Information School - University of Sheffielddagda.shef.ac.uk/dispub/dissertations/2014-15/External/... · 2015. 11. 19. · others were injured”(BP,2010,P.9) After the explosion,

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How information behavior impacted on information failure in the BP Deepwater Horizon disaster

A study submitted in partial fulfilment of the requirements for the degree of

MSc

at

THE UNIVERSITY OF SHEFFIELD

by

Wei Wu

September 2015


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Abstract

Background: Information behavior barriers can cause information failure and

finally trigger disaster. The BP disaster is an example of this. Even though

information behaviour has been widely studied over the last several decades, the

relationships between information behavior, information failure and disaster have not

received extensive attention.

Aims: The aims of this research are to address the detailed relationship of

information behaviour impact on information failure in the BP disaster,and to sum up

the lessons we can learn from this disaster. To achieve these aims, a detailed disaster

reasons analysis is the initially undertaken. Moreover, human behaviour factors need

to be analysed at different levels; including individual, group, organization and

environmental. This is because their behaviour can affect information failure and

finally cause disaster.

Methods: The BP disaster has been selected as a qualitative single-case study for this

research. The research also adopts an interpretive and inductive method to analyse

the relationship between information and information failure. Furthermore,

documentation and desk research are the major method used to obtain secondary

sources. Moreover, the methods of data analysis are triangulation and inductive

reasoning.

Results: The result of this research shows that information behavior barriers have a

strong impact on the information failure. This includes information seeking barriers;

information sharing and communication barriers; and information using barriers.

But information behaviour did not directly cause the BP disaster. It could triggered

information failure, and then lack of information caused wrong decision-making,

which caused a significant impact on the BP disaster. Moreover, avoiding

information behavior barriers is a good way to prevent further disasters.

Conclusions: This research has achieved the research aims. The BP disaster has

exposed the generally information behavior barriers that may exist in this

organization. Therefore, the benefit of this research is to clearly understand this

failure in the BP disaster. Furthermore, combining theories supporting this BP

disaster analysis means that a general phenomenon can be inducted to give alerts to

other high-risk industries.


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Acknowledgements

I am very honored to express my gratitude to my supervisor, Dr Ana Cristina

Vasconcelos, of the Information School, University of Sheffield, for her thorough

guidance at each stage of writing this paper.

I appreciate all lecturers that I had attended in the past year;

I give many thanks to my parents, Yuexiang Wu and Zhiping Hu, who provided

financial support to enable me to take the postgraduate course.

Meanwhile, I also mourn with the deaths of the 11 Deepwater Horizon crewmembers

who lost their lives in the disaster on April 20,2010.

I had a heavy heart in the whole process of this research. Unfortunately, close to the

end of this research, a serious explosion happened on Aug 12, 2015, in Tianjing,

China. I also moum the lives lost in this explosion.


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Contents Abstract ....................................................................................................................... 2

Acknowledgements ..................................................................................................... 3 Chapter 1. Introduction ............................................................................................. 7 1.1.Background and Context ..................................................................................... 7 1.2.Aims ....................................................................................................................... 7 1.3.Research questions and Objectives ..................................................................... 8 1.3.1.Research questions .............................................................................................. 8 1.3.1.1.Main research question .................................................................................... 8 1.3.1.2.Sub-questions ................................................................................................... 8 1.3.2.Objectives ............................................................................................................ 9 Chapter 2: Literature Review ................................................................................. 10 2.1.Information seeking behaviour models ............................................................ 10 2.2.Information needs .............................................................................................. 11 2.3. Information-seeking behaviour barriers ......................................................... 11 2.3.1. Individual level barriers ................................................................................... 12 2.3.2. Group level barriers .......................................................................................... 13 2.3.3.Technicial and Organizational level barriers .................................................... 13 2.3.4.Environment barriers ......................................................................................... 14 2.4.Information sharing barriers ............................................................................ 14 2.5.Man-made disaster and information behaviour .............................................. 17 2.6.Decision-making and Information behaviour ................................................. 18 2.7.Affective Load Theory, Face Threat Theory and Escalation Theory ........... 19 2.8.Preventing information of failure and disaster ............................................... 19 2.9.Summary and implication for the research ..................................................... 20 Chapter 3: Methodology .......................................................................................... 22 3.1.Research purpose and approach ....................................................................... 22 3.1.1.Research purpose .............................................................................................. 22 3.1.2.Research approach ............................................................................................ 23 3.2.Research design .................................................................................................. 24 3.2.1. Components of research designs ...................................................................... 24


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3.2.2.Rationale for single-case study ......................................................................... 24 3.3.Data collection .................................................................................................... 25 3.3.1.Source of evidence ............................................................................................ 25 3.3.2. Triangulation .................................................................................................... 26 3.3.3. Secondary data ................................................................................................. 26 3.3.4.Evaluating secondary sources ........................................................................... 27 3.3.5.Benefits of the secondary data .......................................................................... 28 3.4.Data Analysis ...................................................................................................... 28 3.5.Ethical consideration ......................................................................................... 29 Chapter 4: The BP disaster analysis and findings ............................................. 30 4.1. Individual level .................................................................................................. 30 4.1.1. Position Change ............................................................................................... 30 4.1.2. Cognitive avoidance and information avoidance ............................................. 31 4.1.3. Lack of information and leading to wrong decision ........................................ 32 4.2. Group level ......................................................................................................... 33 4.2.1. Interpersonal conflicts ...................................................................................... 33 4.2.2. Unclear work boundaries ................................................................................. 33 4.3. Organizational level .......................................................................................... 34 4.3.1. Poor Management structure and information monitoring ................................ 34 4.3.2. Failing of training ............................................................................................. 36 4.3.3. Poor information sharing and communication ................................................. 36 4.3.4. Failure to use information and decision consequence ...................................... 38 4.3.5. Economic and time pressure ............................................................................ 39 4.4. Environment level ............................................................................................. 40 4.4.1. Lack of regulation ............................................................................................ 40 4.5. Summary ............................................................................................................ 41 4.6.After disaster improvements ............................................................................. 42 Chapter 5: Discussion and lessons learned from the BP disaster ........................ 43 5.1. Individual level .................................................................................................. 43 5.2. Group level ......................................................................................................... 45 5.3. Organization level ............................................................................................. 46 5.3.1. Poor Management ............................................................................................ 46 5.3.2.Lack of information sharing .............................................................................. 47 5.4.Environment level .............................................................................................. 48


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5.5.Lessons Learned from the BP disaster ............................................................. 49 Chapter 6: Conclusion ............................................................................................. 50 6.1. Contribution to knowledge ............................................................................... 50 6.2. Research limitation ........................................................................................... 52 6.3.Future research .................................................................................................. 53 Bibliograph ............................................................................................................... 54 Appendices ................................................................................................................ 62 Appendix A-Chronology of the accident ................................................................ 62 Appendix B-Access to dissertation form ................................................................ 68 Appendix C-Confirmation of address after completion form .............................. 70


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Chapter 1. Introduction

1.1.Background and Context

On April 20, 2010, an explosion and fire disaster happened in the BP Deepwater

Horizon drilling rig at the Macondo Well. “Eleven people lost their lives, and 17

others were injured”(BP,2010,P.9) After the explosion, the combustion of the rig

lasted for 36 hours and the Deepwater Horizon rig eventually sank (BP, 2010,P.9).

The incident ultimately resulted in large oil spills into the Gulf of Mexico, which

lasted for 85 days. (CSB-V2, 2014, P.42). The oil spill caused the worst

environmental pollution disaster in the U.S. history (Graham, et.al, 2011). To

recovery from the oil spill pollution, BP has already paid more $980 billion, as of

February 2015, and the recovery is still continuous (BP, 2015). This, disaster can

enable us to draw important lessons. Also, it can give a warning signal to other

offshore oil companies and high-risk industries to avoid similar incidents. Moreover,

this disaster also pushes forward the U.S. offshore oil industry regulations.

This dissertation will be divided into six chapters. Firstly, an introduction to the

research is made; which gives basic information of the research, including

background, research aims and objectives. Secondly, there is a discussion of the

relevant theoretical knowledge, from a literature review. Thirdly, the research study

methodology is explained, including data collection and analysis methods. Fourthly,

findings from the BP disaster case study are expounded. Finally, this chapter will

contrast these findings to pervious theories. The last chapter is the conclusion and

includes a consideration of the limitations of this research.

1.2.Aims

This research aims to investigate how information behaviour can impact on the

information failure in real-word disasters. The theories to support and underpin this

research are based on the previous research in information behaviour and information

failure aspects. In order to test the theories of knowledge, the BP oil spill disaster has

been selected as a case study example of this research. Indeed, according to the


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Graham, et.al (2011) investigation report, the BP disaster could have been avoided.

This research tries to build a framework of correlations between information

behaviour and the BP disaster at the Deepwater Horizon rig.

Also, this research aims to point out existent deficiencies of information failure at the

BP Deepwater Horizon rig, in order to generalize phenomena that may occur in other

organizations. Aiming to solve these information failure issues, a framework will be

built, and recommendations made. Indeed, this could assist other high-risk industries

is avoiding similar disasters through preventing information failure.

1.3.Research questions and Objectives

1.3.1.Research questions

1.3.1.1.Main research question

How did information behaviour impact on the information failure in the BP

Deepwater Horizon rig case?

1.3.1.2.Sub-questions

1. What are the causes that led to the BP oil spill disaster?

2. What information behaviour was exhibited by key actors?

3. How did these behaviour led to information failure?

4. What is the relationship between information failure and the BP disaster?

5. What lessons can we learn from the BP disaster in terms of managing information

behaviour?


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1.3.2.Objectives

To better achieve the above research aims, the objectives of this research are divided

into the following:

1. To clearly recognize the reasons that caused the BP disaster, a review of the

official investigation reports was necessary; in order to collect as much detailed

information as possible about the BP disaster.

2. Information behavior is generally caused by human factors; therefore, key actors’

information behavior in the BP disaster will be collected and organized from the

five different investigation reports.

3. In order to develop the connection framework of information behaviour and

information failure through the investigation of BP incident, the barriers in

information behavior which existed in the Deepwater Horizon case that led to

information failure in the BP disaster will be identified; these failure reasons can

categorized into four different levels; including: individual, group, organization

and environment.

4. To gain a better understanding of what factors can affect information failure in

the disaster, theories supporting the analysis is necessary; therefore, a review the

literature concerning information behaviour barriers is a made.

5. A deep and comprehensive analysis information failure in the BP disaster leads

to recommendations regarding how to avoid disasters through managing

information behaviour. This could give other similar high-risk industries a

warning and a special on what that they need do to improve in their own industry.


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Chapter 2: Literature Review

The review of the literature indicated the relationship between information behaviour

and information failure. As Meyer (2009) emphasized, most research is too

restrictive with only several factors, such as cognitive or affective factors. Johnson

(2009) gives an expanded view of information behaviour. This literature review will

expand more factors that may affect information behavior and finally cause

information failure.

Wilson (2000,P.49) indicated that “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.” In order to make a clear

concept, the nested relationship among information behaviours, information-seeking

behaviour and information search behaviours were clearly introduced by Wilson in

1996.

2.1.Information seeking behaviour models

Case (2012,P.92, Para.4) defined the “information-seeking” as awareness of the lack

of information after the activities have been conducted. As information behaviour is

a huge topic, there is much academic research in this area, which tends to concentrate

on the information-seeking behaviour. In this area, a large number of academic

articles has been published about information-seeking behaviour models. There are

several different models of information-seeking behaviour. Wilson (1999)

summarized the five different models of information-seeking behaviour and Case

(2012,P.133-P.162) summarized the nine different models. Combining their

conclusion, ten models have been widely used for information behavior, which

include the following: (1) Wilson’s information-seeking behaviour in 1981;(2)

Krikelas (1983) model is “one of the first explicit depictions of information

seeking”;(3) Shields and Dervin’s sense-making theory in 1983 and 1996; (4) Ellis’s

model includes information seeking strategies that were conducted in 1989 and Ellis,

Cox & Hall generated an information seeking strategies theory that was conducted in

1993; (5)Kuhlthau (1991,2004)’s theory is about “information search processes”; (6)


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Bystorm and Jarvelin’s (1995) study concentrated on “task complexity”; (7)Leckie,

Pettigrew, and Sylvain (1996) created a model for “professionals”;(8),

Savolainen’s(1995) model is for “Everyday Lift Information Seeking (ELIS) in the

context of way of and mastery of life”. (Savolainen, 1995, P.259, Para.1);(9)Wilsion’s

(1996,1999) model, an expansion of his1981 model; and (10) Johnson’s (1997)

model.

2.2.Information needs

Wilson (1981,P.7, Para.5) made clearly that information needs can be split into three

interrelated classes through psychological levels. The first level is “physiological

needs”, which means the information needs to meet the demand for survival. The

second level is “affective needs”, which is also called “psychological or emotional

needs”. And the last level is “cognitive needs”, which means that which can be used

for learning.

2.3. Information-seeking behaviour barriers

Information-seeking behaviour barriers have been studied by lots of different

scholars from different aspects. (Wilson,1981, 1997; Meyers, Nathan and Saxton,

2007; Sharon, Marynieves and Maria, 2009; Karunakaran and Reddy,2012;

Savolainen, 2015)

Wilson (1989, P.8,Para.1) showed that there are many different factors that can give

negatively impact on an individual’s information seeking behaviour. The factors that

could inhibit information seeking behaviour are referred to as “barriers”. These

barriers can be divided into three levels, including “personal barriers”,

“interpersonal barriers” and “environmental barriers”. Indeed, Wilson

(1997,P.556-561) expanded his barriers concepts from the 1981 model, which

referred to “intervening variables”. And Wilson, combining his own theory and

other people’s studies, concluded by dividing “intervening variables” into three

different levels. The second level is “Social/interpersonal variables”, the third level

is “Environmental variables”, which includes two different aspects “Economics


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variables” and “Source characteristics”.

Karunakaran and Reddy (2012,P.1) categorised the barriers in organization into four

different levels; “organization barriers”, “technological barriers”, “individual-level

barriers” and “team-level barriers”.These barriers can affect the information failure

in the organization. Marcella, Pirie & Rowlands (2013) summarized Reason’s theory

about the organizational failure, as “Reason categorizes failure into…active failures

and latent failures”.

2.3.1. Individual level barriers

According to Wilson (1997,P.557-559),“emotional variables”, “educational

variables” and “demographic variables” are three major aspects of “personal

characteristics” classification. Indeed, emotional variables that can affect

information seeking behavior have been summarized by Wilson (1997, P.557-558),

who divided all factors into different categories. Firstly, “cognitive dissonance” was

conducted by Festinger in 1957, which could be said to involve an inconsistency

between individuals new and old cognitive awareness, which could make people

uncomfortable; therefore, people could avoid to seeking information. (Chapanis and

Chapanis, 1964,P.2, Para.1; Cooper,J,P.2,Para.1) Moreover, “Selective exposure” is

another phenomenon that can be affected by individual’s characteristics. Krohne

(1989,P.236, Para.1) referred to this phenomenon as “cognitive avoidance”, which

can be explained as deliberately ignoring some threat information.

The emotional variable could be summarized using Case’s beliefs. He stated that

people are more willing to accept the information that is consistent with “their

internal state”. If an individual is interested in a specific topic, they may prefer to

obtain more information about it. Even though, people can obtain information

through different channels, this information may not change individual’s attitudes or

behavior, because individual’s “perceptions and memory are distorted by their

individual motives and attitudes”. This means that, if different people have obtained

the same information; they can give different reactions and behaviors. This is

because people have different purposes for obtaining information. (Case, 2012, P.109,


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Para.1)

Furthermore educational levels can give impact on the information seeking

behaviour. Moreover, Bettman & Park (1980) indicate that humans with low and

high knowledge lack the motivation to seek information compared to those at the

mid-level because the low educational people do not have enough ability, while the

high-level groups are have a strong knowledge background that they can rely on.

Moreover, Radecki and Jaccard(1995) emphasized that education level can influence

human’s cognition, of decision making and behaviour. Also, information behaviour

is an essential part of making decision; lack of information can lead to a failure of

information strategy.

Lastly, “demographic variables” defined that people are in different categories with

different abilities to seek and accept information, for example, younger people find it

easier to understand new information (Wilson, 1997, P.558-559).

2.3.2. Group level barriers

Wilson (1997,P.559) stated that interpersonal interaction could affect

information-seeking behavior when person plays an important role in information

exchange, as that person is the source of information. In this situation, interpersonal

problems can barrier information-seeking behaviour. In addition, social factor could

also give a negative effect to information-seeking behaviour.

Karunakaran and Reddy (2012,P.7-8) defined the two factors that can cause the

barriers at the team-level. The first is unclear work boundaries; the other is a conflict

time schedule. This situation will occur when team members seek for support

information, but cannot make contact with the specific person.

2.3.3.Technicial and O rganizational level barriers

Karunakaran and Reddy (2012,P.5-6) found that the lack of technology or tools

could inhibit the information seeking behaviour. This can increase the complexity of


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information seeking. This viewpoint was given by Wilson (1997,P.561-562), as he

concluded that when the information is hard to achieve, people may has less

motivation to seeking information.

At the organization level, the barriers that can affect information-seeking behaviour

include “structure, culture, values, rewards, incentives and practices” (Karunakaran

and Reddy, 2012, P.5, Para. 5)

2.3.4.Environmental barriers

The third level is “environmental variables”, Wilson (1997,P.560-561) analyzed that

two different aspects under this categories are “economics variables” and “source

characteristics”. Wilson (1997,P.559) classified the economics issues related to the

information-seeking behavior as “direct economic costs” and “the value of time”.

Information-seeking behaviour can be inhibited when information is hard to access.

Moreover, wrong communication channels can also inhibit this. Moreover,

environmental level barriers also include the impacts from “time”, “geography” and

“national culture” (Wilson, 1997, P.560-561). But, Wilson’s model focuses on how

the market price mechanism gives impact to the information-seeking behaviour. In

the offshore oil industry, the economic pressure can give impacts on the

informationbehaviour. Tabibzadeh and Meshkat (2014, P.201) point out one of the

major organizational factors for the Deepwater rig failure was “economic pressure”.

2.4.Information sharing barriers

Information behavior also has an important part to play, which involves information

sharing. It is also necessary for daily context coordination works (Sonnenwald, 2006).

Lack of information sharing can result in the information failure. Similar to

information behaviour that has barriers, information sharing also has barriers. Dawes

(1996,P.377) states briefly that information barriers also exist, including “technical,

organizational, political barriers”. These barriers can also affect information sharing

and finally cause the information failure.


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Information sharing is complex. Wilson (2010) pointed out the factors that can affect

information sharing, including “risk, reward (or benefit), trust, leadership,

organizational culture, and so forth”. Moreover, in a major oilrigs incident, the

information sharing could affect the “control, management, but limited effect of the

incident.” (Ibrahim & Allen, 2012,P.1916) Ibrahim & Allen also argued that trust

could be affected by information sharing: the better the shared information, the more

trust will be established. This relationship will be amplified in the “time bound,

uncertain and high volatile context”(Ibrahim & Allen, 2012,P.1916).

Communication is another important factor that can bring the information failure to

the internal team operation. Dunn, Lewandowsky, and Kirsner (2002) summarized

Caldwell’s theory that, in an emergeny event, team members need to cooperate with

each other. This is because each individual has different abilities; “the effectiveness

of the team depends upon the ability of its members to communicate with each other

to coordinate activities, to share information, and to implement appropriate

strategies”. The same article presents the models of the communication models, and

also point out that if the interaction of the team are not good enough, it will lead to

decision-making failure.

Moreover, Ibrahim and Allen (2012) showed failure of information sharing and

communication can lead to sacrifices for the oil industry and the environment. In the

event of information not being shared effectively, group cooperation will fail. In

addition, information sharing can also fail in cooperation groups. Indeed, information

sharing between different organizations is hard because, compared to sharing

information, organizations are more likely to collect information from others rather

than share. This can mean the actual information is shared at a restricted level.

(Bharosa, Lee and Janseen,2009). Turner and Pidgeon (1997,P.39, Para.4)

summarized different situation that may cause the “variable disjunction of

information”. This means that, in some events, different groups or individuals are

involved; in this situation, effective information for each group or individual are

non-synchronous, which can cause different understanding of the situation.


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Turner and Pidgeon (1997, P.50-P.53) summarized how information was not always

sharing reasonable, and that this occurred in poorly structured contexts; in this

situation, improving communications does not alter information use much. The root

way to overcome these problems is to improve the poor structure. The following

issues can cause the information not been shared effectively. Indeed, in some

situations, people may concentrate on the well-defined problems; and do not

exchange information about other less obvious problems. Unfortunately, these

missed problems finally cause the disasters. They also highlight several situations

where information may be miscommunicated, including: (1) information does not

send correctly or is sent to the wrong people; (2) during the transfer process, the

essence of the information content may be distorted; (3) individuals negative emotion

could give impact on communication; (4) the communication do not occur through a

formal network, instead an informal network is overused; (5) in some situation

problems may involve “vagueness and complexity”; therefore, during the

information transfer “ambiguity is difficult to avoid”.

Turner and Pidgeon (1997, P.72, Para.2) gave several reasons for “discrepant events”

being unnoticed or not been fully understood. They explained how these “discrepant

events” create an expectation gap between the operational plan and the thing really

taking place. The reasons are as follows: (1) a false of assumption means events go

unnoticed or are incorrectly understood; (2) a complex situation could cause the

information be ignored or misunderstood; (3) warning signals are not been correctly

detected, or properly comprehened; and (4) “formal precautions were not fully

up-to-date violations formal rules and regulations came to be accepted as normal”.

After information is transferred, lack of used of the received information may still

occur. Turner and Pidgeon (1997,P.53) summarized the reasons that may cause such

a lack of use, thus; (1) a lot of useless information can cause the useful information

not to be recognized;(2) information may be receive when danger has appeared,

which may give the information receivers insufficient time to deal with the

information; (3) information receivers may not pay attention to information that they

have received and do not give any response to this information because these issues

are not their concern; therefore, information receivers may be in a passive state until

responses are unavoidable; (4)for the individuals who received the information may


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not integrate it and use the information creatively.

2.5.Man-made disaster and information behaviour

Macintosh-murray and Choo (2002,P.241, Para.2) summarized Turner’s man-made

disaster model, which includes:

(1) “Rigidities in perception and pervasive beliefs in organizational settings”; for

example, organizational culture and other internal factors can lead to the staff

lacking the necessary knowledge or ignoring some important information.

Moreover, according to Mason (2004), organizational culture is “a crucial

determinant of human behaviour”, and leaders play an important role in building

up the organization culture;

(2) Organizations may do not accept external advice, which could make the

organization miss some important earlier warnings;

(3) Information has not been shared effectively or there is a lack of use after sharing;

which has been explained in detail in the above section;

(4) Operational members do not follow the existing regulations;

(5) Estimated the risk in the minimize level.

Choo (2008,P.34-39) argued that two forces might cause the organizational disaster.

The first one is workers being paid less for their daily woek efforts. The second is the

organization trend for “cost efficiency”. Also, Choo clearly stated three primary

kinds of “information impairments”. (1)“epistemic blind sports”, which means the

warning signal has not received enough attention. This may have been caused by the

difference between the information and the receiver’s beliefs, or because there was

no guide to recognize the warning signals. Human effects can also cause the

“epistemic blind spots”, as people do not do not doubt their own beliefs. Moreover,

the most common approach for the organization in the decision-making process is

“justificationist”. In this kind of organization, it may be hard for them to change to

another approach, which means the organization may stich to old approach. (2) “risk

denial”, the “warning signals and precursor incidents are registered”, but a correct

was not conducted. The primary reason is leaders ignored warning signals, where the

leader may believe risks are under the control or they do not want to correct their

mistakes. (3) “Structural impediment”: in this type of the impediment, the warning


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signals have been noticed, but the organizational structure problem makes the

response ineffective.

2.6.Decision-making and Information behaviour

Case, Andrews, Johnson & Allard (2005, P.360) indicated those human beings are

likely to “avoid, ignore…deny information”, and, following Yzerbyt & Leyens’s

argument that “confirmation bias” can influence people when they are making

decisions. This means that people want more positive information than negative

information, when they are making decisions (Yzerbyt & Leyens’s, 1991,P.351).

Nickerson also mentioned this in his work in 1998.

Moreover, Wilson (1981,P.4, P.8) argued that information-seeking behaviour might

never happen or has a time gap between the “recognition” and the

information-seeking behaviour occurs. This is because human’s decisions or

judgments are based on the beliefs or made when there is a lack of information.

Wilson defined this as “prejudices, faith or ideology”. In these situations,

information behaviour can affect the information failure.

Furthermore, “Judgment under uncertain” was brought forward by Tversky and

Kahneman in 1974; they also point out emphatically that the judgments under

uncertain are “high economical” and “usually effective”, but could cause serious

errors. (Tversky and Kahneman, 1974, P.13; Arkes, 1991). Voort and

Bruijn(2009,P.29,Para.6) point out that, before the responsible person makes a

decision, all risk needs to be evaluated. They also indicated in the “highly complex

environments”, risk is hard to be recognized by a single person. Therefore, Voort and

Bruijn summarized the Douglas and Wildavsly opinion, which is that no individual

can fully realize the risks before it has happened. Case also gives a similar viewpoint,

“uncertainty is a key concept in decision making research, as it has been in

information seeking and communication” (Case, 2012, P.97, Para.3). Moreover, for

every individual, “rationality is bounded” when individuals making decisions.

Moreover, a more sensible phenomenon has been summarized by Case (2012, P.98,


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Para.1). In two situations, decision makers will seek to decrease research time

through “simple and less reliable rules”. The first situation of limited time has been

reduced to making a decision; the second situation is that total sum of information

that needs to be processed has increased.

2.7.Affective Load Theory, Face Threat Theory and Escalation Theory

In the case analysis of Fukushima Daiichi nuclear power disaster Thatcher,

Vasconcelos and Ellis (2015,P.58) extend several theories of information behavior

that may influence information failure. The theories include “Affective Load

Theory”(ALT) and “Face Threat Theory” and “Escalation Theory”. Referring to

Nahl (2005), ALT is a “social-behavior perspective” of human’s feeling and

thinking with regard of information behavior. Nahl also indicated that if human

beings are “ineffective cognitive”, then the affective load will be high. Mon (2005)

referred to Goffman’s (1971) Face Threat theory that humans may apply the

“impressive management to obtain, share or hide” the information, which aims to

create a positive public image.

2.8.Preventing information on failure and disaster

Around 80% of accidents or incidents are influenced by human and organizational

factors (Bea, 2003). Choo (2008, P.39-42) also elaborated ways to preventing

organization disasters at three different levels, including individual level, group level

and the organization level.

At the individual level, to avoid the “cognitive heuristics and biases”, individuals

can adopt several methods to increase their “cognitive alertness”, including: (a)

seeking professional advice; and (b) adopting different theories and models to

analysis the problem. To avoid the human factor affecting the information failure in

other similar high-risk industries, Crow Resource Management (CRM) training can

be adopted which is human factors training. The main function is teaching skills to

crews, for instance, “communication, situational awareness, team-work,


20

decision-making, leadership, and personal limitations” (Mearns, Flin and

O’Connor,2001, P.384)

At the group level, “Groupthink and group polarization” needs to be controlled by

the organization. The methods include: (a) encouraging the opinion change between

the groups; (b) leaders need to avoid their personal preferences affecting to the group

members’ opinions;(c) the organization should seek external help; and (d) multiple

subgroups could be deducted to analyse the same problem.

At the organizational level, the “bureaucratic culture and information dispersion”

needs to be avoided. Choo’s five “information priorities” characteristics in the high

reliability organization are similar to Mason’s viewpoint. Mason (2004) analyzed the

NASA organizational culture from the Columbia space shuttle disaster and he drew a

conclusion of how to build up a reliable organization, thus: (1) focus on the failure;(2)

the organization needs to correctly understand that they cannot minimize the risks;(3)

the organization needs to focus on reminding the operation staff to avoid mistakes;(4)

The organizations should have the ability to respond to any problem at the initial

stage; (5) In the daily operations, the most knowledgeable personal should be

assigned to take charge of the tasks.

2.9.Summary and implications for research

In summary, a comprehensive overviews to better understand the connection

between the theories and this research has been given. This section will put emphasis

on the nested interrelationship of information behaviour barriers and their subsequent

effect. Meanwhile, theories can provide support to this research will also be

highlighted.

Many factors in information behaviour can cause information failure and finally

trigger disasters. For the purpose of further understanding, information behaviour can

be interpreted as different human behaviours in relation to information acquisition

and use. The detailed explanation for this is that information behaviour is about

information seeking, information searching, information sharing, and information


21

using. When information failure occurrs, information behaviour barriers could be

considered as important reasons for this failure. The information behaviour barriers

exist in the each aspect of information behaviour described above. Information

barriers can be segmented into four different levels with nested interlathionships, as

shown in the following:

(1) The individual level contains the least influence factors with the narrowest range

of information behaviour barriers. Indeed, interpersonal relationship issues,

which belong to the group level barrier and personal cognition issues, could

trigger this level of barriers. Human factors can give information behaviour an

important influence, where individuals can lead to information barriers in active

and passive way, including psychological and knowledge capability. First,

individual’s emotional issues can inhibit their information seeking behaviour,

which can cause the information failure. People seek for the self-identity, which

means information behaviour barriers will occur when external information does

not accord with individual’s internal cognition. Second, individuals may lack the

knowledge to seek further information, which can could also caused information

failure.

(2) Group level issues contain the individual level and belong to the organization

level, which contains the third widest range of barriers. Interpersonal conflicts are

the major problem at this level; where psychological problems and

communication problems are triggered. This causes the information seeking

behaviour barriers, information sharing barriers and information using barriers,

and finally information failure.

(3) Organisational and technology level barriers belong to environmental level

barriers. This means organisations information barriers can be created both by

environmental problems, and organisation internal problems. The factors that can

trigger enterprise internal information failure problems includes poor

management, incompetent leaders, organisation structure problems and

organizational culture. These problems can lead to information failure and cause


22

the wrong decision to be made. If organizations lack effective technology to

assist human information behaviour, then information failure will occur.

(4) Environmental level barriers are the widest range that could gives impacton to

the information failure. The factors includes economics, time, location and social

culture.

Obviously, information behaviour barriers can lead to information failure. The most

direct impact is making decisions without useful information,which can result in

disasters happen. Post-disaster response effectiveness can also effected by

information behaviour. Furthermore, preventing disaster though aviod information

behaviour barreris, as introducted in Section 2.9. All of these theories preovide

suppot for this research, except technology barriers. Technology problems can cause

information failure, but it does not have strong relationship with information

behaviour. Therefore, technology factors will be ignored in this research.

Chapter 3: Methodology

3.1.Research purpose and approach

3.1.1.Research purpose

Explanatory research has been adapted for this research. Yin (2014, P.238, Para.7)

defined the explanatory research as “a case study whose purpose is to explain how or

why some condition came to be”. Explanatory case studies test “cause-and-effect

relationships” and test theories in a qualitative manner. (Yin, 2012, P.89, Para.3).

The purpose of this research is to find what caused the BP Deepwater Horizon

disaster. Indeed, this research aims to provide a deep explanation and analysis of the

reasons that caused this disaster in terms of information behavior aspects. It also tests

the theories about information behaviour and information failure aspects.


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3.1.2.Research approach

Three major approaches in this research include: (1) qualitative; (2) interpretive and

(3) inductive. Here is a the detailed explanation of each:

(1) Qualitative research has been adopted in this research. According to Buston,

Parry-Jones, Livingston, Bogan and Wood (1998,P.197,Para.3) the “key

characteristic of qualitative research is that it facilitates the researcher’s

understanding of the meaning assigned to the phenomena by those being studied”.

Furthermore, Baxter and Jack (2008,P.544, Para.1) pointed out that if qualitative

research has been used in the right way, it can be a good method to “develop theory,

evaluate programs, and develop interventions”. Above all, qualitative research is an

effective method for helping researchers to better understand how information

behaviour barriers impacted on the information failure in the real world disaster. As

investment in the BP disaster increases, the general interrelationships of information

behaviour barriers and information failure can be obtained. This will help to test

previous theories and develop a framework of relevant theories. Furthermore, the

qualitative research on the BP disaster could provide the theoretical basis for BP and

other organization to develop intervention programs and measures.

(2). Thomas (2011, P.124, Para.3) defined Interpretative as a “classic” approach in

the case study, explaining the close relationship between interpretivism and the case

study; as“…interpretive research marries easily with case study, which also

priorities looking at the whole”. Moreover, Patton (2002) defined interpretation as

“attaching significance to what was found, making sense of findings, offering

explanations, drawing conclusions, extrapolating lessons, making inferences,

considering meanings, and other otherwise imposing order on an unruly but surely

patterned world”. Above all, in this research, the major data collection methods are

different to the investigation reports and use the data to interpretation what happened

in the Deepwater Horizon event, giving an explanation of what information behavior

contributed to the disaster, thus offering recommendations to the offshore industry.

Therefore, combining Patton’s explanation of Schlechty and Noblit’s (1982) theory

that the two aspects will be deduced in this research, which can be summarized as

identifying the obvious problems and uncovering hidden problems in the BP disaster.


24

(3). Neuman (2011,P.70, Para.1) defined inductive as “an approach to developing or

confirming a theory that begins with concrete empirical evidence and works toward

more abstract concepts and theoretical relationships”. The inductive approach could

be adopted in this research to generalize the relationship between information

behaviour and information failure from BP disasters. The BP disaster is not a unique

case throughout history; some general situations that may exist in the high-risk

organizations could be inducted. Therefore, an inductive approach could assist this

research to build a framework of interrelationships for information behaviour and

information failure that may finally frame the disasters.

3.2.Research design

3.2.1. Components of research designs

Yin (2014,P.29, Para.1) defined that the research designs as the “blueprint of the

research”. Yin (2014, P.29, Para.2) defined the five components of the case study

research design. The first and second components are the research questions and

“propositions”, as shown in the Chapter 1. The third point is “unit(s) of analysis”,

which, in this research, could be defined as “bounded research”, where the

information collection is limited to information behavior and information failure

aspects of the BP disaster. In this research, data collection methods will be secondary

data collection through desk research. This will be explained in Section 3.3. The

fourth and fifth points are “the logic linking data to proposition” and “the criteria

for interpreting the findings”; which are about the data analysis. Indeed, the major

method of data analysis is triangulation and inductive reasoning. This will be detailed

explained in Section 3.4.

3.2.2.Rationale for single-case study

The case study has been accepted as “an ideal methodology” to give a deep

understanding of specific issues (Yin, as cited in Nazari, 2010), and the rationales for

selecting the BP disaster as the single case study design in this research rather than


25

multiple-case design could be summarized as “critical, unusual, common, revelatory

or longitudinal” (Yin, 2014, P.51, Para.2). The BP disaster is critical case, which

involves different levels of information behaviour barriers. In addition, it was an

unusual large disaster, and so has detailed accident records. These documents are

worth analyzing because this disaster exposes the information behavior barriers

phenomena that may be common existence in the offshore oil drilling industry.

Comprehensive all above reasons, BP disaster is the single case that worth to

analysis in this research.

3.3.Data collection

3.3.1.Sources of evidence

The information collection in this research is several different disaster investigation

reports conducted by different investigation organizations. Therefore, the sources of

the evidence collection in this research belongs “documentation” (Yin,

2014,P.105-106). Also, “desk research” is the major approach to collect data, which

Woolley(1992) defined as the “process of gathering information available in

published form”. All reports that adopted for the research are public available.

Yin (2014, P.106, Figure 4.1) said that a “documentation” approach has both

advantages and disadvantages. The first advantage is the “stable” text, where the

documentation will not be edited anymore; so researchers can do the repeat studies to

obtain new information. The second advantage is that it is “unobtrusive”, which

means the research is based on the facts, without researcher intervention, and

avoiding the researcher influencing the final result. This approach is also “exact”

and has “broad coverage”, which means the documents provide more details and

information of the event. However, this type of evidence also has limitations, as

Yin’s suggests. The primary limitation that needs to be considered is the bias of the

pervious investigation. Indeed, all investigations were finished and results have been

accepted. It is hard to recognized whether bias existed or nor during the

investigation.


26

3.3.2. Triangulation

(1999, P.159, Para.1) explained the Denzin’s (1989) theory that triangulation in the

qualitative data analysis helps to build up a “richer and potentially more valid

interpretations”. Therefore, data triangulation will be used in this research, as

several different sources of data have been adapted to collect data about the disaster.

Decrop (1999, P.158, Para.7) argued that different sources of data provide different

angle to “corroborate, elaborate or illuminate the research problem”. The BP oil

spill was a large disaster that was caused by serious problems. Therefore, data

triangulation can provide more information to help revivify the facts and limit the

bias from either personnel or organizations in the BP oil spill disaster investigation.

3.3.3. Secondary data

In order to obtain more information, several different accident investigation reports

have been adopted, providing different angles for reviewing the accident and

ensuring that the acquired information is reliable.

1. “Deepwater horizon accident investigation report”. (BP, 2010),which is BP’s

internal investigation report.

2. “Deep water: The Gulf Oil disaster and the future of offshore drilling: Report to

the President”;(Graham, et.al, 2011) which is the National Commission official

investigation report.

3. “Report regarding the causes of the April 20, Macondo Well blowout” (Sep,

2011), which is the Bureau of Ocean Energy Management, Regulation and

Enforcement (BOEMRE) official investigation report.

4. “On Scence Coordinator (OSC) report” (Sep,2011), which is directed by the

National Response Team(NRT).

5. “Investigation report overview”(2014), which is the US Chemical Safety and

Hazard Investigation Board (CSB) investigation report.

Adopted reports were released by different organizations, which contain different

information. The National Commission report gives an overall view of the incidents,

including accident record, subsequent effect and recommendations for improvements


27

in the industry, government and energy policy. The BOEMRE report contains a deep

analysis of different factors involved in the BP Deepwater Horizon failure, including

human, organizational and technology factors. The CSB report concentrates on

“process safety, organizational factors/safety culture, and regulatory analysis”

(CSB-Overview, 2014, P.7). In short, these three reports provide much useful

information for this research, and so will be mainly used to collect information.

Nevertheless, the other two investigation reports can only provide limited

information for this research. The BP internal investigation report gives details of the

technology of the drilling and accident analysis. Also, this report was released a few

months after disaster, so the information is not comprehensive; therefore, less

information could be obtained from this report. The last report is the OSC report,

which focuses on the post-disaster response rather than its causes, therefore, after

in-depth analysis, this report was rejected as a source of for this research.

3.3.4.Evaluating secondary sources

Stewart and Kamins (1999, P.17, Para.1) explained that secondary sources need to be

evaluated, to make sure all information is reliable and valid to the research, even

though the secondary source of data has been organized and analyzed by someone

else. They isolated six aspects of evaluating secondary data, which will be used to

evaluate the investigation reports just mentioned.

In the BP oil spill disaster, the major purpose of data collection is to analyze and

report the antecedents and consequences of the BP disaster. Five different reports

that showed on the above, involving different response teams or organizations. All of

these teams were professional in their area, so the final results presented in the report

were analyzed according to their professional knowledge, which can be considered to

be of high quality. Indeed, the CSB collected approximately one million documents

for analysis. The Graham, et.al (2011) report analyzed thousands of documents and

interviewed more than a hundred people from the different “government agencies,

private companies and other entities” to collect information. The NRT report relied

on the written documentation. The source of the BOEREM report includes both


28

“electronic and written material”, the total size being 400,000 pages. The last

consideration is about time effects, as all BP investigation reports tried to find out the

facts in the BP oil spill disaster; so the time effect of the information can be ignored.

Above all, the BP disaster reports are evaluated as reliable and valid to use in this

research.

3.3.5.Benefits of the secondary data

Seale (2011, P.351) listed the several benefits of using secondary data: (1) it is more

“economical”; considering the BP disaster had huge environment and economic, the

investigation team were directly led by the national government. Therefore,

individual research can not possible be better than of these investigation teams. (2)

When doing the research, secondary data sets can be combined to get a better insight.

Again, several different reports have been adapted for analysis in this research. This

could help find out more specific problems that contributed to the Deepwater

Horizon disaster.

3.4.Data Analysis

Taylor-Powell and Renner (2003) described the processes of analysing the

qualitative data, which are applicable to this study.

(1) Understanding the data. In this research, five different investigation reports have

been adopted to collect data. Therefore, the first step was to know the focus of

each report.

(2) Analysis data. In this step, analyse what data are useful through reviewing

research questions and objectives.

(3) “Categorize information”. In this research, information behaviour barriers in the

BP disaster will be recognized and organized into four categories. These

categories, including individual level barriers, group level barriers, organizational

level barriers and environmental level barriers.

(4) Understanding the relationship between these categorizes. Four levels of

information barriers were not independent; the interrelationship needs to be

understood.


29

(5) “Interpreting data”, which can be considered as describing findings. This will be

showen in Chapter 4.

In additional, Yin (2014,P.142-P.168) summarized “analytic techniques” for data

analysis. The “explanation building” technique is used in this research. This is a

special type of “patterning matching”; where “pattern matching” which compares

the findings and the predicated results through theories. In this research, the BP

disaster variables in information behaviour barriers aspect could be predicted using

theoretical knowledge but the details of information behaviour cannot be accurately

predicted. Therefore, adapting this technique to build up casual links of information

behavior and information failure. Also, this method helps to test pervious theories.

3.5.Ethical considerations

Neuman (2011,P.49, Para.2) defined the secondary analysis as “nonreactive

research”, because there are no human participants active during the research.

Therefore, this project could be considered as “no risk” in the ethical sense. Indeed,

the study includes human factors impacting on the information behavior

investigation in the BP oil spill case but all analysis is based on information from

several different official public available investigation reports. Moreover, the

University Research Ethics Committee (UREC) did audit the ethics issue of this

research. To do the research, an understanding of research ethics is necessary. All

research needs to be conducted under human rights protection, such as respect for

others and necessity to inform participants of the details of research. In addition,

according to Seale (2011,P.351), if a secondary data set is used to find the answers to

research questions, then it is more ethical to use the secondary data set rather than a

new data collection because repeating the process of collecting testimonies could

give participants more psychological pressure, especially major accident survivors,

as in this case.


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Chapter 4: The BP disaster analysis and findings

Construction on the Macondo Well began October 2009, with the drilling platform

Marianas. One month later, Deepwater Horizon replaced the Marianas because of

damage. Transocean owns these platforms. From November 2009 to April 20, 2012

the disaster happened; the chronological order of major events on the rig includes:(1)

“Evenst prior to April 19,2010”, which included OptiCem cement model tests and

installation of centralizers;(2) “cement job”;(3) “positive and negative pressure

test;(4) “temporary abandon procedure”; and (5) aftermath response. The full

chronological order is shown in appendix Tables1. The problems that may have

caused the disaster existed in each phase of these activities (BP, 2010,P.21,Para.1).

The BP investigation report pointed out that (2010,P.11,Para.4) the disaster was not

simply, caused by “…any single action or inaction”, but by “a complex and

interlinked series of mechanical failures, human judgments, engineering design,

operational implementation and team interactions came together to allow the

initiation and escalation of the Deepwater Horizon accident. Multiple companies,

work teams and circumstances were involved over time.” These problems

accumulated and finally led to the explosion and fire on the rig. All factors in this

disaster are divided into four different levels: individual, group, organizational and

environmental, therefore, the chronological order will be disrupted.

4.1. Individual level

This level concerns the factors related to personal psychological issues and lack of

training for staff.

4.1.1. Position Change

The personnel changes on the rig have increased the risk of blowout because the

replacement crew who did change the position may have lacked of professional

knowledge and training to carry on the new work. The lack of knowledge could have

caused the information failure. BOEMRE (2011, P.79, Para.2) pointed out that early


31

on April 2010, the BP started to “implement a reorganization”, which brought

multiple personnel changes to the Macondo Well project. Also their responsibilities

on the well project changed. The reports pointed out that nine BP crew had been in

their current positions for less than half of a year. This reorganization could have led

to these crew failures to seek necessary information to guide their operations, leading

to information failure.

In addition, temporary well leader changes may also have bought a lack of necessary

knowledge and experience, which could have contributed to information failure and

been one of the causes of the disaster. From April 19 to April 24, Bob Kaluza took

the place of Sepulvado to become the temporary leader, but he lacked knowledge and

experience. He had worked for four years on drilling rigs, but did not have much

experience on the Deepwater Horizon (BOERME, 2011, P.181, Para.2).

4.1.2. Cognitive avoidance and information avoidance

BOEMRE (2011, P.80, Para.2) presents a draft of an email that Sims wanted to send

to Guide, pointing out the pointed out that Guide did not like to accept opinions from

other crew members. This could be considered to be an example of as cognitive

avoidance, which made Guide fail of obtain and use information. The evidence of

this is during the cement job, when Kaluza noticed the “low circulating pressure”

and reported this situation to the Guide, but Guide decided to continue the pump up,

without doing any other measurements.

The other example of cognitive avoidance that might have caused information failure

is that an evaluation needed to be done to ensure the cement integration well after the

cement job finished. Then the crew could proceed to the temporary abandonment

process. On April 20, 7:30 a.m., The BP leaders and operators had a meeting to

discuss the cement job; they believed that the cement work has been completed

successfully. Therefore, Guide and other BP engineers decided to not conduct the

cement evaluation test and send the evaluation team back onshore. (Graham,

et.al ,2011, P.102, Para.3).


32

During the negative pressure test, the Horizon crew noticed unusual pressure

readings on the drill pipe three times. Lee Lambert, BP Well Site Leader Trainee,

summarized this as the “bladder effect”, without any further investigation. Then the

second negative pressure was initiated, compared to the first test; this test

concentrated on the “pressure and flow on the kill line”. The crew kept the rig in the

open situation and spent 30 minutes checking whether there was a leak on the well.

But pressure on the drilling pipe was still abnormal. After the second negative

pressure test, the results has been considered successful (Graham, et.al,

2011,P.107,Para.5), so the leakage information was not obtained.

4.1.3. Lack of information and leading to wrong decision

Lack of information and experience may directly cause the information failure

leading to wrong decisions. On April 20, around 9:30 p.m., Revette, the driller, was

aware of the unusual pressure between drillpipe and the kill line. But after he “shut

off the pumps to investigate”, Revette told the floor-hand to eliminate the pressure

difference. The pressure did temporarily reduce, but it rises again shortly after. Even

Revette noticed the pressure problem and informed other crew in the rig, but none of

them has been considered that it was the flow which was the problem (BOEMRE,

2011, P.103, Para.3);(Graham, et.al, 2011, P.112, Para.6).

Later, at approximately 9:40 p.m. to 9:43 p.m., the Deepwater Horzion was a on

“temporary abandonment procedure”, when a kick happened. Anderson and Stephen

Curtis, the assist drill were earliest responders to the kick, but they made another

seriously wrong decision because there was no information to guide their activities,

which can be also considered as information failure. They sent the flow to the

mud-gas separator instead of directly into ocean. Six minutes later, at around 9:49,

the first explosion occurred. (Graham, et.al, 2011, P.114, Para.1). BP (2010, P.11,

Para.1) indicated that if the crew had directly drained the flow into the ocean, the

crew would have had more time to prevent or reduce the disaster damage.


33

4.2. Group level

4.2.1. Interpersonal conflicts

As mentioned above, reorganization has been implemented on the Macondo Well

project, causing interpersonal conflicts between Johe Gudie and the Avid Sims. The

BOEMRE (2011, P.80-83) clearly indicates that Gudie and Sims had conflicts with

each other. This made Sims fails to investigate the kick detection delay on March 8,

2010;because Guide did not care about this information, which caused information

failure and further information was not obtained to investigate the problems.

4.2.2. Unclear work boundaries

BP appoints different systems and crews in different positions to monitor kicks. This

may directly have caused unclear work boundaries and caused the information failure.

According to the Graham (2011, P109, Para.3), in the Deepwater Horizon rig, kick

detection was responded to by several crew in different job positions, including

“driller, assistant drillers and the mudlogger”. All real-time information of the well

was shown at different places on the Deepwater Horizon platform. Although, BP did

these preparations to detect kicks, the kick was still was not obtained on the day of

the disaster.

According to Graham, et.al. report (2011,P.110, Para.3-5), on 20 April, 8:02 p.m.,

the crew began to return the mud, but the response activities of kick detection were

unable to be defined, meaning the crew may not have been concentrating on

collecting well information. The loss of information in the next few minutes confirms

this viewpoint. Drill-pipe pressure was decreased at 9:00 p.m., but one minute later

pressure started to grow and lasted for seven minutes. From 9:08 p.m. to 9:14 p.m.,

the drill-pipe pressure continued to grow; and all this information was visible on the

both real-time data displays. BP reported that during this period no action was taken.

(BP, 2010,P41,Para.5) Therefore, all crewmembers missed this important

information, which could be referred to as information failure.

Leaders time schedule conflict is the other issues that may have contributed to the


34

information failure and blowout. Leaders in the Deepwater Horizon did not play a

good supervisory role. BOERME (2011,P.72-P.73) “the failure of BP’s well site

leaders…between April 19 and April 20 was a possible contributing cause of the

blowout”. According to the BOEMRE (2011, P. 99, Para.4) investigation there was a

lack of superintendence on the rig floor to monitor drilling activates during the

temporary abandonment procedure. Jimmy Harrell, the offshore installation manager,

and Miles Ezell, the senior tool-pusher and Kaluza were not on floor. Without

leaders, the crewmembers may have failure to obtain operational information; this

could also be considered as information failure.

4.3. Organizational level

BP did have several problems on the organization level, which could have caused

information failure. Graham, et.al. (2011, P.122, Para.3) said the fundamental

reasons for BP Deepwater Horizon at the organization level were poor management

and lack of communication.

4.3.1. Poor Management structure and information monitoring

Again, the reorganization on the Macondo Well gives impacted on the individual

sand group level, but the root cause of these problems was on the organization level.

According to the BOEMRE (2011, P.83, Para.3), the reorganization on the Macondo

Well did not have a “clear authority and reporting line”; especially between Guide

and Sims. Again, this could cause a lack of communication and information not

being shared, used and obtained. Moreover, BP failed to obtain information about

Deepwater Horizon crew delays in kick detection on March 8, 2010. As BP did not

investigate on this, ten of the eleven crews were still on duty on April 20. According

to the BOEMRE (2011, P.110, Para.1) that may have contributed to the blowout.

Also, BP failed to plays a positive role in auditing information, which caused

information failure. As mentioned above, Kaluza became the temporary leader, but

BP failed to verify whether he could do an adequate job or not. Also, he did not have


35

the “all access rights to pertinent information within BP’s own system” (BOEMRE,

2011, P.181, Para.2).

In addition, BP also failed to supervise the drilling activities, which could have

contributed to information failure about the kick detection, as Jimmy Harrell, Miles

Ezell and Kaluza were not on platform floor because of other arrangements during

the temporary abandonment procedure. Also both BP and Transocean failed to

provide instructional information to guide the tests during the well construction. BP

did not require rig crew to ask for second opinions when the reading data was

unexpected (Graham, et.al, P.119, Para.3).

BP also did not have “consistent and reliable risk-management processes—and thus

has been unable to meet its professed commitment to safety. BP’s safety lapses have

been chronic.” (Graham, et.al, P.218, Para.4). The BP investigation report pointed

out BP failed to conduct “a documented review and risk assessment” during the

cement job (BP, 2010,P.66, Para.1). On the April 20th, the risks during the drilling

were not correctly recognized and processed. Intra-group communication and that

between the cooperating companies both failed. Also, BP did not inform the crew of

the dangers on the Deepwater Horizon, and so failed to share and use information to

analyse risks in the Macondo Well project, contributiing to information failure.

Furthermore, BP’s poor management problems caused information failure in the

disaster response period. After the explosion, spillage was the major problem that the

responsible teams needed to deal with. In early May, BP tried to stop the spill

through active BOP. Unfortunately, Transocean spent ten days to realise that the

“stack’s plumbing is different from the diagram”. More seriously, this information

was a recording failure, which finally meant BP could not activate BOP. On April 5,

BP abandoned the plan (Graham, et.al, 2011, P.137, Para.2).


36

4.3.2. Failing of training

On the basis of the analysis in Section 4.1, the Deepwater Horizon rig crew lacked

the necessary ability in the operation because BP did not give rig crew the necessary

training, especially in relation to the kick detection and response ability to the

blowout emergency event. Moreover, BP failed to train its staff in how to use the

guidebook for solenoid value. CSB-V2 (2014, P.72, Para.1) indicated that

Transocean has “instructions for rebuilding Cameron Controls Solenoid Valve”,

which is used to guided employees when rebuilding and testing the solenoid. If

information in the instructions had been used properly, the crew in Deepwater

Horizon would recognise the miswiring of the solenoid value.

4.3.3. Poor information sharing and communication

The Macondo Well involved several different companies in to the project. But

different investigation reports noticed that, these cooperation companies lacked of

communication causing information failure in the Macondo Well project. The

Halliburton and BP lack of communication since well design. (BP,2010,P.68, Para.1).

The BOREME report (2011, P.46) noted that there was no information sharing about

the OptiCem model test results between BP and Transocean staff on the Deepwater

Horizon, which is used to predict the likelihood of gas flow. Meanwhile, BP also

failed to inform the drilling risk to other cooperation companies of the drilling risk

(BOREME, 2011, P.70, Para, 1).

Moreover, BOREME report (2011, P.45) pointed out the lack of information sharing

caused the incorrect information to be used in the OptiCem model includes: (1) The

model use the wrong pore pressure data. (2) The model used the wrong centralizer

information. Moreover, the model used seven centralizers, but the actual number of

centralizers installed on the Macondo Well was six. (3) The wrong density of base oil

was used, which was designed by the Halliburton itself; and (4) the model used the

wrong “bottle hole circulating temperature”.

These information failure not only caused the OptiCem model to used the


37

measurement data. The more serious problem was that BP adopted the OptiCem

model. If BP could audit and review the model assumption data, they could easy

have found out about the incorrect information. But BP did not pay attention to

analyzing the “gas flow potential issues”(BOREM,2011,P.58,Para.1).

In addition, the other evidence of lack of information sharing causing information

failure in Macondo Well was in cement job. Halliburton and BP were jointly

responsible for designing the parameter of cement work. During the cement job,

nitrified foam cement been select as a part of the cement work. The Halliburton did a

number of cement slurry tests. Graham, et.al. (2011,P.101,Para.3-5) showed two

form stable test had been completded by the Halliburton laboratory with the

estimated data of the Macondo Well condition, both of these test gave the same result,

which showed that the form cement design in the Macondo Well was not stable. On

April 13, the Halliburton conducted two more form cement tests with more actual

measurement information; the result was same as the pervious result; that is the form

cement was unstable in the well. But Halliburton did not report any form cement test

failed information to BP. And BP also did not review the information about the

stability of the form cement. Graham, et.al (2011,P.101,Para.7) also illustrated that

on April 18, Halliburton started the second test of form cement. On April 19,

Halliburton told the BP well leader and Brain Morel, a BP drilling engineer, that the

analysis was not complete,but BP ignored the information and continued the cement

work. (BOEMRE, 2011, P.43, Para 3).

BOEMRE (2011, P.183, Para.1) analysed the communication problems in the

Macando Well project. BP had its own information exchange plan, which included

BP having full authority over making decisions. To ensure information was

exchanged more efficiently during the drilling period, several different meetings

should have been conducted between Deepwater Horizon offshore leaders and

onshore staff in Houston. But there was no sign that drilling information had been

shared between offshore and onshore office, which could also have caused the

information failure.

Furthermore, information failure not only showed before the disaster in BP, but also

afterwards. CSB-V2 (2014, P.32,Para.2) mentioned, the purpose of collecting and


38

analysing the physical problems of the Deepwater Horizon; CSB requested BP to

provide “BOP performance data”, but BP did not give useful information to the

CSB investigation team.

Later, the national laboratories, Secretary Chu and his team offered to help BP find

out problems and give advice. The Graham, et.al (2011,P.149, Para.2) indicated that

BP did not proactively share information with these external organizations; BP only

shared information when they were required to. Furthermore, authority distribution

was not clear between BP and these external organizations, which affected

performance, as these teams needed to improve their own knowledge and

performance “before they know enough to challenge BP participate in high-level

decision-making”. BP did not establish good relations of cooperation with these

external partners, which caused the information failure during the aftermath

response.

4.3.4. Failure to use information and decision consequence

BOREM (2011,P.70) briefed clearly BP leaders made lots of decisions during the

drilling period, but most of these decisions were made on the information failure

conditions. Graham, et.al (P.96, Para.4) clearly pointed that the engineers decided to

use Long String casing in the Macondo Well. And according to the original designs,

16 or more centralizers are necessary to “screw securely into place between sections

of casing”. On April 1, BP’s supplier only purchased six centralizers. Halliburton

engineer Jesse Gagliano informed BP the well needed more than twenty-one

centralizers on April 15. But BP ignored this information, and only installed six

centralizers.

Actually, BP did order the fifteen additional centralizers; but these centralizers did

not arrive on time; therefore, Guide decided to install six centralizers. BP believed

these additional centralizers accessories could bring potential risk to the well but did

not evaluate the risk of do not use these centralizers. (Graham, et.al, 2011, P.116,

Para.2) In addition, Guide suggested that installing six centralizers could save 10

hours, compared twenty-one centralizers (BOEMER, 2011, P.48, Para.2).


39

BP did not effectively use the information to evaluate the oil spill volume, which led

to information failure and its responsible activities failure. Two days after the

explosion, BP estimated the Macondo Well oil spill involved 1,000 barrels every day;

Unified Command was received this information; and declared the information to the

public. On April 25, the BP response team indicated that their response activities did

not receive the expected effect. 3 days later, Unified Command raised the oil leaking

to 5,000 barrels (The Graham, et.al , P.133, Para.3). In the coming period, BP used

this leakage information as reference value to plan its responsible activities. During

May 6 to 8, BP planned to install “a large containment dome” to control the leakage;

but this plan was failed. According to Doug Suttles, “the BP’s chief operating office”,

the inaccurate estimation of the oil spill gave impact on the containment dome job

failure. Later, on May 18, a scientist estimated the leakage, which was around 50,000

barrels per day. In despite, but BP did not agree with this estimation. From May 27, a

team of scientists began to analyse and estimate the oil spill range. A few days later,

a unified opinion was agreed; they gave the lower limit of the spill range, which was

12,000 to 15,000 barrels. Later analysis insisted this lower limit range was an

“underestimate”. (Graham, et.al ,P.145-7).

4.3.5. Economic and time pressure

The Macondo Well project was under pressure from both financial and in terms of e

time schedule, as the cost of the project had excess the budget and the well

construction completion time was behind schedule.

On April 14, the cost of the drilling work in the Macondo Well is exceeded the

budget by $154.5 million, as the original budget was $96.16 million to $139.5

million (BOEMRE, 201, P.26, Para.3). Actually, the Macondo Well project was not

only facing budgetary pressure, the leaders also needed to try to save costs. Since

2008, BP had committed to decreasing costs, with the slogan “every dollar counts”.

BP used the ability to decrease cost as a part of performance evaluation. This may

directly have caused some of decisions were made base on the consideration of

decrease cost, which caused information failure an increased risk of the blowout on

April 20 (BOEMRE, 2011, P.184, Para.2-5).


40

Moreover, with the aim of saving money, BP pumped a low volume of cement in the

well, which may have increase the risk of blowout. (Graham, et.al, 2011,P.118,Para.2)

The example for this is that Graham, et.al (2011,P.117, Para.4) indicated that this

temporary abandonment procedure was not necessary. The reason for BP took this

step was because they wanted to bring a smaller and cheaper rig to subsequent

production in the Macondo. The Graham, et.al (2011,P.103, Para.1), in addition,

CSB-V2 (2014, P.13, Para.2) indicated that the Macondo Well started to leak after

this process.

Meanwhile, the Macando Well project was behind the schedule. BP projected The

Deepwater Horizon construction plan to finished by March 8, 2010; therefore. (CSB,

2014, P.78, Para.1)

4.4. Environmental level

Graham, et.al (2011, P.122, Para.2) believed that the root causes of the BP disaster

were “failures in industry and government”. The major problem was a lack of

regulation.

4.4.1. Lack of regulation

“Federal authorities lacked regulations covering some of the most critical decisions

made on the Deepwater Horizon”; which may have affect the information failure and

increase the chance of a blowout (Graham, et.al, P.225, Para.6). There were no

regulations or standards requiring BP to conduct the negative pressure test. When the

group finished the cement work, the US regulators required the cementing team to do

the positive pressure test, which could check that there was no leak in the well. On

April 20 between 10:30 to 12:30, the positive pressure test was completed and the

conclusion drawn was the well passed the test. Nonetheless, the test could not test

leaks at the bottom of the well. To compensate, a negative pressure test could use to

test the “integrity of the bottom-hole cement” (CSB-V1, 2014, P.27, Para.2). The

Graham, et.al, (2011,P.108, Para.1) pointed out that the crew got the unexpected

pressure reading several times. Despite of this, the crew did not make any adjustment


41

to this information, but directly determined the well “passed” the final negative

pressure test.

Furthermore, information failure issues also existed in the Minerals Management

Service (MMS), as MMS failed to regulate to Deepwater Horizon, which increased

the risks of the well disaster. MMS had four different functions in the offshore

drilling industry; including “offshore leasing, revenue collection and auditing,

permitting and operational safety, and environmental protection”. Graham,

et.al ,(2011, P.73, Para.1) demonstrated that the offshore industry change fast and the

technology is developed quickly, and MMS did not keep up with the development

and lacked this information. Finally, regulation developments were behind the

industry change; which could be considered as information failure, in the MMS ,

which triggered the information failure in Deepwater Horizon.

Graham, et.al, (2011, P.83-84) says that The Oil Pollution Act of 1990 requests “all

owners or operators of offshore oil-handling, storage, or transportation facilities to

prepare Oil Spill Response Plans”. This regulation has detailed rules on the

information of oil spill preventon and treatment plans, with the aim of protecting the

environment and ecological system. But in the Macondo project, BP failed to

develop an appropriated plan. The report pointed out that the half of BP’s appropriate

plan information was directly copied from NOAA online pages without any review

of whether this was suitable for the Gulf of Mexico or not. This led to the BP oil spill

treatment plan differing fundamentally from the actual situation in the Gulf of

Mexico. Furthermore, the MMS did not analyse or review detailed BP’s oil spill

prevention and treatment plan. This situation illustrated that both BP and MMS

contributed to information failure on Deepwater Horizon.

4.5. Summary

Gramham (2011,P.115, Para.1) emphasized that the BP disaster was not caused by a

single problem, but was created by a series of cumulative action. It is hard to find out

determine, which action or inaction caused the disaster. The factors that caused

information failure in the Deepwater Horizon can be summarized in terms of the four

different levels as mentioned earlier:


42

(1) At the individual level, physical and psychology issues caused the information

failure or wrong decision, which increased the risk of disaster.

(2) At the group level, the major problem was that interpersonal relationship caused

information failure; which could also triggered information failure issues at the

individual level.

(3) At the organization level, information failure was triggered by external and

internal factors. BP’s internal problems caused information failure. The problems

including management problems, leadership problem, lack of training

crewmembers and contribution pressure. All of these factors led to different

information failures in the organization and were reflected at the group level.

(4) At the environment level, a lack of regulations was the major external reasons

that caused information failure and increased risks of the blowout. Both of

Federal authorities and MMS lacked of regulations to guide BP drilling activities

at the Macondo Well. In these situations, environmental level problems could be

considered as external factors to information failure at the organization level,

which finally caused information failure at deepwater Horzion.

4.6.Post-disaster improvements

The US offshore industry has learned from the Macondo disaster. API Bulletin 97 has

been created to guideline information share in the offshore drilling activities, which

aims to mitigate risks. Indeed, the bulletin emphasized that when planning well

construction and other related activities, risks need to be recognized and some plan

needs to be set up with the aim of reduce risks. Moreover, all of these plans need to

be shared and updated with all relevant personnel (CSB-V2, 2014, P.84, Para.1).


43

Chapter 5: Discussion and lessons learned from the BP disaster

In order to better relate the theories, combining Wilson’s (1989) model and

Karunakaran and Reddy’s (2012) model, the discussion of the BP disaster will be

divided into four different levels. There are individual group, organization and

environment levels.

5.1. Individual level

The major reasons at this level that added to information failure and disaster can be

concluded through two different aspects use the Wilson’s theory (1997). The first is

the psychological level. During the well construction period, Guide played the

leading role on Deepwater Horizon, but he had strong subjectivity with a dictatorial

manner. Guide does not like to listen to others, which could be considered as the

selective exposure. In the BP disaster Guide received useful information several

times, but he did not effectively use the information. Combine the theory from

Yzerbyt & Leyens’s (1991); Case, Andrews, Johnson & Allard (2005) and Case

(2012), this external information was not consistent with Guide’s beliefs. Therefore,

the useful information that Guide received did not change his decision, which caused

the information fail of using. Therefore, Guide’s personal psychology issues caused

information failure. And increase risk of blowout.

Moreover, another reason that BP leaders failed to use information effectively is the

leaders believed to strongly in themselves and downplayed the risk. Cement

evaluation can test the integrity of a cement job; Guide and other leaders decided not

conduct the test, because they believed the cement job had been successful. In

addition, kick detection is an important monitoring activity during well construction,

in order to prevent blowout. In the Macondo Well, the kick signal was found by

different rig crewmembers, but Lee Lambert believed that this was a “bladder

effect”. Both of these two examples can be considered as the BP leaders not seeking

for external information but simply concluding themselves, which may mean

Lambert did seek information from their internal knowledge but they failed to

provide it. Also, this man-made disaster illustrates that, in some institutions, people


44

may minimize risk; this is also the reason why leaders made the wrong decision.

Both Guide and Lambert believed there was no risk to blowout in the Macondo Well

project. Information failure occurred, as they failed to seek information to recognize

risk. Chapanis and Chapanis, (1964), Krohne (1989) and Cooper (2007) defined this

as “cognitive avoidance”. Leaders information avoidance increased the risk of

blowout.

The other aspect at the individual level is that crewmembers in the rig did not have

enough ability and knowledge for their position. Lack of knowledge could inhibit

individual’s information seeking behaviour (Bettman & Park,1980). These behaviour

barriers can cause information failure. Moreover, this theory also matches the

Turner’s man-made disaster model, where Turner believes individual lack of

knowledge can cause disasters. On the Deepwater Horizon, the reorganization and

position changes led to the crew having low-level knowledge on their new position.

This could directly have caused the crew to miss important information or not seek

further information to support their doubts and decision making (Radeck and Jaccard,

1995) This could be considered as information failure.

In the BP disaster, Kaluza instead of Sepulvado become the temporary leader of the

Macondo Well site, but he did not have enough working experience on Deepwater

Horizon; which caused information failure as he did not correctly recognized the

danger or seek further information support. In addition, as just mentioned, there was

the well site leader, Guide’s autocratic style and penchant for confrontation. In this

situation, even Kaluza recognized the important information and try to avoid

information failure, as he may have not ability to give any change. The evidence for

this is Kaluza realized the “low circulating pressure”, but Guide ignored this

information. Moreover, information failure directly caused Anderson and Curtis’s

response activities failure.


45

5.2. Group level

Reorganization not only meant the Deepwater Horizon crew had a lack of knowledge

in their new position, but also caused the interpersonal conflicts between group

members (Wilson, 1997). The most serious conflicts were between two leaders,

Guide and Sims. As mentioned above, Guide had strong cognitive avoidance. After

reorganization, Sims had less authority to challenge Guide’s decision. Guide was too

confident about the safety issues on the Macando Well. Combining Turner and

Pidgeon (1997), Wilson (1997) and Macintosh-murray and Choo (2002) theories, we

can say that the conflicts between the two leaders can triggered a chain reaction of

the problems and finally caused the information failure. The most direct reaction was

that they may avoided contact with each, which could cause the communication

problems. As a result, information had not been effectively shared between them. In

some situations, information sharing was successful, but was not used effectively to

make decision. Negative, emotion can inhibit information seeking behaviour. This

chain reaction could make the information fail and finally cause the disaster. The

events that happened on March 8 could prove this analysis. On that day, the crew

was delay for 30 minutes when it detected the kic, which should be considered as the

warning signal for the blowout. Both of Sims and Guide received this information

neither took effective action or sought further information. This could seen as the

evidence of interpersonal relationship triggering information failure.

According to Karunakaran and Reddy (2012), unclear work boundaries and

conflicting time schedule can inhibit information seeking behaviour, which led to

information failure in the BP disaster. From Section 4.2.2, on the data of the accident,

the BP assigned different staff to the rig in response to the kick detection, this could

have resulted in these individuals believing other people would respond to the

detection and eventually caused a lax situation. Graham, et.al, (2011) noted that no

one collected information about kicks, In addition, leaders time schedule conflicts

also give impacted on the rig crew’s information-seeking behaviour. During the

temporary abandonment procedure, three monitors were not in their positions

because of other arrangements. Generally, supervisors have experience and

knowledge; therefore, they could be seen as the source of information. On the day of


46

the disaster, no monitors in their position could result in the operation crew members

failing to obtain the information. According to Wilson (1997) information failure is

happens more easily when supervisors are not there, as they can be the source of

information.

5.3. Organization level

5.3.1. Poor Management

The BP disaster exposed the organization’s internal problems and related information

failure. Obviously, BP failed in its management of the Macondo Well project. Again,

as analysed above, the reorganization of the well site resulted in information failure

on the Deepwater Horizon. According to Karunakaran and Reddy (2012), the new

structure inhibited the crew information behavior and caused information failure.

Other aspects showed the BP management problem was BP’s fails to obtain

information to support its decisions. BP did not audit Kaluza’s information about

whether he could qualify as temporary leader or not, but directly made the decision

to appoint Kaluza. Another unexpected thing about Kaluza is that BP did not give

him any access to obtain information from BP’s system, so he could not obtain the

necessary information during the well construction period. BP’s behaviour meant it

and Kaluza made decision under uncertainty, causing information failure. According

to Tversky and Kahneman (1974) and Arkes (1991), “judgment under uncertain”

may give high value to the organization. But in BP, this kind of judgment increased

the risks of information failure and disaster.

Moreover, BP also failed in its duty of supervision. On March 8 and April 20, kick

signals were detected, but BP failed to require further information on the safety

situation. BP’s conflicts time schedule, three major monitors were not on their

position. Moreover, BP also failed of training its crew to get necessary knowledge to

competent for their position. In addition, BP not just failed in their daily management,

but also in risk management, as well failing to measure the risks of the temporary

abandonment process. Another problem was that BP could not find the design


47

drawing record information for the Macondo Well during the disaster response

period. Again, these issues caused information failure in BP.

BP also undertook the “every dollar counts” program, resulting from the

organization’s cultural trend to save costs but not concentrate on safety issue. Wilson

(1997) analyzed this as environmental barriers, but in the BP case, the economic

pressure was internal. Macintosh-murray and Choo (2002) showed that worker not

follow existing regulations could cause a disaster. BP lacked of internal regulation

for guiding operation activities. In the BP disaster case, all of these problems

contributed to the disaster.

5.3.2. Lack of information sharing

Dawes (1996) and Sonnenwald (2006) explained information sharing can affect by

information behavior. In BP, information sharing barriers and communication

problems gave great impact to information failures and finally caused a disaster.

Followed by Ibrahim and Allen’s (2012) theory, information sharing between

cooperating companies could be hard. BP did not proactively share information with

its cooperating parties; either before the disaster or after the disaster.

Ibrahim and Allen (2012); Bharosa, Lee and Janseen (2009) and Turner and Pidgeon

(1997)’s opinion about lack of information sharing and communication could cause

information failure. This has reflected in the BP disaster. In the BP disaster, lack of

information sharing caused Halliburton fail to use the correct information to do the

OptiCem model measurement. BP did adopt this model to construct the cement job.

Unfortunately, BP, as a fully experienced offshore industry leader, did not recognize

incorrect measurement information in the model. This may be the combined action of

two instances of Halliburton and BP lack of communication. Later, during the

cement job construction period, Halliburton did not inform BP cement stable tests

had failed. Halliburton told BP the last cement test was not finished, but BP ignored

this information, and conducted their own cement job. All of above information

barriers caused information failure during cement job, and finally caused the cement

job to fail, which increased the risk of blowout. What is surprising is that after the


48

disaster, BP still lacked of the motivation to prove information to formal

investigation organizations and response teams.

Information may still lack of use after information transformed; which could be seen

as information failure. For example, in the BP disaster having only instead six

centralizers increased the risk of blowout. Different reports made clear that

Halliburton suggested the BP Macondo Well needed to have at least twenty-one

centralizers installed to keep the long string in the centre, but BP did not accept this

recommendation, through this was later repudiated. Combining Turner and Pidgeon’s

(1997) idea of “discrepant events”, and Choo (2008) and Turner’s man-made

disaster model, the reasons for BP’s failure to accept the recommendations can be

considered in terms of the from following aspects. The first one is the complex

situation, which caused BP to decide to ignore the recommendation, as the

centralizers did not arrive on time, and BP’s leader believed six centralizers was

enough to ensure the safety. The second aspect is the organization did not like to

adopt recommendations from other companies. The third aspect could be considered

the cost and the time pressures of the well construction. Moreover, Wilson (2010)

defined that leadership can also impact on the information sharing activities. Guide’s

personality pushed the failure of adopted external recommendation. Moreover, after

the disaster, BP still did not accept the external scientist’s measurement of leakage to

plan the emergency response activities.

An interesting pointed has been found out in this research. According to Goffman

(1971); Mon (2005); Thatcher, Vasconcelos and Ellis (2015), after the disaster, the

organization wanted to create a positive image to the public, as profitable enterprises

need to do to maintain public trust and loyalty; But the BP disaster response

activities failure to achieve this.

5.4.Environmental level

According to Wilson (1997), the offshore location of the Deepwater Horizon could

have impacted information failure.; as the location of the rig could have made it hard

for the crew members to seek information to support their daily work.


49

In addition, there was a lack of industry and U.S. government regulation to supervise

the offshore drilling industry. There was no regulation to require BP to conduct the

negative pressure test on the cement job, which increased the risk of a disaster.

Furthermore, MMS did not have enough information to update the regulations. Also

it did not play a supervision role in the BP disaster.

5.5.Lessons Learned from the BP disaster

The BP disaster is an example of how information behavior causes information

failure. To avoid other similar disasters happening again, lessons must be learned.

First, to avoid individual level information barriers, the cognitive biases need to be

avoided. In this disaster, Guide had strong cognitive avoidance, and played an

important role in the decision-making on the rig. Guide’s cognitive bias gave

negative effects to his information behavior and caused information failure. This

increased the risk of the disaster. To avoid leaders “cognitive heuristics and biases”;

Choo (2008) gives two methods to increase “cognitive alertness”. First, different

methods or models could be used to analyse the problem. Second, avoidance of

single individuals holding all decision-making authority, and encouraging people in

such roles to seek more professional advice in vital. Moreover, according to

Macintosh-murray and Choo (2002) minimize risk could cause disaster. This has

been confirmed by the BP disaster. To avoid this, risk analysis is the foremost

element that individuals need to consider when making decisions. Indeed, CRM

training can help organization decrease the risk of disaster. (Mearns, Flin,

O’Connor,2001)

An interpersonal relationship conflict between Guide and Sims was the most serious

problem of the group level barriers, which increased the risk of disaster. BP holds all

authority for making decisions on the Macondo Well project. This increased the risk

of disaster. Choo (2008) believes that to prevent disaster at the group level, the

authorities need to distribute information equally to each group involving. This could

encourage information sharing between groups. Also, leaders need to think seriously


50

about group member’s opinions. The negative example in the BP disaster is Guide’s

dictatorial manner.

At the organization level, BP did not pay attention to the potential risks during

offshore drilling activities. Graham, et.al (2011) summarized the previous incidents

involving BP. Despite, the Macondo Well disaster, BP still takes risk in offshore

drilling. One lesson to organizations is that they need to learn from previous failures

and risks cannot be minimized. To keep daily production activities safe,

organizations need to inform staff of all risks during operations, to avoid information

failure. BP failed to informs its crewmembers or its cooperating companies of

drilling risks. Initial response activities needed to be correct when the emergency

situation happened, but BP failed to have an emergency response (Choo, 2008) and

(Masn, 2004). Again, Guide and Kaluza did not have enough knowledge to perform

the duties of leader required on the rig, so BPs failure to emplpy sufficed experiences

leaders also contribute to information failure in Deepwater Horizon. From the BP

case we know that organizations need to promote people who have enough

knowledgeable. Furthermore, BP failed to adopt Hallibuton’s advices, which caused

the centralizers’ installation failure. So the organization also needs to adopt advices

from external partners to avoid information failure.

At environmental level, as discussed in Section 4.6; the U.S. regulation were

improved after the disaster.

Chapter 6: Conclusion

6.1. Contribution to knowledge

The major aim of this research was to identify how information behavior barriers

impacted on information failures in the BP disaster. In this research four different

levels of information behaviour barriers were found and analyzed in detail.

Obviously, information behaviour barriers significantly affected information failure

and finally caused the BP disaster. To better understand the results of this research,

this section will summarize the research achievements through redefining the

research objectives.


51

The first objective was to indentify the reasons that caused that BP disaster, which

have been shown to be the cumulative outcome of many different factors, as

following:

(1) BP adopted the Halliburton OptiCem model, which used the wrong information

for key measurements.

(2) BP failed to install enough centralizers to keep the casing in center of the well;

(3) BP failed to complete the cement job and conduct the negative test;

(4) BP failed to detect kick during temporary the abandonment process;

(5) BP failed to provided emergency response activities after the blowout;

(6) BP failed to take corrective actions to stop oil spills.

The second objective was to identify the key actors in the disaster. All personnel and

organizations involved in Macondo Well project made different degree of

contribution to the disaster. Indeed, Guide could be considered as the key actor that

had the most impact because he was is the well site leader.

The third objective was to develop the interrelation framework of information

behavior and information failure. Here, information behaviour barriers existed in the

whole process, contributing to the disaster. These barriers caused information

failures directly and can be divided into four types:

(1) Environmental level factors can impact to the information behavior and involves

the broadest range of barriers. In the BP disaster, the offshore location inhibited

information seeking behaviour, which caused information failure. Also, offshore

industry practices and lack of government regulations increased the risks of the

BP disaster.

(2) Organization level barriers were nested into environment level barriers; therefore,

the organization level was the second broadest level. Organization level barriers

impact most on information failure. Enterprise interior factors inhibited

information seeking, sharing and using behaviour. Indeed, poor management,

lack of staff training, and a lack of communication and information sharing

caused the internal information system to fail.


52

(3) Group level barriers were triggered by reorganization in the rig; this caused

interpersonal conflicts, which raised information-sharing and -seeking behaviour

barriers.

(4) Interpersonal conflicts triggered their psychological problems, which belonged to

individual level barriers. This is the narrowest level of information behaviour

barriers. The bad emotion caused information failure. Also, strong cognitive

avoidance can increase the risk of information failure. Furthermore,

crewmembers’ knowledge levels can affect their information-seeking behavior.

Lack of this behaviour caused information to not be effectively obtained, which

can cause information failure.

The fourth objective was to identify how information failure could cause disasters.

From this research, a conclusion can be drawn that information failure cannot

directly cause a disaster, but can lead to wrong decisions being made out by

organizations or leaders which can cumulatively caused a disaster.

The fifth objective was to give recommendations to BP and other high-risk

organizations about how to avoid information failure and disasters. The BP disaster

gives a significant lesson to itself and other organizations, which organizations need

to try to avoid information behaviour barriers at individual, group and organization

levels.

6.2. Research limitation

Although this research has achieved the research aims, but limitations still exist. First,

the researcher’s personal ability limitations may have influenced the research. In this

research, five different investigation reports were adopted, totalling more than 1,000

pages. Researcher subjectively selected the relevant information. Also, the limitation

of dissertation length has impacted on for information selection. Therefore, it may be

that some relevant information has been missed.

Secondly, the source limitation may exist in this research. This research is desk

research; with the aim of ensuring accreted information has been adapted to analysis;


53

the source of evidence is five different reports from different investigation teams.

Unfortunately, only three reports provide information related to this research. Also,

during the research, it was found out that these investigation teams or organizations

were not completely independent. A part of the information was shared betweent

them. Therefore, the weakness of desk research is highlighted. There may be bias or

hidden information during the previous investigation, but the desk researcher cannot

uncover this.

Third, theory support was limited by the scope of this research. Information behavior

has been widely studied. The relevant theories will be more than selected in this

research. Therefore, theories support existing limitations.

6.3.Future research

In the future research more detailed information selection could be conducted with

the researcher’s personal ability improvement. And, if future research does not have

time and word count limitations, more relevant information could be selected to give

a deeper cause-consequence analysis of the BP disaster. It is impossible to

re-investigate the BP disaster sorely based on a personal ability; therefore, more

sources and information fro previous disasters could be selected to summarize BP

internal information barriers, as BP had several different explosions before the

Macodo disaster, including the 1965 sea gem offshore oil disaster; and the 2005

Texas City refinery disaster, et.ac. Also, more relevant theories not mentioned in this

research could be adapted to further research; for instance, organizational culture

may have affected BP’s emergency response information behaviour. Above all, a

more comprehensive framework of information behaviour impacts on the

information failure in the BP disaster could be built up in future research.


54

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Appendices

Appendix A-Chronology of the accident


63


64


65


66


67

＊Tables taken from BP Deepwater Horizon Accident Investigation Report (2010),P.22-27


68

Appendix B-Access to dissertation form

Information School.

Access to Dissertation

A Dissertation submitted to the University may be held by the Department (or School) within which the Dissertation was undertaken and made available for borrowing or consultation in accordance with University Regulations.

Requests for the loan of dissertations may be received from libraries in the UK and overseas. The Department may also receive requests from other organisations, as well as individuals. The conservation of the original dissertation is better assured if the Department and/or Library can fulfill such requests by sending a copy. The Department may also make your dissertation available via its web pages.

In certain cases where confidentiality of information is concerned, if either the author or the supervisor so requests, the Department will withhold the dissertation from loan or consultation for the period specified below. Where no such restriction is in force, the Department may also deposit the Dissertation in the University of Sheffield Library.

To be completed by the Author – Select (a) or (b) by placing a tick in the appropriate box

If you are willing to give permission for the Information School to make your dissertation available in these ways, please complete the following: ✔ (a) Subject to the General Regulation on Intellectual Property, I, the author,

agree to this dissertation being made immediately available through the Department and/or University Library for consultation, and for the Department and/or Library to reproduce this dissertation in whole or part in order to supply single copies for the purpose of research or private study

(b) Subject to the General Regulation on Intellectual Property, I, the author, request that this dissertation be withheld from loan, consultation or reproduction for a period of [ ] years from the date of its submission. Subsequent to this period, I agree to this dissertation being made available through the Department and/or University Library for consultation, and for the Department and/or Library to reproduce this dissertation in whole or part in order to supply single copies for the purpose of research or private study

Name Wei Wu

Department : Information School

Signed Wei Wu Date: 29/08/2015

To be completed by the Supervisor – Select (a) or (b) by placing a tick in the appropriate box

(a) I, the supervisor, agree to this dissertation being made immediately available through the Department and/or University Library for loan or consultation, subject to any special restrictions (*) agreed with external organisations as part of a collaborative project.

*Special restrictions

(b) I, the supervisor, request that this dissertation be withheld from loan,


69

consultation or reproduction for a period of [ ] years from the date of its submission. Subsequent to this period, I, agree to this dissertation being made available through the Department and/or University Library for loan or consultation, subject to any special restrictions (*) agreed with external organisations as part of a collaborative project

Name

Department

Signed Date THIS SHEET MUST BE SUBMITTED WITH DISSERTATIONS BY DEPARTMENTAL REQUIREMENTS.

Documents

Information School - University of Sheffielddagda.shef.ac.uk/dispub/dissertations/2014-15/External/... · 2015. 11. 19. · others were injured”(BP,2010,P.9) After the explosion,