers Commission found a

NASA blinded by its “Can-Do” attitude, a cultural artefact of the Apollo

era...bolstered administrators’ belief in an achievable launch rate, the belief

29

that they had an operational system, and an unwillingness to listen to outside

experts. (CAIB, 2003, p. 199, Ch. 7)

These characteristics are also identified in the way in which NASA treated and

classified the foam-debris strikes. Although there were increasing concerns regarding

the foam events that occurred during Columbia’s ascend and several requests for

extra imagery were pending, managers insisted on the “in-family” and later on the

“no safety-of-flight issue” classification. NASA continued making decisions based

on previous success rather than on firm data so as to support its image. Therefore,

“blind-spots” were created and the significance of the danger was diminished.

″...that detection of the dangers posed by foam was impeded by “blind

spots” in NASAʼs safety culture... the Board witnessed a consistent lack of

concern about the debris strike on Columbia. NASA managers told the

Board “there was no safety-of-flight issue” and “we couldn’t have done

anything about it anyway″. (CAIB, 2003, p. 184, Ch. 7)

This led to a situation where foam loss events were normalised and treated as a

simple maintenance issue; managers strived to maintain and promote such rationale,

which inevitably led to the adoption of behaviours of information avoidance.

Information concerning potential hazards in regards to foam strikes was dismissed or

rejected so as to support the unanimous perception that it is safe to fly with events of

foam loss.

″At every juncture of STS-107 [Columbia], the Shuttle Program’s structure

and processes, and therefore the managers in charge, resisted new

information... Overwhelming evidence indicates that Program leaders

decided the foam strike was merely a maintenance problem long before any

analysis had begun. Every manager knew the party line: “we will wait for

the analysis – no safety-of-flight issue expected”″. (CAIB, 2003, p. 181,

Ch. 7)

To accept that foam-debris strikes are more than just a maintenance issue and that

they may cause loss of the shuttle and the lives of the crew, would be disastrous for

the organisation’s image and the program itself. To that end, managers recognised

30

only what was congruent with their existing beliefs and opinions, and rejected or

avoided what could disturb and damage NASA’s image and undermine its goals.

″A tile expert told managers during frequent consultations that strike

damage was only a maintenance-level concern and that on-orbit imaging of

potential wing damage was not necessary. Mission management welcomed

this opinion and sought no others. This constant reinforcement of managers’

pre-existing beliefs added another block to the wall between decision

makers and concerned engineers″. (CAIB, 2003, p. 169, Ch. 6)

Consequently, such decisions and behaviours led to gradual acceptance of risk and

creation of learned attitudes that supported the prevailing opinion that foam strikes

are in-family and not a safety-of-flight issue, and hence that it was safe to continue

flying.

″...learned attitudes about foam strikes diminished management’s wariness

of their danger. The Shuttle Program turned the experience of failure into

the memory of success″. (CAIB, 2003, p. 181, Ch. 7)

During both incidents, information and signals concerning the imminent disaster

were available. However, those were misinterpreted and many occasions ignored and

avoided as they could interfere with the arrangement that NASA had inflicted.

Culture played a leading role in the cultivation and maintenance of behaviours of

selective exposure to and information avoidance. It constituted a frame against which

all new information had to be judged and evaluated; if information was consistent

with NASA’s objectives, it was accepted and acted upon. Otherwise, it was avoided

or ignored.

″In both situations, all new information was weighed and interpreted against

past experience. Formal categories and cultural beliefs provide a consistent

frame of reference in which people view and interpret information and

experiences. Pre-existing definitions of risk shaped the actions taken and not

taken...In both cases, managers’ techniques focused on the information that

tended to support the expected or desired result at that time...Management

did not listen to what their engineers were telling them″. (CAIB, 2003, p.

200-201, Ch. 8)

31

More specifically, in regards to Challenger, the strong signal of the low temperature

and the data from previous O-ring erosions, were minimised and in the end avoided

during the teleconference. Similarly, in the case of Columbia managers had weak but

continuous signals of the disastrous prospects of foam strikes. Engineers strived to

gather and present more data but were faced with the management’s strong

perceptions and denial of accepting information inconsistent with the agency’s

image.

″Over the course of 22 years, foam strikes were normalized to the point

where they were simply a “maintenance” issue – a concern that did not

threaten a mission’s success. This oversimplification of the threat posed by

foam debris rendered the issue a low-level concern in the minds of Shuttle

managers. Ascent risk, so evident in Challenger, biased leaders to focus on

strong signals from the Shuttle System Main Engine and the Solid Rocket

Boosters. Foam strikes, by comparison, were a weak and consequently

overlooked signal, although they turned out to be no less dangerous″.

(CAIB, 2003, p. 181, Ch. 7)

32

4.2 Pressures

NASA was under significant political pressures throughout its history to fulfil its

goals, which subsequently resulted in the development of tremendous internal

production pressures regarding the flight schedules. Since its inception the human

space shuttle program required great amounts of funding for its operations and

government was increasingly demanding more to be done. Consequently, the

relationship between them became more customer and demand oriented.

Competition from other space agencies as well as the fear of budget cuts led NASA

to classify the shuttle as operational, whereas in reality it was still at a developmental

stage, in order to be able to support the defined schedule, satisfy political demands

and thus ensure future funding.

″There were two reasons for declaring the Space Shuttle “operational” so

early in its flight program. One was NASAʼs hope for quick Presidential

approval of its next manned space flight program, a space station, which

would not move forward while the Shuttle was still considered devel-

opmental. The second reason was that the nation was suddenly facing a

foreign challenger in launching commercial satellites″. (CAIB, 2003, p. 23,

Ch. 1)

This situation had as a result the intensification of devotion to the perception and

promotion of the shuttle as operational.

″The prevalent attitude in the program appeared to be that the Shuttle should

be ready to emerge from the developmental stage, and managers were

determined to prove it "operational." Various aspects of the mission design

and development process were directly affected by that determination″.

(Presidential Commission Report, 1986, p. 165, Vol. I, Ch. VIII)

Furthermore, as the fulfilment of the flight schedule was intertwined with the

approval of further funding and acceptance from the government, and hence NASA’s

ability to continue its program, further political pressures were inevitably developed

that affected the way in which the agency operated.

33

″Pressures developed because of the need to meet customer commitments,

which translated into a requirement to launch a certain number of flights per

year and to launch them on time. Such considerations may occasionally

have obscured engineering concerns″. (Presidential Commission Report,

1986, p. 165, Vol. I, Ch. VIII)

To that end, during the preparation for the Challenger launch, several changes were

made to the flight manifest so as to ensure that the schedule will be met.

″We have done enough complaining about it [changes in the manifest] that I

[Tommy Holloway] cannot believe there is not a growing awareness, but the

political aspects of the decision are so overwhelming that our concerns do

not carry much weight... And in the face of that, political advantages of

implementing those late changes outweighed our general objections″.

(Presidential Commission Report, 1986, p. 173, Vol. I, Ch. VIII)

Such activity indicates that in order for NASA to achieve its goals and meet the

predefined requirements that would result in the enhancement of government’s

support, several actions closely related to information avoidance behaviour were

taken. Amending an official flight document so as to “fit” the existing information

and avoid acknowledging the new one, while allowing a mission to go ahead and

thus stay on schedule, is one of them.

In the years following the Challenger accident, pressures continued. Due to the

political objectives and the negative implications that the failure in fulfilling them

would have, NASA set out to complete a mission of great importance, the “Node 2”

with the aim to restore its credibility and image. This, however, meant that even

more pressure would be imposed both to the agency itself and its personnel.

″... the Board received several unsolicited comments from NASA personnel

regarding pressure to meet...February 19, 2004, the scheduled launch date of

STS-120...It became apparent that the complexity and political mandates

surrounding the International Space Station Program, as well as Shuttle Pro-

gram management’s responses to them, resulted in pressure to meet an

increasingly ambitious launch schedule...If this goal was not met, NASA

34

would risk losing support from the White House and Congress for

subsequent Space Station growth ″. (CAIB, 2003, p. 131, Ch. 6)

So important was to meet the “Node 2” that management did not accept any delays.

In the past, when a technical issue occurred and a flight had to be delayed, it did and

another mission could be flown instead. With the commencement, however, of

“Node 2” this activity changed. Missions had to be completed in a specific order,

otherwise the schedule would be jeopardised. Such a change hampered the process of

potential repairs after every mission, as time is needed for it to be completed, which

due to the tight and increasing rate of flights was not sufficient.

″...“the serial nature” of having to fly Space Station assembly missions in a

specific order made staying on schedule more challenging. Before the Space

Station, if a Shuttle flight had to slip, it would; other missions that had

originally followed it would be launched in the meantime. Missions could

be flown in any sequence. Now the manifests were a delicate balancing act.

Missions had to be flown in a certain order...Any necessary change they

made on one mission was now impacting future launch dates. They had a

sense of being “under the gun″. (CAIB, 2003, p. 134, Ch. 6)

Accordingly, when managers dealt with the foam-debris strikes issue, they

intensified their persistence on classifying it as an “in-family” and later on as a “no

safety-of-flight” event in order to go ahead with the launch; if it was classified as an

“out-of-the-family” issue, the flight would be delayed for an unknown period of time

and thus the schedule could not be met. A potential delay of the Columbia flight

would result in subsequent delay of the next mission and eventually in failure to meet

the goal of the “Node 2”, which was a high priority goal for management.

Consequently, information concerning the severity of the foam strikes was avoided

and in many cases its importance was minimised and normalised.

During the STS-112 flight, two missions before Columbia’s, an unexpectedly large

foam debris hit the shuttle. Because it was the first time such a significant event, both

in size and in the damage it caused, that had occurred the rationale to continue flying

was investigated. Nevertheless, the STS-113 flight was launched.

35

″Hamʼs focus on examining the rationale for continuing to fly after the foam

problems with STS-87 and STS-112 indicates that her attention had already

shifted from the threat the foam posed to STS-107 to the downstream

implications of the foam strike″. (CAIB, 2003, p. 148, Ch. 6)

This particular incident constituted evidence that foam-debris strikes posed threat to

the safety of both the shuttle and those on board. However,

″...at STS-113ʼs Flight Readiness Review, managers formally accepted a

flight rationale that stated it was safe to fly with foam losses″. (CAIB, 2003,

p. 125, Ch. 6)

Such rationale was adopted in order for the schedule not to be delayed and the

decision to launch was made despite the information that illustrated the significance

of the strike depicts that

″...most of the Shuttle Program’s concern about Columbia’s foam strike

were not about the threat it might pose to the vehicle in orbit, but about the

threat it might pose to the schedule″. (CAIB, 2003, p. 139, Ch. 6)

Consequently, information that supported and strengthened the engineers’ concerns

about potential danger regarding the foam-debris was either ignored or avoided by

management.

According to NASA’s regulations, if a technical or structural problem occurs during

a mission, the vehicle needs to be grounded and examined until the issue is resolved.

This would have as a result the delay of the next flight. Accordingly, if the decision

concerning the foam loss, during the Flight Readiness Review of STS-113, was

found to be flawed, the pivotal for “Node 2” flight would be delayed and the

schedule would not be met. Therefore, any information that would have such impact

was either rejected or normalised.

″...Ham was due to serve, along with Wayne Hale, as the launch integration

manager for the next mission, STS-114. If the Shuttle Program’s rationale to

fly with foam loss was found to be flawed, STS-114, due to be launched in

about a month, would have to be delayed per NASA rules that require

36

serious problems to be resolved before the next flight. An STS-114 delay

could in turn delay completion of the International Space Station’s Node 2,

which was a high-priority goal for NASA managers″. (CAIB, 2003, p. 148,

Ch. 6)

Due to the increased pressures, the “Node 2” goal was characterised as “performance

gate”. As the Task Force Chairman Thomas Young stressed in his testimony before

the House Committee on Science on November 7, 2001:

″... over the next two years, NASA should plan and implement a credible

“core complete” program. If satisfactory, resource needs would be assessed

and an [ISS] “end state” that realized the science potential would become

the baseline. If unsatisfactory, the core complete program would become the

“end state”. (CAIB, 2003, p. 117, Ch.5)

Thus, automatically the achievement of an on-schedule Node 2 launch would

become the affirmation of NASA’s image as a successful organisation. To that end,

the agency’s management had to ensure the achievement of this goal. Consequently,

″any suggestions that it would be difficult to meet that launch date were

brushed aside″. (CAIB, 2003, p. 117, Ch.5)

The increasing production pressures were also noticed by the employees during both

incidents:

″...it seemed to some that budget and schedule were of paramount concern.

As one employee reflected:

″I guess my frustration was … I know the importance of showing that you …

manage your budget and that’s an important impression to make to

Congress so you can continue the future of the agency, but to a lot of

people, February 19th just seemed like an arbitrary date … It doesn’t make

sense to me why at all costs we were marching to this date″.

″...I felt personally that management was under a lot of pressure to

launch...This was a meeting [teleconference] where the determination was

to launch, and it was up to us [engineers] to prove beyond a shadow of a

37

doubt that it was not safe to do so″. (Presidential Commission Report, 1986,

p. 93, Vol. I, Ch. V)

38

4.3 Communication and decision-making

Production pressures are also considered to have an impact on the decision-making

process.

″...the need to adhere to the Node 2 launch schedule also appears to have

influenced their decision. Had the STS-113 mission been delayed beyond

early December 2002...Node 2 launch date, a major management goal,

would not be met″. (CAIB, 2003, p. 125, Ch. 6)

Classifying the foam loss as an “out-of-family event”, would result in delaying STS-

113 and subsequently the launch of the STS-107, a pivotal point in a series of

missions towards achieving an important goal. Accordingly, little attention was paid

to information related to foam-debris strikes and in most cases was either ignored or

avoided.

″The foam-loss issue was considered so insignificant by some Shuttle

Program engineers and managers that the STS-107 Flight Readiness Review

documents include no discussion of the still-unresolved STS-112 foam

loss″. (CAIB, 2003, p. 126, Ch. 6)

Likewise, information concerning the O-ring erosion and its potential negative

results was not promptly communicated throughout all levels of authority and was

merely absent from official reporting documents.

″In any event, no mention of the O-ring problems in the Solid Rocket

Booster joint appeared in the Certification of Flight Readiness, signed for

Thiokol on January 9, 1986, by Joseph Kilminster, for the Solid Rocket

Booster set designated BI026. Similarly, no mention appeared in the

certification endorsement, signed on January 15, 1986, by Kilminster and by

Mulloy. No mention appears in several inches of paper comprising the

entire chain of readiness reviews for 51-L [Challenger] ″. (Presidential

Commission Report, 1986, p. 85, Vol. I, Ch. V)

In addition, flawed communication and strictly hierarchical and bureaucratic

structure of authority and reporting contributed to this situation, as information did

39

not reach the appropriate level within the chain of command and in some cases,

because it was difficult to reach the person accountable for a certain issue,

individuals chose to follow informal ways of communicating.

″It is clear that crucial information about the O-ring damage in prior flights

and about the Thiokol engineers' argument with the NASA telecon

participants never reached Jesse Moore or Arnold Aldrich, the Levels I and

II program officials, or J.A. (Gene) Thomas, the Launch Director for 51-L″.

(Presidential Commission Report, 1986, p. 102, Vol. I, Ch. V)

Moreover, this way of acting and communicating made it easier for discomforting or

disturbing information to be avoided, ignored or even rejected. When the official

channels of communication are not followed, information might get lost and thus

decision-makers will not be able to make informed decisions. In addition, when

pressures are compulsive, such situation facilitates the manipulation of information

and cultivates behaviours of selective exposure to and information avoidance.

″An e-mail that he [Rocha] did not send but instead printed out and shared

with a colleague follows....When asked why he did not send this e-mail,

Rocha replied that he did not want to jump the chain of command. Having

already raised the need to have the Orbiter imaged with Shack, he would

defer to management’s judgment on obtaining imagery″. (CAIB, 2003, p.

157, Ch. 6)

Consequently, misinformation took place and led to decisions being made based on

inadequate information. For instance, problems with O-rings were minimised and

communicated as just “technical issues”. Furthermore, only a few flights before

Challenger, important information regarding the temperature and its subsequent

impact on O-rings was missing from the Flight Readiness Review.

″The inattention to erosion and blow-by anomaly changed when Thiokol

filed a problem report on the field joint erosion after STS 41-B. The O-ring

problems (field and nozzle) on 41-B were briefed as a "technical issue" in

the 41-C Flight Readiness Review. At the Level I Flight Readiness Review

for 51-E on February 21, 1985, the previous 18-page analysis had been

40

reduced to a one page chart with the resolution: "acceptable risk because of

limited exposure and redundancy. No mention of temperature was found in

the Level I report″. (Presidential Commission Report, 1986, p. 147, Vol. I,

Ch. VΙ)

During both the Challenger and Columbia missions, managers were concerned with

following and maintaining the flight schedule, a persistence that led to overlooking

several opportunities that could have reversed the negative outcome3. Their primary

goal was to achieve the agency’s predefined objectives and increasing escalation of

commitment to continue launching was cultivated. More specifically, in the case of

Challenger, the decision to go ahead with the launch was merely a management one

that was based on criteria other than firm engineering data.

″The Commission concluded that the Thiokol Management reversed its

position and recommended the launch of 51-L, at the urging of Marshall and

contrary to the views of its engineers in order to accommodate a major

customer″. (Presidential Commission Report, 1986, p. 104, Vol. I, Ch. V)

To that end, information that would result in delaying launch was disregarded or its

importance was normalised and emphasis was given to those that were in favour.

This is a clear indication that management chose to be selectively exposed to

information depending on its suitability in regards to the agency’s goals.

″Communication did not flow effectively up to or down from Program

managers. As it became clear during the mission managers were not as

concerned as others about the danger of the foam strike, the ability of

engineers to challenge those beliefs greatly diminished. Managers’ tendency

to accept opinions that agree with their own dams the flow of effective

communications″. (CAIB, 2003, p. 169, Ch. 6)

Similar behaviours are identified during Columbia’s flight. NASA’s persistence in

meeting the schedule influenced decision-making towards accepting risk so as to

continue flying.

3 See appendix 4

41

″The agency’s commitment to hold firm to a February 19, 2004, launch date

for Node 2 influenced many of decisions in the months leading up to the

launch of STS-107, and may well have subtly influenced the way managers

handled the STS-112 foam strike and Columbia’s as well. When a program

agrees to spend less money or accelerate a schedule beyond what the

engineers and program managers think is reasonable, a small amount of

overall risk is added. These little pieces of risk add up until managers are no

longer aware of the total program risk, and are, in fact, gambling. Little by

little, NASA was accepting more and more risk in order to stay on

schedule″. (CAIB, 2003, p. 139, Ch. 6)

The escalation of managers’ commitment to the course of the predefined action

regarding Columbia bares similarities with Challenger. In both cases, NASA

accepted erosions, which were not expected and regularly altered the flight

requirements and criteria so as to fit certain circumstances and be able to meet the

increasing flight rate and not deviate from the schedule.

″The phenomenon of accepting … flight seals that had shown erosion and

blow-by in previous flights is very clear ... But erosions and blow-by are not

what the design expected … The O-rings of the Solid Rocket Boosters were

not designed to erode. Erosion was a clue that something was wrong … If a

reasonable launch schedule is to be maintained, engineering often cannot be

done fast enough to keep up with the expectations of originally conservative

certification criteria designed to guarantee a very safe vehicle. In these

situations, subtly, and often with apparently logical arguments, the criteria

are altered so that flights may still be certified in time″. (CAIB, 2003, p.

130, Ch. 6)

The intensification of commitment to achieving the so promoted Challenger mission

and the highly important “Node 2” goal had an impact on decision-making in both

incidents. During the former, NASA and its contractor accepted escalating risk

because erosion was observed in several flights and no problems were recorded.

Thus those events were considered to be within their “experience base” and further

action was taken so as to address its cause and resolve it. As a consequence and since

nothing disastrous has happened before, they lowered their standards and erosion as

42

well as blow-by became an minor issue that was known and later on was

characterised as acceptable risk.

This led to a situation where:

″As Commissioner Feynman observed, the decision making was: "a kind of

Russian roulette″. (Presidential Commission Report, 1986, p. 148, Vol. I,

Ch. VΙ)

Similarly, during the Columbia mission, the opinion that is safe to fly with potential

foam loss was established and all managers were in favour of such rationale as it was

congruent with the agency’s goals. The pivotal decision of accepting the foam strike

of STS-113 as not a safety-of-flight issue influenced the subsequent decision-making

process and therefore STS-107 [Columbia] flight. Changing or questioning a

rationale that was accepted from the management as a whole just one flight before

Columbia, while management was so vigorous to meet the schedule, would be seen

as it had fail to address and efficiently resolve a safety issue. Consequently,

managers escalated their commitment to the launch decision.

″It is here that the decision to fly before resolving the foam problem at the

STS-113 Flight Readiness Review influences decisions made during STS-

107. Having at hand a previously accepted rationale – reached just one

mission ago – that foam strikes are not a safety-of-flight issue provides a

strong incentive for Mission managers and working engineers to use that

same judgment for STS-107. If managers and engineers were to argue that

foam strikes are a safety-of-flight issue, they would contradict an

established consensus that was a product of the Shuttle Program’s most

rigorous review – a review in which many of them were active participants″.

(CAIB, 2003, p. 150, Ch. 6)

43

4.4 Conclusion

The themes that derived from the analysis of the reports revealed the existence of

certain information behaviours and highlight their impact on the Challenger and

Columbia space shuttles’ disasters.

A culture was prevalent in NASA that promoted an image of a capable, safe, healthy

and self-confident agency as well as a myth of NASA as the “best organisation”, one

that could make the access to space “routine and economic”. Furthermore, the

pressures the agency faced both political and production, subconsciously forced

managers to lower their standards and treat information concerning potential

problems in a way that would not pose delays and allow them to achieve a

predefined goal. Information that was seen as threat to the flight schedule and

subsequently to NASA’s launch goals and its image was ignored or avoided.

On the other hand, information that supported the dominant position was accepted

and acted upon. It can be, thus, argued that NASA’s “can-do” culture in conjunction

with the political and production pressures imposed to the agency cultivated the

existence of behaviours of information avoidance and selective exposure to

information, influencing the way in which information was treated and consequently

the outcome of the disasters.

Furthermore, the communication was in many cases hampered by the strictly

hierarchical chain of command. This had as a result the creation of informal channels

of communication and dissemination of information, and thus its rejection and

treatment as not valid. Additionally, flawed communication contributed to an equally

flawed decision-making, as information regarding the potential disaster was available

but not effectively communicated through the proper channels of command to all

levels of decision-makers. Moreover, the informal communication and dissemination

of information allowed certain behaviours to be cultivated, which in turn enabled

unwanted and inconsistent with the prevailing position information to be ignored or

avoided. Consequently, actions were taken based on insufficient and biased

information.

Moreover, the analysis revealed an escalation of commitment to the “myth of NASA

as the best organisation”. Since its establishment and the inception of the human

44

space shuttle program everyone was committed to the notion that space flight was

safe, routine and cost-effective. To accept information supporting that this is not

feasible would mean losing face and shuttering NASA’s image. Conversely,

avoiding such information and accepting only what is congruent with the predefined

goals would support the myth and lead to decisions that enabled it to be maintained.

Such situation makes it clear that escalation took place for a long period of time and

cultivated behaviours of information avoidance and selective exposure to information

which led to information failure and thus the disasters. These behaviours, informed

by the escalation of commitment to the myth surrounding NASA, led to ineffective

information dissemination and gradual loss of awareness of the catastrophic

consequences.

45

5. Discussion

The findings of the analysis performed on reports investigating the Challenger and

Columbia space shuttles’ disasters revealed several aspects of information behaviour

and its impact on information failures. Information avoidance behaviours were found

to be significant contributing factors to both disasters. Furthermore, the findings are

consistent with what the theories of information behaviour, that is Affective Load

and Face Threat, suggest. It also became clear that in both disasters the same

information behaviours and escalation of commitment to the course of launching

took place, despite the 17-year time frame between the two incidents, and the

recommendations for changes imposed by the Rogers Commission after the

Challenger accident. Moreover, NASA’s culture played an important role and

contributed to the ongoing cultivation of information behaviours. The organisation’s

strong “can-do” culture that was mirrored in its personnel’s decision-making made it

harder for the agency to become a learning organisation and thus avoid the second

disaster.

5.1. Framework

The culture surrounding NASA was a major contributing factor in both disasters.

Since its establishment, the space shuttle program promised to make the access to

space routine and economic. In order to get approval for more funding, NASA

promoted an image of “a capable of achieving everything organisation” and created a

myth around its mission and the exploration of space. Throughout the years this

image cultivated and established a strong “can-do” and over-confident culture, which

was also adopted by the people working within the agency (Deninson, 1990).

Consequently, the organisation’s “face” became an “accepted public norm” and got

ingrained in the personnel’s and public’s notion as a fact. As a result, any

information that would jeopardise or disturb this image was treated as threat and was

either ignored or avoided (Mon, 2005).

“Affective Load” (Nahl, 2005) and “Face Threat” theories (Mon, 2005), explain why

such behaviours took place. During the course of NASA’s progress, “learned

affective norms” were developed which placed an emphasis on information that

supported the agency’s statement regarding the ease and safety of space travel and its

46

ability to make it “routine and economic”. Such statement became a norm according

to which information was judged (Julien & McKechnie, 2005).

Additionally, a need to present the space shuttle’s flight as safe and cost-efficient to

the government, with the aim of ensuring its support and funding, led to the

development of information behaviours in order to sustain the image and myth that

NASA had created (Mon, 2005). This resulted in the creation of a cultural narrative

that drove information behaviours and the way in which information was shared and

communicated (Thatcher, Vasconcelos & Ellis, 2015). Moreover, in both incidents

there is a clear correlation between the two theories. The cultural narrative, “Face

Threat” theory, contributed to the establishment of certain learned affective norms,

which are informed by what “Affective Load” theory suggests, in that norms are

present and affect how information is assessed; and result in information avoidance

behaviours.

During their investigation, both the Rogers Commission and the CAIB, found that

apart from the technical causes, cultural elements also contributed to the catastrophic

outcomes. In the aftermath of the Challenger accident, several recommendations for

changes were made by the Rogers Commission, one of which concerned NASA’s

overconfident culture. Yet, 17 years later and after Columbia’s disaster had occurred,

the CAIB investigation revealed that not only the organisational culture had not

changed but it had evolved to a “culture of invincibility” that permeated the

management (CAIB, 2003, p.199). This had a result the interpretation of events and

the related information according to the agency’s cultural frames. Mahler and Hogan

Casamayou’s (2009) definition of NASA’s culture, as a ″deeply held, widely shared

beliefs about... the mission, the identity of the workforce and the legacy of the

organisation’s founders″ mirrors perfectly CAIB’s findings.

Furthermore, the cultural attitude of “the way things are done” and the “taken for

granted” (Martin, 2002) success hindered the possibility of a cultural change and

contributed to the development of behaviours of information avoidance. More

specifically, information that did not fit the cultural frames or may damage the

organisation’s image were avoided, rejected or ignored (Johnson, 2009; Case, 2012).

NASA could not afford losing face or support by either the public or the government

and therefore relied on what knew best about “how things are done” and discarded

47

information that opposed to that method. Consequently, the information

communicated and promoted to all parties was incomplete leading to the cultivation

of certain information behaviours and thus resulted in information failure (Westrum,

1992; Maclntosh-Murray & Choo, 2002)

In addition to NASA’s strong and resistant to change culture, the political and

production pressures posed to the agency played a key role in the disasters. NASA

suffered significant budget cuts. Several goals were set in order for the agency to

prove its ability to meet its funders’ requirements for further financial support. This

situation led to the creation of significant internal production pressures to meet the

schedule. In both cases, management was in a way forced to go ahead with

launching, despite the fact that concerns were raised and information regarding

potential hazards existed, so as not to delay and meet the increasing flight rate

schedule.

NASA was driven by its need to stay on track and therefore the information

processing and interpretation was made accordingly (Grunig, 1989; Atkin, 1973).

In the case of Challenger, one day before the launch, Thiokol’s engineers voiced

their reservations and raised strong concerns about the low temperatures and the

impact they may have on the O-rings. However, those along with the data presented

were minimised and subsequently disregarded by the management (Vaughan, 1997).

To accept such information, would mean that the flight would have to be delayed and

NASA automatically not being able to meet the schedule. To that end, Thiokol’s

leading engineer, during the teleconference pause, was strongly urged to “put off his

engineer hat and put on his management one”.

Clearly, the decision to proceed with Challenger’s launch was a management

decision driven by the agency’s need to survive (Atkin, 1973). It was made on the

grounds that O-ring erosion was observed during previous flights where nothing has

happened. Consequently, partly due to previous success, the ingrained cultural “can-

do” attitude, and the need to stay on schedule, information regarding the engineers’

concerns were avoided or ignored. More specifically, “any suggestions that it would

be difficult to meet that launch date were brushed aside”. (CAIB, 2003, p. 117,

Ch.5). Conversely, information that was congruent with the dominant position of

launching was accepted and promoted (Mon, 2005).

48

The reluctance to accept inconvenient facts and the tendency to avoid disturbing

information is a frequent event (Perrow, 1999; Forgas & George, 2001). A similar

situation to Challenger’s was repeated 17 years later, during Columbia’s mission.

Although foam shedding was formally precluded from the shuttle’s specifications,

relevant events were seen as common and treated as maintenance or turnaround

rather than safety-of-flight issues (CAIB, 2003). Information and concerns about the

foam-debris strikes were repeatedly minimised and ignored. Instead, information in

favour of proceeding were accepted and acted upon. Subsequently, the rationale of

flying with foam-loss was promoted and seen as safe.

From a management point of view, such decision meant that the so important “Node

2” schedule goal would be achieved. ″This pattern of avoiding the rigorous

application of safety procedures...mirrored the events seen before the loss of the

Challenger″ (Mahler & Hogan Casamayou, 2009, p. 66). It can be, thus, argued that

the strong political and production pressures contributed to the development of

behaviours of selective exposure and avoiding information, and hence to information

failure.

Flawed communication and subsequent biased decision-making also contributed to

both disasters. Due to the strictly hierarchical structure of NASA’s chain of

command (Daft, 2003), informal channels of communication emerged, which had as

a result information coming through them not to be acknowledged or be rejected as

invalid This situation affected the efficient and timely flow of information to

decision-makers (Turner & Pigeon, 1997) and enabled behaviours of information

avoidance, as if it was considered to be unwanted and inconsistent with the dominant

position it was ignored or rejected (Markoulides & Heck, 1993).

Accordingly, the pattern of decisions made during both the Challenger and Columbia

disasters reveal escalation of commitment to the course of the predefined by NASA

action, in that meeting the flight schedule. The agency’s culture also contributed to

the intensification of commitment towards launching (Schein, 1985). To accept the

concerns regarding the low temperature and the foam-debris strikes would result in

delaying or worse cancelling the launch, which in both cases would be seen as failure

of NASA’s behalf to achieve the desirable goal. Consequently, the organisation

would lose further funding and support and its myth would be chattered. Thus, in

49

order to avoid such possibility, NASA escalated commitment to its current course of

action with information that supported the decision to launch (Staw & Fox, 1997).

Conversely, information that was inconsistent with the predefined course was

avoided, ignored or distorted (Drummond, 1999).

Furthermore, changing a previously accepted rationale, in that flying with recorded

O-ring erosion and foam shedding is safe, would be seen as the management was

incapable of addressing and acting upon potentially sources of hazard and may have

resulted in permanent termination of the program. Therefore, intensification of

commitment to completing the mission took place by avoiding or distorting the

discomforting and inconsistent information (Staw, 1981).

The escalation took place for such a long period of time and became so ingrained to

NASA’s culture and the way it operated that such behaviour was normalised; it was

almost impossible for those in the chain of command to recognise it occurred and

then change it. Moreover, in both incidents decision-making was subject to

unanimity. During stressful situations, where important decisions have to be made,

individuals are under great pressure to conform to the dominant position (Whyte,

1993). Additionally, collective decision-making require simplified assumptions,

which result in the creation of “blind-spots”. Consequently, collective erroneous

perceptions are generated, and thus distinctive information may be ignored and

signals of hazard may be missed (Weick, 1998).

50

Framework diagram

: Information behaviours are consistent with the theories

: Information behaviours informed by the themes

: The decision-making trajectory

: Interaction between the themes

: The interrelation between the culture and information behaviours

Culture

Myth Image

Image

Flawed

communication

& decision-

making

Pressures:

political &

production

Information

behaviours.

Information seen as

threat to image/myth

is avoided or ignored

“Face Threat”

“Affective

Load”

Theories

Information behaviour

of selective exposure.

Information consistent

with dominant opinion

accepted

Information

inconsistent with

dominant opinion:

avoidance & selective

exposure

Escalation of

commitment

51

6. Conclusion

6.1. Contribution to knowledge

Challenger and Columbia’s space shuttle disasters constitute prime examples of the

impact information behaviours have on an organisation leading to information failure

and ultimately to catastrophic outcomes. This research highlighted the actors

involved in the two disasters and revealed the existence of certain information

behaviours within NASA that affected the way in which it operated, treated and

communicated information. More specifically, information avoidance, selective

exposure to information and escalation of commitment to a predefined course of

action were found to be significant influencing factors in decision-making during

both incidents.

In addition to these behaviours, the agency’s culture played an important role

throughout NASA’s history and in the course of the events in particular. A pattern of

similarities derived from the analysis of the official reports shows a strong

correlation between the information behaviours followed during both incidents.

Moreover, these behaviours were found to have significant impact on the decision-

making process leading to a trajectory and eventually to the disasters.

NASA’s management can be seen as the protagonist of the incidents, as in both cases

it employed certain information behaviours and insisted in following the predefined

course rather than acknowledge and act upon its engineers’ concerns and

recommendations. During both Challenger and Columbia, managers were found to

be in the centre of the events being unable to fully grasp the importance of the

information communicated by the engineers. Due to the pressures, political and

internal, they were in a way forced to follow a certain path so as to meet the schedule

and thus achieve the agency’s goals, in that to fulfil the governments requirements

and ensure further funding and support. It could be, hence, argued that the

government is as much responsible for the disasters as NASA. Had not had the

organisation experienced political pressures, it would not have insisted on meeting

the schedule and information behaviours would not have been developed.

Additionally, the agency’s culture was found to be over-confident and with a “can-

do” attitude. A sense of invincibility was cultivated over the years, which resulted in

52

the creation of “blind spots” and enabled the establishment and adoption of an

erroneous perception that NASA could achieve anything. Consequently, an image of

a “great organisation” was built, which NASA was determined to promote and

sustain. This resulted in the agency’s culture being more resistant to change. Due to

the intensification and continuous denial to accept that goals might not be met,

behaviours of selective exposure to and information avoidance were developed and

got ingrained in NASA’s culture. From that point onwards, avoiding and ignoring

information that would jeopardise the organisation’s image and goals was acceptable.

Furthermore, a pattern of similar information behaviours was identified in both

incidents. Information regarding the hazards of low temperature and foam-debris

strikes existed and concerns about their potential catastrophic consequences were

voiced. They were, however, systematically ignored and avoided. On the contrary,

what was consistent with the agency’s goals was accepted and promoted. In addition,

in both disasters, intensification of commitment to the decision of launching took

place and led to information failure.

The research also revealed an interrelation between the organisation’s culture and the

aforementioned behaviours. It became clear that the adopted information behaviours

were informed by the agency’s culture. Α strong organisational culture is seen as

integrated patterns of meaning, which guide relationships and operations within an

organisation and provide a reference point based on which actions are taken and

decisions are made. Consequently, certain taken-for-granted cultural assumptions

were espoused and NASA became constrained within a certain way of thinking and

acting. This resulted in a decision-making trajectory leading to information failure

and ultimately to the disasters.

Moreover, the framework that was developed delineates the connection between the

organisation’s culture and the information behaviours that were identified. It also

depicts the impact it has on all aspects of the agency as throughout the course of both

disasters, culture was a powerful yet subliminal driver. It can be, thus, argued that a

strong and resistant to change culture leads to the adoption of certain information

behaviours which in turn may result in information failure.

53

6.2. Limitations of the study

This research was limited by the scarcity of official reports other than the ones of

NASA regarding the two disasters. Their analysis might have provided diverse

perspectives on the incidents and a point of reference for the results of the research as

well as a measure for comparison on how third parties perceive and deal with such

situations.

6.3. Further research

The results of this research suggest that during both incidents certain information

behaviours were adopted leading to information failure. In addition, an interrelation

between the organisation’s culture and these behaviours was identified as

contributing factor to the disasters. Although a great number of literature deals with

organisational culture and information behaviour as two separate subjects, no

extensive research has been conducted regarding their connection and potential

consequences to the organisational environment. With the above limitations removed

a more in depth study of their relationship and impact on decision-making and

information failure within organisations can be performed, resulting in the

establishment of a better understanding.

(Word count: 14.214)

54

7. References

Alvesson, M. (2002). Understanding organisational culture. London: Sage

Publications.

Argote, L., & Miron-Spektor, E. (2011). Organizational learning: from experience to

knowledge. Organization Science, 22(5), 1123-1137. doi: 10.1287/orsc.1100.0621

Atikin, C. (1973). Insrumental utilities and information-seeking. In P. Clarke (Ed.),

New models for mass communication research (205-242). Beverly Hills, CA:

Sage Publications.

Bandura, A. (1977). Social learning theory. Englewood Cliffs ; London: Prentice-

Hall.

Bate, B. (1995). Strategies of cultural change. Oxford: Butterworth-Heinemann

Bell, E. (2013). Organisational culture and learning: a case study. Nurse Education

Today, 33(11), 1337-1341. doi: 10.1016/j.nedt.2013.02.009

Bettis-Outland, H. (2012). Decision-making's impact on organizational learning and

information overload. Journal of Business Research, 65(6), 814-820.

doi: 10.1016/j.jbusres.2010.12.021

Biyalogorsky, E., Boulding, W., & Staelin, R. (2006). Stuck in the past: why

managers persist with new product failures. Journal of Marketing, 70(2), 108-121.

Retrieved from:

http://web.b.ebscohost.com.eresources.shef.ac.uk/ehost/pdfviewer/pdfviewer?sid=

a3ef7e78-9ae7-4a54-816e-05e39611d05d%40sessionmgr113&vid=1&hid=123

Boyatzis, R. (1998). Transforming qualitative information : Thematic analysis and

code development. Thousand Oaks, Calif ; London: Sage.

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative

research in psychology, 3(2), 77-101. doi: 10.1191/1478088706qp063oa

Brockner, J. (1992). The escalation of commitment to a failing course of action:

toward theoretical progress. The Academy of Management Review, 17(1), 39-61.

Retrieved from:

http://www.jstor.org.eresources.shef.ac.uk/stable/pdf/258647.pdf?acceptTC=true

Brown, A. (1990). Organizational culture. Journal, American Psychologist, 45(2),

109-119. doi: 10.1037/0003-066X.45.2.109

55

Brown, A. (1992). Organizational culture: the key to effective leadership and

organisational development. Leadership & Organization Development

Journal, 13(2), 3-6. Doi: 10.1108/01437739210009545

Brown, A. (1998). Organisational culture (2nd

ed.). Essex: Financial Times.

Cabbage, M & Harwood, W. 2004. Comm check . . . The final flight of shuttle

Columbia. New York: Free Press

CAIB (2003). Columbia Accident Investigation Board. Vol. 1. Retrieved from:

Case, D. (2012). Looking for information: a survey of research on information

seeking, needs and behaviour (3rd

ed.). Bingley: Emerald Group Publishing

Limited.

Case, D., Andrews, J., Johnson, J., & Allard, S. (2005). Avoiding versus seeking: the

relationship of information seeking to avoidance, blunting, coping, dissonance,

and related concepts. Journal of the Medical Library Association, 93(3), 353-362.

Retrieved from:

http://web.b.ebscohost.com.eresources.shef.ac.uk/ehost/pdfviewer/pdfviewer?sid=

dd85283c-c920-4049-a376-7755c114a87c%40sessionmgr113&vid=1&hid=123

Chakravorty, S. (2009). Six sigma failures: an escalation model. Operations

Management Research, 2(1), 44-55. doi: 10.1007/s12063-009-0020-8

Daft, R., L. (2003). Management (6th ed.). Mason, Ohio: Thomson Learning/South-

Western.

Davis, S. M. (1984). Managing corporate culture. Cambridge: Ballinger.

Deltor, B., Choo, C.W., Bergeron, P., & Heaton, L. (2006), Information behaviour

realities in organisations, Proceedings of the American Society for Information

Science and Technology, 43(1), 1-6. doi: 10.1002/meet.1450430131

Denison, D. (1990). Corporate culture and organisational effectiveness. Willey:

New York.

Drummond, H. (1999), Are we and closer to the end? Escalation and the case of

Taurus, International Journal of Project Management, 17(1), 11-16. Retrieved

from: http://ac.els-cdn.com/S0263786397000744/1-s2.0-S0263786397000744-

main.pdf?_tid=38f0e15e-f268-11e4-91a3-

00000aacb360&acdnat=1430749197_75ee741ed83850a9700a60001548264b

Fereday, J., & Muir-Cochrane, E. (2006). Demonstrating rigor using thematic

analysis: a hybrid approach of inductive and deductive coding and theme

56

development. International Journal of Qualitative Methods, 5(1). Retrieved from:

http://ejournals.library.ualberta.ca/index.php/IJQM/article/view/4411/3530

Festinger, L. (1957). A theory of cognitive dissonance. Stanford, California: Stanford

U.P.

Flick, U. (2007). Designing qualitative research. London: SAGE.

Forgas, J., P. & George. J., M. (2001). Affective influences on judgments and

behavior in organizations: an information processing perspective. Organizational

Behavior and Human Decision Processes, 86(1), 3-34.

doi:10.1006/obhd.2001.2971

Gauld, R. (2007). Public sector information system project failures: lessons from a

New Zealand hospital organization. Government Information Quarterly, 24(1),

102-114. doi: 10.1016/j.giq.2006.02.010

Goffman, E. (1975). Frame analysis: an essay on the organization of

experience (Peregrine books). Harmondsworth: Penguin.

Goltz, S. (1992). A sequential learning analysis of decisions in organisations to

escalate investments despite continuing costs or losses. Journal of Applied

Behavior Analysis, 25(3), 561-574. doi: 10.1901/jaba.1992.25-561

Grunig, J. (1989). Publics, audience, and market segments: segmentation principles

for campaigns. In C.Salmon (Ed.), Information campaigns: balancing social

values and social change (199-228). Beverly Hills, CA: Sage Publications.

Howell, J. L. & Shepperd, J. A. (2012). Reducing information avoidance through

affirmation. Psychological Science, 23(2), 141-145. doi:

10.1177/0956797611424164

Howell, J. L. & Shepperd, J. A. (2013). Behavioural obligation and information

avoidance. Annals of Behavioural Medicine, 45(2), 258-263. doi:

10.1007/s12160-012-9451-9

Jensen, C. (1996). No downlink: a dramatic narrative about the Challenger accident

and our time. New York: Farrar, Straus and Giroux.

Johnson, D. J. (2009). An impressionistic mapping of information behaviour with

special attention to contexts, rationality, and ignorance, Information Processing

and Management, 45(5), 593-604. doi: 10.1016/j.imp.2009.04.005

Julien, H., & McKechnie, L. E. (2005). What we've learned about the role of affect in

information behaviour/information retrieval. In La dimensió humana 60 de

57

l'organització del coneixement, Facultat de Biblioteconomia i Documentació, 7,

342-356. Retrieved from: http://bd.ub.edu/isko2005/julien.pdf

Lee, J., & Bui, T. (2000), A template-based methodology for disaster management

information systems, Proceedings of the 33rd Annual Hawaii International

Conference on System Sciences, IEEE, 1-7. doi: 10.1109/HICSS.2000.926635

Maclntosh‐Murray, A., & Choo, C. (2002). Information failures and catastrophes:

what can we learn by linking information studies and disaster

research? Proceedings of the American Society for Information Science and

Technology, 39(1), 239-249. doi: 10.1002/meet.1450390126

Mahler, J & Hogan-Casamayou, M. (2009). Organisational learning at NASA: the

Challenger and Columbia accidents. Georgetown University Press: Washington,

DC.

Marcoulides, G., & Heck, R. (1993). Organisational culture and performance:

proposing and testing a model. Organization Science, 4(2), 209-225. Retrieved

from:

http://web.b.ebscohost.com.eresources.shef.ac.uk/ehost/pdfviewer/pdfviewer?sid=

1f0a7992-e90e-4e9e-88cd-a6259e9cca58%40sessionmgr114&vid=1&hid=125

Martin, J. (2002). Organizational culture. Thousand Oaks, CA: Sage.

Maull, R., Brown, P. & Cliffe, R. (2001). Organisational culture and quality

improvement. International Journal of Operations & Production

Management, 21(3), 302-326. doi: 10.1108/01443570110364614

McConnell, M. (1987). Challenger: A major malfunction. Garden City, NY:

Doubleday.

McCurdy, H., E. (1990). The space station decision: incremental politics and

technological choice. Baltimore, MD: Johns Hopkins University Press.

Mon, L. (2005), Face Threat, In Fisher, K.E., Erdelez, S. & Mechnie, L. (Εds),

Theories of Information Behaviour. (149-152). New Jersey, USA: ASIST.

Nahl, D. (2001). A conceptual framework for explaining information behaviour.

Studies in Media & Information Literacy Education, 1(2). Retrieved from:

http://www2.hawaii.edu/~donnab/lis610/nahl_2001.html

Nahl, D. (2004). Measuring the affective information environment of web

searchers. Proceedings of the ASIST Annual Meeting, 41, 191-197. doi:

10.1002/meet.1450410122

58

Nahl, D. (2005), Affective Load. In Fisher, K.E., Erdelez, S. & Mechnie, L. (Εds),

Theories of Information Behaviour. (39-43). New Jersey, USA: ASIST.

Norman, D., A. (2004). Emotional Design: why we love (or hate) everyday things.

New York: Basic Books, 2004.

Ogbonna, E. (1992). Managing organisational culture: fantasy or reality? Human

Resource Management Journal, 3(2), 42-54. doi: 10.1111/j.1748-

8583.1992.tb00309.x

Perrow, C. (1999). Normal accidents. Princeton, NJ: Princeton University Press.

Punch, K. (2005). Introduction to social research: quantitative and qualitative

approaches (2nd ed.). London: SAGE.

Report of the Presidential Commission on the Space Shuttle Challenger Accident.

(196). Vol. I-VIII.

Rice, P., & Ezzy, D. (1999). Qualitative research methods: a health focus.

Melbourne: Oxford University Press.

Rudestam, K., & Newton, Rae R. (2015). Surviving your dissertation: a

comprehensive guide to content and process (4th ed.). London: SAGE.

Schein, E. H. (1985). Organizational culture and leadership. San Francisco: Jossey

Bass.

Schein, E. H. (1990). Organizational culture. American Psychologist, 45(2), 109-119.

doi: 10.1037/0003-066X.45.2.109

Sietzen, F., J., & Cowling, K. L. (2004). New moon rising: the making of America’s

new space vision and the remaking of NASA. Ontario: Apogee Books.

Silverman, D. (2013). Doing qualitative research (4th ed.). London: SAGE.

Sinclair, A. (1993). Approaches to organisational culture and ethics. Journal of

Business Ethics, 12(1), 63-73. doi: 10.1007/BF01845788

Smith, S., Fabrigar, L., & Norris, M. (2008). Reflecting on six decades of selective

exposure research: progress, challenges, and opportunities. Social and Personality

Psychology Compass, 2(1), 464-493. doi: 10.1111/j.1751-9004.2007.00060.x

Solomon, P. (1997). Conversation in information-seeking contexts: a test of an

analytical framework, Library and Information Science Research, 19(3), 217-248.

doi:

59

Spink, A., & Cole, C. (2006). Human information behavior: Integrating diverse

approaches and information use. Journal of The American Society For

Information Science And Technology, 57(1), 25-35.doi: 10.1002/asi.20249

Staw, B. M. (1981). The Escalation of commitment to a course of action, The

Academy of Management Review, 6(4), 577-587. Retrieved from:

http://www.jstor.org.eresources.shef.ac.uk/stable/pdf/257636.pdf

Staw, B. M., & Fox, F. U. (1977). Escalation: the determinants of commitment to a

chosen course of action, Human Relations, 30 (5), 431-450. doi:

http://dx.doi.org/10.1177/001872677703000503

Sun, S. (2008). Organisational culture and its themes. International Journal of

Business and Management, 3(12), 137-141. Retrieved from:

http://www.ccsenet.org/journal/index.php/ijbm/article/viewFile/760/726

Sweeny, K., Melnyk, D., Miller, W., & Shepperd, J. (2010). Information avoidance:

who, what, when, and why. Review of General Psychology, 14(4), 340-353. doi:

10.1037/a0021288

Thatcher A. (2013). An investigation into the impact of information behaviour on

information failure: the Fukushima Daiichi nuclear power disaster. (Dissertation,

University of Sheffield, Sheffield, United Kingdom). Retrieved from:

http://dagda.shef.ac.uk/dispub/dissertations/2012-

13/External/Thatcher_A_Y75.pdf

Thatcher, A., Vasconcelos, A. C., & Ellis, D. (2015). An investigation into the

impact of information behaviour on information failure: the Fukushima Daiichi

nuclear power disaster. International Journal of Information Management, 35(1),

57-63. doi: 10.1016/j.ijinfomgt.2014.10.002

Thomas, J. & Harden A. (2008). Methods for the thematic synthesis of qualitative

research in systematic reviews. BMC Medical Research Methodology, 8(1), 45.

doi: 10.1186/1471-2288-8-45

Trento, Joseph. J. 1987. Prescription for disaster. New York: Crown.

Turner, B., & Pidgeon, N., F. (2004). Man-made disasters (2nd ed.). Ann Arbor,

Michigan: University Microfilms International.

Vaughan, D. (1997). The Challenger launch decision: risky technology, culture, and

deviance at NASA. Chicago; London: University of Chicago Press.

60

Weick, K. (1998). Foresights of failure: an appreciation of Barry Turner. Journal of

Contingencies and Crisis Management, 6(2), 72-75. doi: 10.1111/1468-

5973.00072

Westrum, R. (1992). Cultures with requisite imagination. In Wise, J. A., Hopkin, V.

& Stager, P. (Eds.). Verification and validation of complex systems; human factor

issues (401-416). Berlin: Springer-Verlag.

Whyte, G. (1993), Escalating commitment in individual and group decision making:

a prospect Theory approach, Organisational Behaviour and Human Decision

Processes, 54(3), 430-445. doi:

Wilson, T. D. (1981). On user studies and information needs. Journal of

Documentation, 37 (1), 3-15. doi: 10.1108/eb026702

Wilson, T. D. (1997). Information behaviour: an interdisciplinary perspective,

Information Processing and Management, 33(4), 551-572. doi: 10.1016/S0306-

4573(97)00028-9

Wilson, T. D. (1999). Models in information behaviour research, The Journal of

Documentation, 55(3), 249-270. doi:

http://dx.doi.org/10.1108/EUM0000000007145

Wilson, T.D. (2000), Human information behaviour, Informing Science, 3(2), 49-56.

Retrieved from: http://inform.nu/Articles/Vol3/v3n2p49-56.pdf

Wong, K. F. E. (2005), The role of risk in making decisions under escalation

situations, Applied Psychology: An International Review, 54 (4), 584-607.

Retrieved from:

http://web.b.ebscohost.com.eresources.shef.ac.uk/ehost/pdfviewer/pdfviewer?sid=

e1f092e3-4a5b-4944-b70d-f9db3c0783d0%40sessionmgr112&vid=1&hid=125

Woolley, M. (1992). Using statistics for desk research. Aslib Proceedings, 44(5),

227-233. Retrieved from:

http://www.emeraldinsight.com.eresources.shef.ac.uk/doi/pdfplus/10.1108/eb051

276

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8. Appendices

Appendix 1 Themes

Theme 1:

Label: NASA’s Culture

Definition: The basic values, norms, beliefs and practices that define an

organisation’s functioning and its employees’ assumptions.

Indicators: Coded when the report states “cultural traits”, “program culture”

or “organisational culture”.

Differentiation: Occasionally “history” is treated as intertwined with

“culture”.

Theme 2:

Label: Political and production pressures

Definition: The idea that an organisation must move from one status

(expectations) to another (achievement of goal).

Indicators: Coded when the report states “pressures to stay on schedule”,

“schedule pressures” or “pressures to meet the schedule”, “faster, better, cheaper”,

“pressing need to launch”,.

Theme 3:

Label: Communication and decision-making

Definition: The dissemination of information throughout all levels and lines

of authority, and the process of selecting a logical choice among available options

that is followed by individuals and/or organisations.

Indicators: Coded when the report states “communication of information”,

“communication failures, incomplete and misleading information”,

“communication difficulties”, and “decision-making”, “decision-making process”,

“managers accepted”, “management judgement”.

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Appendix 2 Research classification

Notification sent via e-mail concerning the classification of the research.

Research ethics risks assessment

Information School Research Ethics

Dear Stavroula,

I am writing to inform you that your dissertation proposal has been re-assessed, and

it has been confirmed that your dissertation is actually no risk. As such, you are not

required to apply for ethics approval.

Instead, you should include a statement in the Methods section that indicates that the

research has no risks, and you should indicate why, illustrating that you understand

research ethics implications. If you have re-used data collected by another person,

you must indicate that the data was ethically collected, that is, you should know

whether you are using viable data.

You are advised to keep a copy of this email for your records.

With best regards

63

Appendix 3 Definitions of foam-loss events classification

In-Family: A reportable problem that was previously experienced, analyzed, and

understood. Out of limits performance or discrepancies that have been previously

experienced may be considered as in-family when specifically approved by the Space

Shuttle Program or design project.8

Out-of-Family: Operation or performance outside the expected performance range

for a given parameter or which has not previously been experienced.

Accepted Risk: The threat associated with a specific circumstance is known and

understood, cannot be completely eliminated, and the circumstance(s) producing that

threat is considered unlikely to reoccur. Hence, the circumstance is fully known and

is considered a tolerable threat to the conduct of a Shuttle mission.

No Safety-of-Flight-Issue: The threat associated with a specific circumstance is

known and understood and does not pose a threat to the crew and/or vehicle.

(CAIB, 2003, p. 122, Ch. 6)

64

Appendix 4 Missed opportunities

1. Flight Day 4. Rodney Rocha inquires if crew has been asked to inspect for

damage. No response.

2. Flight Day 6. Mission Control fails to ask crew member David Brown to

downlink video he took of External Tank separation, which may have

revealed missing bipod foam.

3. Flight Day 6. NASA and National Imagery and Mapping Agency

personnel discuss possible request for imagery. No action taken.

4. Flight Day 7. Wayne Hale phones Department of Defense representative,

who begins identifying imaging assets, only to be stopped per Linda

Hamʼs orders.

5. Flight Day 7. Mike Card, a NASA Headquarters manager from the Safety

and Mission Assurance Office, discusses imagery request with Mark

Erminger, Johnson Space Center Safety and Mission Assurance. No action

taken.

6. Flight Day 7. Mike Card discusses imagery request with Bryan OʼConnor,

Associate Administrator for Safety and Mission Assurance. No action

taken.

7. Flight Day 8. Barbara Conte, after discussing imagery request with Rodney

Rocha, calls LeRoy Cain, the STS-107 ascent/entry Flight Director. Cain

checks with Phil Engelauf, and then delivers a “no” answer.

8. Flight Day 14. Michael Card, from NASAʼs Safety and Mission Assurance

Office, discusses the imaging request with William Readdy, Associate

Administrator for Space Flight. Readdy directs that imagery should only be

gathered on a “not-to-interfere” basis. None was forthcoming.

(CAIB, 2003, p. 167, Ch. 6)

65

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