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Information School
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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,
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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
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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
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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.
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(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
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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.
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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
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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
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“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.
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(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
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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).
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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.
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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
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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
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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).
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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
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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
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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).
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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).
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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
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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:
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(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).
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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
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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.
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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
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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
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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
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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.
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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
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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.
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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.
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(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;
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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.
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54
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Appendices
Appendix A-Chronology of the accident
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*Tables taken from BP Deepwater Horizon Accident Investigation Report (2010),P.22-27
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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,
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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.