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Information School
Dissertation COVER SHEET (TURNITIN)
Module Code: INF6000 Dissertation (GRADUATE YEAR 2014~15)
Registration Number 140135310
Family Name Angoura First Name Stavroula
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The Challenger and Columbia space shuttle accidents: a comparative
research on the impact of information behaviour on information failure.
A study submitted in partial fulfilment
of the requirements for the degree of
Information Management.
at
THE UNIVERSITY OF SHEFFIELD
by
Stavroula Angoura
September 2015
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Abstract
Background: Research in information behaviour has focused on the information-
seeking processes, whereas research concerning information failure has focused on
information systems. Less attention, however, has been paid to the relationship
between information behaviours and organisational culture and its impact on
information failure
Aims: This dissertation aims at investigating the impact that information behaviours
have on information failure and the extent to which organisational culture influences
the development of such behaviours. Τhe Challenger and Columbia space shuttles’
disasters are used as cases studies and NASA constitutes the organisational context
in which the above aims are examined.
Methods: The methodology employed in this research is qualitative interpretive and
the approach inductive using thematic analysis. Due to travel and access limitations
desk research was conducted. NASA’s official reports on the Challenger and
Columbia space shuttles’ disasters were chosen to be analysed as they provide
diverse aspects of a complex organisation during a 17-year time frame.
Results: Through the analysis of the official reports three different themes were
developed, namely NASA’s culture, pressures and communication and decision-
making. The findings revealed that the agency’s culture was so strong and resistant
to change that during the years the image and a myth of an invincible organisation
had been established. This led to the development of political and production
pressures, which in turn affected the communication and decision-making. As a
consequence behaviours of information avoidance and escalation of the commitment
to launching were evolved allowing concerns about safety to be overlooked. These
behaviours were detected during both disasters. This indicates an interrelationship
between organisational culture and information behaviours which leads to
information failure.
Conclusions: It is concluded that information behaviours were a major factor in both
disasters. These behaviours, influenced by the agency’s strong culture as well as
political and production pressures, created by an escalation of commitment to the
image and myth surrounding NASA and its resistance to change, resulted in flawed
communication and decision-making and eventually in information failure. Further
research, could lead to a more comprehensive understanding of the relationship
between organisational culture and information behaviours and the impact it has on
information failure.
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Contents
Abstract…………………………………………………………………………….....3
Acknowledgements.......................................................................................................5
1. Introduction...............................................................................................................6
1.1. Aims.......................................................................................................................6
1.2. Objectives..............................................................................................................6
1.3. The disasters of Challenger and Columbia............................................................7
2. Literature review…………………………………………………...........................8
2.1. Background............................................................................................................8
2.2. Information behaviour…………………………………………………………...9
2.3. Information behaviour theories …………...........................................................10
2.3.1. Affective Load Theory......................................................................................10
2.3.2. Face Threat Theory...........................................................................................12
2.3.3. Escalation Theory.............................................................................................13
2.4. Information failure.................................................…………………..................15
2.5. Decision-making and organisational learning.……......…..................................16
2.6. Organisational culture..........................................................................................16
2.7. Conclusion...........................................................................................................17
3. Methodology………..……………………….....................……………................19
3.1. Research methodology…………………………….............................................19
3.2. Research design…………………………………………..........….....................20
3.3. Data analysis…………………………………………………........………........21
3.4. Ethical aspects......................................................................................................24
4. Findings………………………......................................................……................25
4.1. NASA’s culture ……………….………………..................................................25
4.2. Pressures..............................................................................................................32
4.3 Decision-making...................................................................................................38
4.4. Conclusion...........................................................................................................43
5. Discussion……………………………………………………...............................45
5.1. Framework...........................................................................................................45
6. Conclusion…………………………………………………..................................51
6.1. Contribution to knowledge.......………….....……………..................................51
6.2. Limitations of the study.......................................................................................52
6.3. Further research...................................................................................................53
7. References………………………………………………………………………...54
8. Appendices ……………………………………………………………………….61
Appendix 1 Themes....................................................................................................61
Appendix 2 Research classification............................................................................62
Appendix 3 Definitions of foam-loss events classification........................................63
Appendix 4 Missed opportunities...............................................................................64
Access to Dissertation.................................................................................................65
Address & first employment destination details.........................................................66
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Acknowledgements
I would like to thank Dr Ana CristinaVasconcelos for her support and guidance as
well as all the staff at the Information School for the excellent services and help they
provided throughout the course.
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1. Introduction
1.1. Aims
The aim of this research is to address the impact that information behaviour has on
information failure, using the Challenger and Columbia space shuttle’s disasters as
cases studies. Those two events were chosen because they represent significant
organisational failures, which marked NASA’s history and became the subject of
several debates concerning the agency’s culture and the way in which it operates and
treats vital information. Rudestam and Newton (2015), suggest that the term case
study indicates a focus on a specific incident, organisational body or activity that
took place. Similarly, Punch (2005) states that a case study can be defined as ″a
research strategy which focuses on the in-depth, holistic and in-context study of one
or more cases″ (p. 289).
Furthermore, this research seeks to investigate and reveal potential patterns and
similarities between the information behaviours that were adopted during the two
incidents and the impact they had on the final outcomes. There is a great deal of
literature concerning the Challenger and Columbia’s disasters. Past research has
focused on different aspects of both the agency and those incidents. Several authors
investigated them in detail and highlighted their causes (McConnell’s, 1987; Trento,
1987; Jensen, 1996; Vaughan, 1996; Cabbage & Harwood, 2004), whereas others
dwelled on the political consequences they had as well as on the agency’s strengths
and weaknesses (Sietzen & Cowling, 2004; McCurdy, 1990).
1.2. Objectives
In addition to the above aims, the research has several objectives, which are:
To identify the actors that were involved in the Challenger and Columbia
space shuttles disasters as well as the role they played in them.
To identify the information behaviours that were adopted by the actors of the
two incidents and indicate potential similarities and differences.
To address the relationship between the information behaviours and the
culture of the organisation.
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To address the extent to which such information behaviours led to a decision-
making trajectory that affected the outcome of the disasters.
1.3. The disasters of Challenger and Columbia
In 1986, January 28th
at 11:39:13 EST, the flight 51-L of Challenger ended suddenly
entraining its crew in death; it exploded just 73 seconds after launch. The cause of
this disaster was ″a failure in the joint between the two lower segments of the right
Solid Rocket Motor. The specific failure was the destruction of the seals that are
intended to prevent hot gases from leaking through the joint during the propellant
burn of the rocket motor″ (Presidential Commission Report, 1986, p.40). Several
concerns regarding the low temperature and its impact on the O-rings as well as
objections against launching were raised by Thiokol’s engineers, NASA’s contractor
However, those were all overruled and Challenger was launched. In its aftermath, a
Presidential Commission was created so as to investigate the reasons it happened and
made recommendations for changes in order for future accidents to be avoided.
Nevertheless, in 2003, February 1st, fifteen years later, NASA experienced another
tragic accident; the Columbia space shuttle, disintegrated while re-entering earth.
During its launch, a piece of foam insulation debris hit and damaged the orbiter’s left
wing. This ″allowed superheated air to penetrate the leading-edge insulation and
progressively melt the aluminium structure of the left wing, resulting in a weakening
of the structure until increasing aerodynamic forces caused loss of control, failure of
the wing, and breakup of the orbiter″ (CAIB, 2003, p.49). The Columbia Accident
Investigation Board was brought together to investigate the cause of the disaster and
concluded that although several of the Presidential Commission’s recommendations
were followed, the two incidents bare similarities in terms of information
communication and processing.
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2. Literature review
2.1. Background
Given the aims of the study and research questions cited above, this chapter reviews
the literature in this topic area and identifies the most relevant sources. Past research
in information behaviour tends to focus on the information-seeking processes
followed by individuals, so as to satisfy the need for information acquisition in
regard to certain information tasks, and on how the acquired information fulfils the
emerged needs (Wilson, 2000). Conversely, research concerning information failure
usually focuses on information systems in order to identify the reasons that led to an
adverse outcome (Gauld, 2007). Less attention, however, has been paid to the
correlation between information behaviours and information failure at an
organisational level in terms of its impact on significant events (Thatcher,
Vasconcelos & Ellis, 2014).
Weick (1998) claims that after a disaster has occurred certain information behaviours
have been identified as contributing factors to the information failure of the incident.
Subsequently, several researchers have cited information failure as having an impact
on organisational disasters (Vaughan, 1996; Turner & Pigeon, 1997). More
specifically, studies have shown that although vital information was available to
decision-makers prior and during the course of a disaster, it was not properly utilised
or acted upon (Lei & Bui, 2000; Mahler & Hogan-Casamayou, 2009). Others suggest
that information behaviours are ingrained in the organisational culture and therefore
in the behavioural patterns, perceptions and beliefs of the individuals interacting with
it (Deltor, Choo, Bergeron & Heaton, 2006; Brown, 1998). Political and financial
barriers and pressures have also been found to affect information behaviour and
information failure within an organisation (Vaughan, 1996; Mahler & Hogan-
Casamayou, 2009).
Moreover, culture is considered to be a significant influencing factor of the way in
which an organisation operates and manages its information flow (Alvesson, 2002;
Brown, 1998). Relevant literature highlights the complexity and interrelation of
organisational culture with internal and external environments, and stresses the
importance of coherence and consistency of culture in order for an organisation to be
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efficient and able to achieve its goals. It is also considered to affect the way
individuals think and act and denotes that a person’s decisions and actions may have
an effect on the organisation as a whole (Brown, 1992)
There are, however, different perspectives on how culture is treated (Alvesson, 2002;
Brown, 1998). Organisational culture could be viewed as a metaphor. According to
this position, an organisation is seen as if it is a culture; it manifests individuals’
consciousness and permeates every aspect of an organisation, which can be
understood and represented in terms of its symbolic and ideal aspects (Alvesson,
2002). Subsequently, culture is viewed as the intellectual device that enables a
coherent understanding of an organisation in terms of its elements (Brown, 1998).
From another perspective, culture is seen as a variable, an objective reality measured
by certain phenomena and a set of behavioural and cognitive elements (Schein,
1985). It is viewed as a functional part of an organisation that holds all segments of
an organisation together. Accordingly, an organisation has rather than is a culture
(Alvesson, 2002).
2.2. Information behaviour
According to Wilson (2000), information behaviour is ″the totality of human
behaviour in relation to sources and channels of information, including both active
and passive information seeking, and information use″ (p. 49). Information seeking is
considered as an action that is prompted by a conscious purpose to aggregate
information from specific sources (Johnson, 2009). By active information-seeking,
Wilson (1997) refers to the occasions where a person proactively seeks information,
whereas passive information-seeking is the outcome of a search that results in the
retrieval of the relevant information by the seeker. Similarly, information use refers
to the acts, both physical and mental, intended to incorporate the acquired
information into an individual’s existing knowledge (Spink & Cole, 2006). Three
types of information behaviour have been identified: information-seeking,
information searching and information use. These behaviours are viewed as the result
of a secondary need, which is driven by the primary one to fulfil an activity or goal
(Wilson, 1997). It could be, thus, argued that this differentiation concedes the need
for information as a secondary and not as a basic one (Case, 2012).
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Grunig (1989) defines need as an inmost motivational state that facilitates actions
and thoughts. Atkin (1973), on the other hand, argues that a need is the outcome of a
perceived discrepancy between a person’s confidence about a certain situation and a
desirable goal. It is also suggested that a need may vary depending on its nature; it
may be contestable, in that it is different from a person’s ″wants″ and therefore
debatable; alternatively it may have a sense of necessity, in that individuals tend to
stress the degree of a need so as to ensure that everyone accepts a certain goal state
(Case, 2012). In addition, Wilson (1981) has acknowledged three types of
information needs; the physiological, cognitive and affective.
An individual’s information behaviour is affected by several barriers within their
environment. These might be personal, social and interpersonal, work related,
technology related, political or financial (Wilson, 1997). Personality and personal
attributes may affect information-seeking behaviour in terms of motivation. During
stressful circumstances, in their attempt to decrease the uncertainty that derives from
such situations individuals are likely to make use of strategies that affect their
information behaviour (Wilson, 1999). Similarly, the concept of cognitive
dissonance suggests that ″the existence of non-fitting relations among cognitions″
(Festinger, 1957, p. 3) has a significant impact on information-seeking. More
specifically, cognitions, that is any knowledge, opinion or belief about oneself and
one’s environment which are opposed to an individual’s knowing, lead to the
commencement of actions aiming at reducing dissonance (Festinger, 1957).
2.3. Information behaviour theories
Information behaviour is considered to be a major factor in information failures. The
motivational state that is created as a result of the desire to reduce uncertainty may
prompt the individual to avoid information (Johnson, 2009), or be selectively
exposed to it (Case, 2012). Such behaviours are predominant in information
behaviour theories, namely Affective Load, Face Threat and Escalation Theories.
2.3.1 Affective Load Theory
The theory of Affective Load suggests that ″through membership of cultural groups
people inherently develop learned affective norms which influence cognitive
strategies employed for information use″ (Thatcher, Vasconcelos & Ellis, 2014,
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p. 58). It provides a social-behavioural point of view in the context of information
behaviour. According to Nahl (2001), information searching behaviour can be
classified as an ordered sequence, in that a motive arises (affective behaviour); an
interpretation related to the motive is chosen (cognitive behaviour); and a decision
about the action to be taken is made (sensorimotor behaviour). More specifically,
individuals are motivated by a goal-directed behaviour to create and follow a strategy
towards reaching the desirable outcome (Nahl, 2004).
Affect can be viewed as the conscious or subconscious judging of situations or the
process of experiencing feelings (Norman, 2004). It is, also, inextricably connected
with emotions, the conscious realisation of affect (Norman, 2004), which in turn
have a significant impact on information use. Consequently, the affective
motivations that are produced through the individual’s perception of their needs, and
the context in which they interpret them, result in the creation of cognitive processes
(Julien & McKechnie, 2005).
The affective behaviour of an individual can begin, continue and terminate a
cognitive process depending on whether their affective state is negative or positive
and the affective motivation high or low. Thus, it is can be argued that if an
individual’s information behaviour is not supported by an affect of goal oriented
feeling, the behaviour cease and is replaced by a new one. Maintaining an ongoing
affective motivation is the key factor towards completing a task (Nahl, 2004).
Based on their affective motivations, it is observed that individuals tend to create
their unique norms and attributes regarding their information behaviour so as to
achieve a goal. This process results in the development of certain learned affective
norms (Julien & McKechnie, 2005). These norms are created in a social context to
which values can be added at any stage of the cognitive process. As a result, certain
information behaviours are strengthened and new norms are created. According to
Nahl (2005), when the levels of the affective load are high, individuals tend to
present disruptive emotional states such as frustration and pessimism. Conversely,
when affective load is low, individuals tend to employ better coping strategies and
develop positive emotional states as they are not faced with uncertainty and the
negative consequences it may have.
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Moreover, affect has an impact on organisational behaviour, as it influences the
whole cognitive process of those who work within it. Past research has shown that it
plays an important role in organisational decision-making as it influences
information sharing among individuals within an organisation, thereby affecting their
information behaviour and the organisation as a whole (Forgas & George, 2001).
2.3.2 Face Threat Theory
Face Threat Theory posits that people create a sense of self, a public image based on
the accepted social roles and attributes. An individual’s public image or ″face″ is,
then, developed in a social context and influenced by the perceptions of all members
within a social group. Information-seeking and sharing are also regarded as social
activities that take place through interaction, and during which all participants have a
socially defined role or face. The interaction itself is, in turn, framed by the
expectations, socially accepted attributes and roles of the participants. Any
information that disturbs that public image is treated as a threat and as a result is
either avoided, or ignored (Mon, 2005). Face Threat Theory also seems to bare
similarities with Goffman’s Face Theory, which focuses on the social interaction
through which individuals present themselves to the members of the society they are
part of. It also seeks to address the way in which experiences and actions are
organised based on the socially accepted attributes and norms (Goffman, 1974).
Furthermore, individuals have different expectations and they may change their point
of view in different occasions; the interactions might be observed in a different way
and this might result in the creation of certain behaviours and barriers (Thatcher,
Vasconcelos & Ellis, 2014). The consequence of these may be information
avoidance and selective exposure by ignoring or rejecting certain information
(Johnson, 2009).
Information avoidance can be defined as the behaviour that aims at preventing or
obstructing the acquisition of available and potentially discomforting information. As
an information activity, it may be either passive, in that individuals might fail to
complete the information seeking process at any stage, or active, in that a person
acknowledges the unwanted information and chooses to reject it. This behaviour may
also be temporary or permanent, in that one might decide to be engaged with the
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information at a later stage, or avoid it by all means (Sweeny, Melnyk, Miller &
Shepperd, 2010).
The loss of autonomy is an important motivation for avoiding information as well.
Being able to decide and act upon issues based on personal motivations and desires
rather than external variables and pressures, is considered to be an explicit form of
autonomy. Information may jeopardise autonomy, when individuals are forced to
adopt a behaviour which they object to. Consequently, if the acquisition of
information leads to unwanted and unpleasant behaviours, it is most likely to be
avoided or rejected (Howell & Shepperd, 2012).
Conversely, the selective exposure to information suggests that individuals seek what
is congruent with their existing knowledge, opinions and beliefs and choose to
dispose of information that is inconsistent (Smith, Fabrigar & Norris, 2008). When
information is inconsistent with existing beliefs or knowledge, it is likely that it will
be ignored and new information will be introduced. According to Case, Andrews,
Johnson and Allard (2005), if acquiring new information is seen as a cause of
experiencing extra mental or affective discomfort or dissonance, then this will be
avoided or ignored. It is not the information itself that individuals are threatened by,
but the ″cognitive, affective and behavioural consequences of learning the
information″ (Howell & Shepperd, 2012, p. 258).
2.3.3 Escalation Theory
Information behaviours such as information avoidance and selective exposure are
major factors of information failure and are considered to be closely related to
escalation theory (Thacher, 2013).
Escalation Theory is concerned with the escalation of commitment to a course of
action, and to what motivates the stakeholders who are involved in decision making
to persist on such a course, even if it is obvious that the outcome would be negative
(Drummond, 1999; Staw & Fox, 1997). Past research has found two pertinent points
of view related to the theory of escalation. One refers to the perspectives of the
decision-dilemma theorists and the other supports the social-psychological theorists.
The former group claims that escalation is a result of ″information poverty″ and
inadequate data and suggests that it is not possible to predict the outcome of a
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planned project, especially if the feedback is ambiguous and insufficient. They also
state that in some cases persistence on a course of action is sensible so as to give time
to the project to overcome difficulties (Goltz, 1992).
On the other hand, social-psychological theorists argue that escalation is a result of a
desire to avoid the consequences of a failure. More specifically, it is suggested that
personal responsibility for an adverse outcome is highly instrumental to escalation
(Brockner, 1992). In order to defend decisions previously made, decision-makers
tend to seek information that supports them. Conversely, if its acquisition forces
them to admit wrongdoing, it is ignored. Such inherent biased information processing
would result in developing a false view of the situation, in that the issues the
organisation is facing are temporary and the positive outcome is imminent
(Drummond, 1999).
When escalation occurs, it is observed that the process of decision-making is unlikely
to remain rational and objective. In situations, where an individual or organisations
escalate their commitment to a course of action, when the right decision would be to
abandon it, the result is a continuous cycle of escalation, in order to keep on the
course, increasing commitment of both resources and effort is required (Staw, 1981).
In many cases of escalation, the acquisition of information tends to be oriented
towards decreasing the negative outcomes of a situation as much as possible rather
than altering it (Thatcher, Vasconcelos & Ellis, 2014; Staw, 1981). The key
motivations behind the intensification of persistence in such occasions are self-
justification and refusal to recognise that a decision was the false one to make. ″Once
started, self-justification can lead to a self-perpetuating sequence of escalation
activities″ (Chakravorty, 2009, p.45). Accordingly, in order to justify their position,
the decision-makers seek information that supports their position and avoid others.
Consequently, any information that is not congruent with prior decisions would be
discarded or avoided. In addition, they would cognitively distort any adverse results
and would attempt to put the blame on external factors, instead of altering course
(Staw & Fox, 1978).
Furthermore, commitment may be escalated as a result of external pressures for
success, when failure is not an option (Staw, 1981). Therefore, outcome expectancy,
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which refers to the extent to which a desirable outcome can be controlled and
predicted, is seen as an influencing factor of escalation (Wong, 2005). In addition to
the expectations concerning the outcome of a situation, a culture in which risk
oriented behaviours are ingrained could also lead to intensification of commitment.
The level of risk related to a decision is likely to influence in a negative way the
outcome of a situation and lead to information failure (Thatcher, Vasconcelos &
Ellis, 2014).
2.4. Information failure
Information failure has been identified as contributing to organisational disasters and
accidents. Deficiency in capturing and interpreting information that could have
prevented an incident is seen as a reason for information failure and therefore a
disaster or accident (Maclntosh-Murray & Choo, 2002).
Shared thinking and practices within an organisation may obstruct the dissemination
of information concerning possible failures and hinder their effective deterrence. Its
absence or inefficient communication is also identified as a cause of information
failure (Westrum, 1992). Information disjunction may also hamper sense-making and
lead to the development of diverse interpretations of a set of information and thus
complicate an existing situation (Turner & Pigeon, 1997).
Furthermore, the tendency to make decisions based on inadequate or pre-existing
information, and to interpret it in a simplified way, creates collective erroneous
perceptions, which lead to negative outcomes (Weick, 1998). Similarly, collective
sense-making is influenced by an organisation’s culture and has an impact on
information failures, as they occur due to inefficient dissemination and
communication of information (Turner & Pigeon, 1997).
Nevertheless, there are several organisational features that contribute to failures. A
rigid organisational culture and its ingrained beliefs and norms bias members’ sense-
making. Organisational exclusivity also results in rejecting warnings about a
potential incident coming from ″outsiders″ (Turner & Pigeon, 1997). Furthermore,
difficulties in interpreting information may result in failure; the organisation may not
be able to retrieve the information needed, individuals might employ a negative
attitude when responding to issues; or fail in attending the information (Maclntosh-
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Murray & Choo, 2002). Moreover, individuals might not comply with rules or not be
able to cope with emergent hazard due to the lack of sufficient information
(Vaughan, 1996).
Weick (1998) suggests that a persistent effort to comprehend a situation might result
in ignoring distinctive information and in adopting a solution accepted by the
majority. In many occasions, such an activity creates ″blind-spots″ and leads to
information failure. Collective actions require simplified assumptions, which in turn
confine precautions and allow the accumulation of anomalies. Consequently, the
possibilities of undesired outcomes are gradually increasing.
2.5. Decision-making and organisational learning
Decision-making is a process that results in the activity of choosing and is subject to
various influences. It could be said that the information behaviour of escalation is a
prime example. When decision-makers are responsible for a choice that is likely to
fail, they stay on course by altering their beliefs and changing practices. Hence, they
escalate commitment to the decision due to biased updating of beliefs aiming at
supporting it (Biyalogorsky, Boulding & Staelin, 2006). It is argued that decision-
making is closely related to and affects the way in which organisational learning
takes place, as past mistakes become guides for future success. If a decision is
harmful, although it may lead to failure, organisations strive to identify and record
faults in order not to repeat them, and thus go through a learning process (Bettis-
Outland, 2012). Accordingly, organisational learning refers to the change in an
organisation’s behaviour; the acquisition and further processing of new knowledge
and experiences which in turn have an impact on individuals (Argote & Miron-
Spektor, 2011).
2.6. Organisational culture
Organisational culture is an important yet complex segment of an organisation. The
structure of an organisation in conjunction with its culture are considered to be
influencing factors of information sharing and use, and consequently of information
behaviours (Markoulides & Heck, 1993). Similarly, cultural and social norms have
an impact on how individuals act and interact with information (Chatman, 2000).
Therefore, a strictly hierarchical structure obscures the efficient flow of information
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and smooth communication among the different parts of an organisation (Daft,
2003).
Several researchers view organisational culture differently. For example, Sun (2008)
describes it as the right way in which issues are understood and dealt with, whereas
Ogbonna (1992) argues that it is a set of ingrained values and beliefs shared by all
members of an organisation. Likewise, Brown (1998) defines culture as a set of
beliefs, values and norms developed throughout an organisation’s history and
identifiable in the behaviour of its members. Conversely, Schein (1985) deems
organisational culture to be a learned entity; ″a pattern of shared basic assumptions″
(p. 9) that is learned, is efficient and can be taught to new members.
Moreover, organisational culture can either be strong, in that a diffusible
commitment is present and the consistency of its elements guides information
behaviour and establishes solid compliance (Deninson, 1990), or have several sub-
cultures, in that a subset of individuals interact with each other and build distinctive
groups, which share a different understanding from the one of the predominant
culture (Bell, 2013).
The former occurs due to a long history or important shared experiences; it is highly
resistant in change and although it fortifies an organisation from external influences,
it hinders internal change. Contrariwise, sub-cultures which are developed within
different units due to the existence of more than one set of beliefs, enable deviant
groups to grow and result in a paralysed organisation (Sinclair, 1993; Schein, 1990).
2.7. Conclusion
Information behaviours, such as information avoidance, selective exposure and
escalation, are considered to have an impact on information failures. Similarly,
information failure is viewed as contributing to organisational disasters and
accidents. In situations where discomfort or information inconsistent with current
beliefs and knowledge exist, information behaviours may result in its dismissal or
rejection. This would result in ineffective communication and dissemination of
information and thus lead to failure.
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Decision-making would also be affected by the existence of certain information
behaviours. More specifically, escalation is viewed as a strong influencing factor.
Responsibility for a decision ignites escalation of bias and compels decision-makers
to modify their original beliefs in accordance with the requirements of the decision.
Furthermore, organisational learning is likely to be interrupted on minimised, since it
is intertwined with the decision-making process.
Organisational culture provides a shared set of values which manifests the way in
which an organisation operates. It both influences and is influenced by information
behaviours and in turn affects decision-making and organisational learning. Culture
underpins how information is treated and utilised in regard to the desirable outcome.
If information is viewed to be opposed to existing rationale or have undesirable
consequences, it is unlikely to be sought out. Instead, it will be avoided and replaced.
Such activity reveals ingrained perceptions and respective behaviours, which inform
decision-making and shape organisational learning. Consequently, misinformation
takes place, threats are underrated or not fully acknowledged and hence organisations
are unable to react properly; as a result failure occurs.
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3. Methodology
3.1 Research methodology
The methodology employed in this research is qualitative interpretive and the
approach inductive. According to Flick (2007), qualitative research is considered to
be subjective. Its purpose is to capture the image of the world as it is and interpret,
delineate and disclose inner social norms. It emphasizes on understanding the
meaning, experiences and perspectives of the individuals over the social
construction. Similarly, Silverman (2013) deems that qualitative research seeks to
explain the social phenomena and cultures that underpin different communities and
the thinking as well as the social structure behind it. It makes use of empirical
material, in that everything that can be observed with broad and variant
interpretations (Punch, 2005), such as textual or discursive, documents and
transcriptions of interviews.
Rudestam and Newton (2015) suggest that qualitative research ″begins with specific
observations and moves toward the identification of general patterns that emerge
from the cases under study″ (p. 39). The reason for employing a qualitative
methodology is the purpose of the project itself, which is to identify the impact that
information behaviour has on information failure during disastrous events within a
complex organisational context, which is open to different interpretations. To that
end, NASA was chosen as it constitutes a prime instance of a convoluted
organisation. Subsequently, the cases of Challenger and Columbia space shuttles’
disasters were selected as case studies in order to provide a longitudinal perspective
on the cultural remaining commonalities and ingrained information behaviours of the
organisation; the time-frame between these two incidents is 17 years. According to
Rudestam and Newton (2015), the use of case studies is closely affiliated with
qualitative research, where an endeavour to discern the complex context of an
individual unit is postulated.
NASA is a federal agency and a highly matrixed organization, meaning that there are
several lines of authority. ″At the simplest level, there are three major types of
entities involved in the Human Space Flight Program: NASA field centres, NASA
programs carried out at those centres, and industrial and academic contractors. The
20
centres provide the buildings, facilities, and support services for the various
programs ″ (CAIB, 2003, p. 16).
3.2 Research design
The approach taken is inductive as the project deals with two specific cases in order
to conclude and provide an answer to the research question through the analysis of
the official related reports, which constitute the data set of the research. The idea of
conducting an inductive research is to step aside and become an observer so as to
take a closer look to the situation in question (Silverman, 2013).
Additionally, since the goal of the research is to identify, analyse and record patterns
that derive from the data, thematic analysis was employed (Braun and Clarke, 2006).
According to Fereday and Muir-Cochrane (2006), thematic analysis ″is a search for
themes that emerge as being important to the description of the phenomenon...a form
of pattern recognition within the data, where emerging themes become the
categories. Braun and Clarke (2006) suggest that thematic analysis or thematic
synthesis, as Thomas and Harden (2008) name it, is characterised by its flexibility.
They posit that it can be either an essentialist or realist method, in that it records the
experiences and reality of the participants as they understand it, or constructionist
method, in that it explains how these experiences and meanings have an effect on the
discourses created within a community. Boyatzis (1998), however, argues that
thematic analysis can be either theory-driven or data-driven. Moreover, a hybrid
model of this analysis that incorporates both a deductive, theory-driven and a data-
driven, inductive approach can be adopted. For the purposes of this research the
inductive data-driven approach to thematic analysis was chosen as the most
appropriate.
Conducting thematic analysis requires ″reading and re-reading of the data″ (Rice &
Ezzy, 1999, p. 258), coding them and then creating themes. Coding constitutes
prerequisite for the identification and development of themes. A useful code captures
the deep meaning of the data and leads to coherent themes (Fereday &Muir-
Cochrane, 2006). According to Boyatzis (1998), a theme can be defined as “a pattern
in the information that at minimum describes and organises the possible observations
and at maximum interprets aspects of the phenomenon (p. 161). Thematic analysis
21
may have several steps and stages through which codes are created depending on the
approach that is followed (Boyatzis, 1998; Braun & Clarke, 2006). Moreover,
Boyatzis (1998) suggests that in order for a theme to be robust and valid it must
contain three elements: a label or name for the theme, its definition and a description
of how to identify when the theme occurs.
3.3 Data analysis
For the purposes of this research, NASA’s official reports on the Challenger and
Columbia space shuttles’ disasters were chosen to be analysed. These reports were
selected because they provide diverse dimensions and different perspectives of a
complex organisation during a time-frame of more than a decade. Furthermore, the
analysis of the reports aims at disclosing the information behaviours that are rooted
within the organisation’s culture as a phenomenon, and at identifying the way in
which they affect NASA’s interpretation of a situation of hazard. The two reports
are:
The Roger’s Commission official report on the Space Shuttle Challenger
Accident: This report, which is also known as the Presidential Commission
Report, was created by a Commission appointed by the President of the USA so
as to conduct an investigation regarding the Challenger’s destruction just
seconds after its launch. (http://history.nasa.gov/rogersrep/genindex.htm)
The official report of the Columbia Accident Investigation Board (CAIB): This
report was created by the Investigation Board, which was assembled by NASA
so as to investigate the disintegration of the Columbia space shuttle during its re-
entry into the earth’s atmosphere.
(http://s3.amazonaws.com/akamai.netstorage/anon.nasa-
global/CAIB/CAIB_lowres_full.pdf)
Furthermore, since the reports are the source of the data, quotations were used so as
to support the findings of the research. To that end, a referencing system based on the
reports was employed. More specifically, for the Roger’s Commission official report
on the Space Shuttle Challenger Accident the abbreviated title “Presidential
Commission Report” is used, whereas for the official report of the Columbia
22
Accident Investigation Board the acronym “CAIB” is adopted. The publication date
follows and then goes the page and the volume or chapter number. For example, the
reference for a quotation from the Presidential Commission Report would be:
“Presidential Commission Report, 1986, p. 15, Vol. I, Ch. III”, while for the CAIB
would be “CAIB, 2003, p. 15, Ch. 3”. The difference between the two reports is that
the former is divided in volumes, from which the first is the full report and the rest
are the appendices, and then in chapters, whereas the latter is divided only in
chapters.
Nevertheless, a problem was encountered in terms of format. The Presidential
Commission Report is available in a different type of format than the CAIB, that is
XML and pdf respectively. In order to conduct the analysis the documents had to be
downloaded and printed. In the case of the Presidential Commission Report that was
problematic and time consuming as each volume of the report had to be converted
into pdf and then be printed and studied.
The data analysis was conducted in four phases. Firstly, the documents were read and
re-read several times with the aim to become familiarised with the material. During
this process, notes and initial ideas were written down and hence a list of premature
and broad codes was created. These ideas were then processed and narrowed down,
reviewed and organised into meaningful groups. Each group consisted of codes with
similar context. As a result, several mind-maps of codes were created. At a later
stage, these codes were analysed and sorted into potential themes and sub-themes.
Relationships between codes were identified, combinations for overarching
categories were tested and candidate themes were formed. Subsequently, some of
them were collapsed into others due to several similarities or repetitions. As a result
of this process three final themes were generated.
The fourth phase of the analysis was divided into two stages. During the first stage,
all candidate themes were reviewed at the level of the coded data extracts. If there
was a pattern formation, the process moved on to the second stage. If themes did not
fit, they were either processed again or dismissed. At the second stage the validity of
each theme was examined in relation to the data set and the extent to which they
reflected its meaning. Thereafter, according to Boyatsis (1998), the themes were
23
given a label, definition and indicators. An example of the final presentation of the
themes is provided below whereas a full list can be found in the appendices1.
Theme 1:
Label: NASA’s culture
Definition: The basic values, norms, beliefs and practices that define an
organisation’s functioning and its employees’ assumptions.
Indicators: Coded when the report states “cultural traits”, “program culture”
or “organisational culture”.
Differentiation: Occasionally “history” is treated as intertwined with
“culture”.
1 See appendix 1
24
3.4 Ethical aspects
Both reports are publically available and easily accessible. No further access to or
contact with the organisation was required. Thus, the research was based on desk
rather than on primary research. According to Woolley (1992), ″desk research is used
to describe the process of gathering information available in published form, rather
than obtaining the data directly″ (p. 227). Furthermore, no human participants were
engaged with the research at any stage. Consequently, the research was classified as
“no risk” and no ethical approval was required2.
2 See appendix 2
25
4. Findings
The analysis of the official reports on the Challenger and Columbia space shuttles’
disasters revealed that apart from the technical causes there were additional elements
and respective information behaviours that contributed to the outcome, which are
rooted in NASA’s history and the way in which it operates. These are grouped into
three themes; NASA’s culture, political and production pressures and decision-
making. Each will be discussed in the following chapter.
4.1 NASA’s culture
It became clear that the disasters occurred not only due to the technical issues but
also because of the existence of certain elements that are ingrained in the agency’s
culture.
″The Board recognized early on that the accident was probably not an
anomalous, random event, but rather likely rooted to some degree in
NASAʼs history and the human space flight program’s culture″. (CAIB,
2003, p. 9)
NASA was considered to be the most important political underpinning and was
surrounded by the perception of a strong and safe organisation. Since its inception,
the human space shuttle program generated high expectations and created a myth
around the agency concerning the ease of travelling to space and completing its
missions.
″...the Shuttle emerged from a series of political compromises that produced
unreasonable expectations – even myths – about its performance. ″ (CAIB,
2003, p. 9, Ch. 1)
The successes of the Apollo mission also contributed to the enrichment and
enhancement of this myth as well as the cultivation and promotion of an image,
presenting NASA as the “perfect organisation” that can achieve everything.
″Apollo successes created the powerful image of the space agency as a
“perfect place,” as “the best organization that human beings could create to
accomplish selected goals.” During Apollo, NASA was in many respects a
26
highly successful organization capable of achieving seemingly impossible
feats. ″ (CAIB, 2003, p. 102, Ch. 5)
Subsequently, this image was promoted not only within the organisation itself but
also to the public.
″... NASA promised it could develop a Shuttle that would be launched almost on
demand and would fly many missions each year. Throughout the history of the
program, a gap has persisted between the rhetoric NASA has used to market the
Space Shuttle and operational reality, leading to an enduring image of the
Shuttle as capable of safely and routinely carrying out missions with little
risk″ (CAIB, 2003, p. 23, Ch. 1)
″From the inception of the Shuttle, NASA had been advertising a vehicle
that would make space operations routine and economical″. (Presidential
Commission Report, 1986, p. 15, Vol. I, Ch. VIII)
The “Apollo era” signalled the consolidation of the idea of NASA as an organisation
capable of achieving anything and as such it was viewed by the public and those who
worked within it. As a result, over the years certain cultural attitudes were developed
that strengthened the agency’s “can-do” culture, accepted risk and ignored signals of
potential danger.
″The Apollo era created at NASA an exceptional “can-do” culture marked
by tenacity in the face of seemingly impossible challenges. The culture also
accepted risk and failure as inevitable aspects of operating in space″. (CAIB,
2003, p. 101-102, Ch. 5)
Reliance on past success and ambitions for future developments lead managers to
overlook the developmental condition of the shuttle and go ahead with an increasing
flight-rate schedule in order to maintain the image of the successful organisation.
″NASA managers “may have forgotten–partly because of past success,
partly because of their own well-nurtured image of the program– that the
Shuttle was still in a research and development phase″. (CAIB, 2003, p.
100, Ch. 5; Presidential Commission Report, 1986, p. 165, Vol. I, Ch. VIII)
27
Both Challenger and Columbia were nodal points in achieving important goals. A
potential failure of attaining these goals meant loss of funding from the government
and significant damage in NASA’s reliability and image. For that reason, information
opposed to or seen as threat to the desirable outcome was avoided or ignored.
More specifically, in the case of Challenger, indications of O-ring erosion and hence
strong signals of danger were present yet avoided or rejected. Concerns regarding the
low temperature were raised from the Thiokol’s engineers who suggested delaying
the launch. Accepting, however, such suggestion meant that the flight schedule
would not be met; a choice that was unacceptable. Consequently, managers made use
of information that was congruent with their intension of launching and ignored
those that opposed in any way to the goal. Such decision shows that behaviours of
information avoidance took place.
Despite the engineers’ objections about launching and indications for the potential
results of low temperature, managers decided that because erosion had occurred
before it did not constitute a discriminating factor, and hence to go ahead as planned.
During the teleconference, where the Thiokol engineers’ recommendation was not to
launch, information avoidance was clear.
″The conclusion was we should not fly outside of our data base, which was
53 degrees...Listeners on the telecon were not pleased with the conclusions
and the recommendations″. (Presidential Commission Report, 1986, p. 90,
Vol. I, Ch. V)
Even though the recommendation was not to launch and despite engineers’
continuous efforts to stress the potential danger, managers rejected the information
opposed to launching and acted upon those in favour.
″I [Boisjoly] tried to make the point that it was my opinion from actual
observations that temperature was indeed a discriminator and we should not
ignore the physical evidence that we had observed...After Arnie and I had
our last say, Mr. Mason said we have to make a management decision.″
(Presidential Commission Report, 1986, p. 92-93, Vol. I, Ch. V)
28
″...we just don't know how much further we can go below the 51 or 53
degrees or whatever it was. So we were concerned with the unknown. And
we presented that to Marshall, and that rationale was rejected. They said that
they didn't accept that rationale...Mr. Hardy said he was appalled that we
would make such a recommendation″. (Presidential Commission Report,
1986, p. 94, Vol. I, Ch. V)
The avoidance and rejection of information that would delay the launch is closely
related to the “can-do” attitude that is prevalent to the organisation. Even after the
Challenger’s accident, NASA strived to maintain its image of the “best organisation”
by avoiding information that threatened to disturb it. As a result, information
avoidance and selective exposure continued to occur as they were ingrained within
the agency’s culture.
″In the aftermath of the Challenger accident, these contradictory forces [the
trend toward bureaucracy and the associated increased reliance on
contracting] prompted a resistance to externally imposed changes and an
attempt to maintain the internal belief that NASA was still a “perfect
place...Within NASA centres, as Human Space Flight Program managers
strove to maintain their view of the organization, they lost their ability to
accept criticism, leading them to reject the recommendations of many
boards and blue-ribbon panels, the Rogers Commission among them″.
(CAIB, 2003, p. 102, Ch. 5)
It could be argued that the behaviours that took place in Challenger’s mission, also
occurred during the course of Columbia flight, which in conjunction with the self-
confidence and the sense of invisibility that had been cultivated led to the disaster.
″NASAʼs safety culture has become reactive, complacent, and dominated by
unjustified optimism″. (CAIB, 2003, p. 180, Ch. 7)
″NASA appeared to be immersed in a culture of invincibility, in stark
contradiction to post-accident reality. The Rogers Commission found a
NASA blinded by its “Can-Do” attitude, a cultural artefact of the Apollo
era...bolstered administrators’ belief in an achievable launch rate, the belief
29
that they had an operational system, and an unwillingness to listen to outside
experts. (CAIB, 2003, p. 199, Ch. 7)
These characteristics are also identified in the way in which NASA treated and
classified the foam-debris strikes. Although there were increasing concerns regarding
the foam events that occurred during Columbia’s ascend and several requests for
extra imagery were pending, managers insisted on the “in-family” and later on the
“no safety-of-flight issue” classification. NASA continued making decisions based
on previous success rather than on firm data so as to support its image. Therefore,
“blind-spots” were created and the significance of the danger was diminished.
″...that detection of the dangers posed by foam was impeded by “blind
spots” in NASAʼs safety culture... the Board witnessed a consistent lack of
concern about the debris strike on Columbia. NASA managers told the
Board “there was no safety-of-flight issue” and “we couldn’t have done
anything about it anyway″. (CAIB, 2003, p. 184, Ch. 7)
This led to a situation where foam loss events were normalised and treated as a
simple maintenance issue; managers strived to maintain and promote such rationale,
which inevitably led to the adoption of behaviours of information avoidance.
Information concerning potential hazards in regards to foam strikes was dismissed or
rejected so as to support the unanimous perception that it is safe to fly with events of
foam loss.
″At every juncture of STS-107 [Columbia], the Shuttle Program’s structure
and processes, and therefore the managers in charge, resisted new
information... Overwhelming evidence indicates that Program leaders
decided the foam strike was merely a maintenance problem long before any
analysis had begun. Every manager knew the party line: “we will wait for
the analysis – no safety-of-flight issue expected”″. (CAIB, 2003, p. 181,
Ch. 7)
To accept that foam-debris strikes are more than just a maintenance issue and that
they may cause loss of the shuttle and the lives of the crew, would be disastrous for
the organisation’s image and the program itself. To that end, managers recognised
30
only what was congruent with their existing beliefs and opinions, and rejected or
avoided what could disturb and damage NASA’s image and undermine its goals.
″A tile expert told managers during frequent consultations that strike
damage was only a maintenance-level concern and that on-orbit imaging of
potential wing damage was not necessary. Mission management welcomed
this opinion and sought no others. This constant reinforcement of managers’
pre-existing beliefs added another block to the wall between decision
makers and concerned engineers″. (CAIB, 2003, p. 169, Ch. 6)
Consequently, such decisions and behaviours led to gradual acceptance of risk and
creation of learned attitudes that supported the prevailing opinion that foam strikes
are in-family and not a safety-of-flight issue, and hence that it was safe to continue
flying.
″...learned attitudes about foam strikes diminished management’s wariness
of their danger. The Shuttle Program turned the experience of failure into
the memory of success″. (CAIB, 2003, p. 181, Ch. 7)
During both incidents, information and signals concerning the imminent disaster
were available. However, those were misinterpreted and many occasions ignored and
avoided as they could interfere with the arrangement that NASA had inflicted.
Culture played a leading role in the cultivation and maintenance of behaviours of
selective exposure to and information avoidance. It constituted a frame against which
all new information had to be judged and evaluated; if information was consistent
with NASA’s objectives, it was accepted and acted upon. Otherwise, it was avoided
or ignored.
″In both situations, all new information was weighed and interpreted against
past experience. Formal categories and cultural beliefs provide a consistent
frame of reference in which people view and interpret information and
experiences. Pre-existing definitions of risk shaped the actions taken and not
taken...In both cases, managers’ techniques focused on the information that
tended to support the expected or desired result at that time...Management
did not listen to what their engineers were telling them″. (CAIB, 2003, p.
200-201, Ch. 8)
31
More specifically, in regards to Challenger, the strong signal of the low temperature
and the data from previous O-ring erosions, were minimised and in the end avoided
during the teleconference. Similarly, in the case of Columbia managers had weak but
continuous signals of the disastrous prospects of foam strikes. Engineers strived to
gather and present more data but were faced with the management’s strong
perceptions and denial of accepting information inconsistent with the agency’s
image.
″Over the course of 22 years, foam strikes were normalized to the point
where they were simply a “maintenance” issue – a concern that did not
threaten a mission’s success. This oversimplification of the threat posed by
foam debris rendered the issue a low-level concern in the minds of Shuttle
managers. Ascent risk, so evident in Challenger, biased leaders to focus on
strong signals from the Shuttle System Main Engine and the Solid Rocket
Boosters. Foam strikes, by comparison, were a weak and consequently
overlooked signal, although they turned out to be no less dangerous″.
(CAIB, 2003, p. 181, Ch. 7)
32
4.2 Pressures
NASA was under significant political pressures throughout its history to fulfil its
goals, which subsequently resulted in the development of tremendous internal
production pressures regarding the flight schedules. Since its inception the human
space shuttle program required great amounts of funding for its operations and
government was increasingly demanding more to be done. Consequently, the
relationship between them became more customer and demand oriented.
Competition from other space agencies as well as the fear of budget cuts led NASA
to classify the shuttle as operational, whereas in reality it was still at a developmental
stage, in order to be able to support the defined schedule, satisfy political demands
and thus ensure future funding.
″There were two reasons for declaring the Space Shuttle “operational” so
early in its flight program. One was NASAʼs hope for quick Presidential
approval of its next manned space flight program, a space station, which
would not move forward while the Shuttle was still considered devel-
opmental. The second reason was that the nation was suddenly facing a
foreign challenger in launching commercial satellites″. (CAIB, 2003, p. 23,
Ch. 1)
This situation had as a result the intensification of devotion to the perception and
promotion of the shuttle as operational.
″The prevalent attitude in the program appeared to be that the Shuttle should
be ready to emerge from the developmental stage, and managers were
determined to prove it "operational." Various aspects of the mission design
and development process were directly affected by that determination″.
(Presidential Commission Report, 1986, p. 165, Vol. I, Ch. VIII)
Furthermore, as the fulfilment of the flight schedule was intertwined with the
approval of further funding and acceptance from the government, and hence NASA’s
ability to continue its program, further political pressures were inevitably developed
that affected the way in which the agency operated.
33
″Pressures developed because of the need to meet customer commitments,
which translated into a requirement to launch a certain number of flights per
year and to launch them on time. Such considerations may occasionally
have obscured engineering concerns″. (Presidential Commission Report,
1986, p. 165, Vol. I, Ch. VIII)
To that end, during the preparation for the Challenger launch, several changes were
made to the flight manifest so as to ensure that the schedule will be met.
″We have done enough complaining about it [changes in the manifest] that I
[Tommy Holloway] cannot believe there is not a growing awareness, but the
political aspects of the decision are so overwhelming that our concerns do
not carry much weight... And in the face of that, political advantages of
implementing those late changes outweighed our general objections″.
(Presidential Commission Report, 1986, p. 173, Vol. I, Ch. VIII)
Such activity indicates that in order for NASA to achieve its goals and meet the
predefined requirements that would result in the enhancement of government’s
support, several actions closely related to information avoidance behaviour were
taken. Amending an official flight document so as to “fit” the existing information
and avoid acknowledging the new one, while allowing a mission to go ahead and
thus stay on schedule, is one of them.
In the years following the Challenger accident, pressures continued. Due to the
political objectives and the negative implications that the failure in fulfilling them
would have, NASA set out to complete a mission of great importance, the “Node 2”
with the aim to restore its credibility and image. This, however, meant that even
more pressure would be imposed both to the agency itself and its personnel.
″... the Board received several unsolicited comments from NASA personnel
regarding pressure to meet...February 19, 2004, the scheduled launch date of
STS-120...It became apparent that the complexity and political mandates
surrounding the International Space Station Program, as well as Shuttle Pro-
gram management’s responses to them, resulted in pressure to meet an
increasingly ambitious launch schedule...If this goal was not met, NASA
34
would risk losing support from the White House and Congress for
subsequent Space Station growth ″. (CAIB, 2003, p. 131, Ch. 6)
So important was to meet the “Node 2” that management did not accept any delays.
In the past, when a technical issue occurred and a flight had to be delayed, it did and
another mission could be flown instead. With the commencement, however, of
“Node 2” this activity changed. Missions had to be completed in a specific order,
otherwise the schedule would be jeopardised. Such a change hampered the process of
potential repairs after every mission, as time is needed for it to be completed, which
due to the tight and increasing rate of flights was not sufficient.
″...“the serial nature” of having to fly Space Station assembly missions in a
specific order made staying on schedule more challenging. Before the Space
Station, if a Shuttle flight had to slip, it would; other missions that had
originally followed it would be launched in the meantime. Missions could
be flown in any sequence. Now the manifests were a delicate balancing act.
Missions had to be flown in a certain order...Any necessary change they
made on one mission was now impacting future launch dates. They had a
sense of being “under the gun″. (CAIB, 2003, p. 134, Ch. 6)
Accordingly, when managers dealt with the foam-debris strikes issue, they
intensified their persistence on classifying it as an “in-family” and later on as a “no
safety-of-flight” event in order to go ahead with the launch; if it was classified as an
“out-of-the-family” issue, the flight would be delayed for an unknown period of time
and thus the schedule could not be met. A potential delay of the Columbia flight
would result in subsequent delay of the next mission and eventually in failure to meet
the goal of the “Node 2”, which was a high priority goal for management.
Consequently, information concerning the severity of the foam strikes was avoided
and in many cases its importance was minimised and normalised.
During the STS-112 flight, two missions before Columbia’s, an unexpectedly large
foam debris hit the shuttle. Because it was the first time such a significant event, both
in size and in the damage it caused, that had occurred the rationale to continue flying
was investigated. Nevertheless, the STS-113 flight was launched.
35
″Hamʼs focus on examining the rationale for continuing to fly after the foam
problems with STS-87 and STS-112 indicates that her attention had already
shifted from the threat the foam posed to STS-107 to the downstream
implications of the foam strike″. (CAIB, 2003, p. 148, Ch. 6)
This particular incident constituted evidence that foam-debris strikes posed threat to
the safety of both the shuttle and those on board. However,
″...at STS-113ʼs Flight Readiness Review, managers formally accepted a
flight rationale that stated it was safe to fly with foam losses″. (CAIB, 2003,
p. 125, Ch. 6)
Such rationale was adopted in order for the schedule not to be delayed and the
decision to launch was made despite the information that illustrated the significance
of the strike depicts that
″...most of the Shuttle Program’s concern about Columbia’s foam strike
were not about the threat it might pose to the vehicle in orbit, but about the
threat it might pose to the schedule″. (CAIB, 2003, p. 139, Ch. 6)
Consequently, information that supported and strengthened the engineers’ concerns
about potential danger regarding the foam-debris was either ignored or avoided by
management.
According to NASA’s regulations, if a technical or structural problem occurs during
a mission, the vehicle needs to be grounded and examined until the issue is resolved.
This would have as a result the delay of the next flight. Accordingly, if the decision
concerning the foam loss, during the Flight Readiness Review of STS-113, was
found to be flawed, the pivotal for “Node 2” flight would be delayed and the
schedule would not be met. Therefore, any information that would have such impact
was either rejected or normalised.
″...Ham was due to serve, along with Wayne Hale, as the launch integration
manager for the next mission, STS-114. If the Shuttle Program’s rationale to
fly with foam loss was found to be flawed, STS-114, due to be launched in
about a month, would have to be delayed per NASA rules that require
36
serious problems to be resolved before the next flight. An STS-114 delay
could in turn delay completion of the International Space Station’s Node 2,
which was a high-priority goal for NASA managers″. (CAIB, 2003, p. 148,
Ch. 6)
Due to the increased pressures, the “Node 2” goal was characterised as “performance
gate”. As the Task Force Chairman Thomas Young stressed in his testimony before
the House Committee on Science on November 7, 2001:
″... over the next two years, NASA should plan and implement a credible
“core complete” program. If satisfactory, resource needs would be assessed
and an [ISS] “end state” that realized the science potential would become
the baseline. If unsatisfactory, the core complete program would become the
“end state”. (CAIB, 2003, p. 117, Ch.5)
Thus, automatically the achievement of an on-schedule Node 2 launch would
become the affirmation of NASA’s image as a successful organisation. To that end,
the agency’s management had to ensure the achievement of this goal. Consequently,
″any suggestions that it would be difficult to meet that launch date were
brushed aside″. (CAIB, 2003, p. 117, Ch.5)
The increasing production pressures were also noticed by the employees during both
incidents:
″...it seemed to some that budget and schedule were of paramount concern.
As one employee reflected:
″I guess my frustration was … I know the importance of showing that you …
manage your budget and that’s an important impression to make to
Congress so you can continue the future of the agency, but to a lot of
people, February 19th just seemed like an arbitrary date … It doesn’t make
sense to me why at all costs we were marching to this date″.
″...I felt personally that management was under a lot of pressure to
launch...This was a meeting [teleconference] where the determination was
to launch, and it was up to us [engineers] to prove beyond a shadow of a
37
doubt that it was not safe to do so″. (Presidential Commission Report, 1986,
p. 93, Vol. I, Ch. V)
38
4.3 Communication and decision-making
Production pressures are also considered to have an impact on the decision-making
process.
″...the need to adhere to the Node 2 launch schedule also appears to have
influenced their decision. Had the STS-113 mission been delayed beyond
early December 2002...Node 2 launch date, a major management goal,
would not be met″. (CAIB, 2003, p. 125, Ch. 6)
Classifying the foam loss as an “out-of-family event”, would result in delaying STS-
113 and subsequently the launch of the STS-107, a pivotal point in a series of
missions towards achieving an important goal. Accordingly, little attention was paid
to information related to foam-debris strikes and in most cases was either ignored or
avoided.
″The foam-loss issue was considered so insignificant by some Shuttle
Program engineers and managers that the STS-107 Flight Readiness Review
documents include no discussion of the still-unresolved STS-112 foam
loss″. (CAIB, 2003, p. 126, Ch. 6)
Likewise, information concerning the O-ring erosion and its potential negative
results was not promptly communicated throughout all levels of authority and was
merely absent from official reporting documents.
″In any event, no mention of the O-ring problems in the Solid Rocket
Booster joint appeared in the Certification of Flight Readiness, signed for
Thiokol on January 9, 1986, by Joseph Kilminster, for the Solid Rocket
Booster set designated BI026. Similarly, no mention appeared in the
certification endorsement, signed on January 15, 1986, by Kilminster and by
Mulloy. No mention appears in several inches of paper comprising the
entire chain of readiness reviews for 51-L [Challenger] ″. (Presidential
Commission Report, 1986, p. 85, Vol. I, Ch. V)
In addition, flawed communication and strictly hierarchical and bureaucratic
structure of authority and reporting contributed to this situation, as information did
39
not reach the appropriate level within the chain of command and in some cases,
because it was difficult to reach the person accountable for a certain issue,
individuals chose to follow informal ways of communicating.
″It is clear that crucial information about the O-ring damage in prior flights
and about the Thiokol engineers' argument with the NASA telecon
participants never reached Jesse Moore or Arnold Aldrich, the Levels I and
II program officials, or J.A. (Gene) Thomas, the Launch Director for 51-L″.
(Presidential Commission Report, 1986, p. 102, Vol. I, Ch. V)
Moreover, this way of acting and communicating made it easier for discomforting or
disturbing information to be avoided, ignored or even rejected. When the official
channels of communication are not followed, information might get lost and thus
decision-makers will not be able to make informed decisions. In addition, when
pressures are compulsive, such situation facilitates the manipulation of information
and cultivates behaviours of selective exposure to and information avoidance.
″An e-mail that he [Rocha] did not send but instead printed out and shared
with a colleague follows....When asked why he did not send this e-mail,
Rocha replied that he did not want to jump the chain of command. Having
already raised the need to have the Orbiter imaged with Shack, he would
defer to management’s judgment on obtaining imagery″. (CAIB, 2003, p.
157, Ch. 6)
Consequently, misinformation took place and led to decisions being made based on
inadequate information. For instance, problems with O-rings were minimised and
communicated as just “technical issues”. Furthermore, only a few flights before
Challenger, important information regarding the temperature and its subsequent
impact on O-rings was missing from the Flight Readiness Review.
″The inattention to erosion and blow-by anomaly changed when Thiokol
filed a problem report on the field joint erosion after STS 41-B. The O-ring
problems (field and nozzle) on 41-B were briefed as a "technical issue" in
the 41-C Flight Readiness Review. At the Level I Flight Readiness Review
for 51-E on February 21, 1985, the previous 18-page analysis had been
40
reduced to a one page chart with the resolution: "acceptable risk because of
limited exposure and redundancy. No mention of temperature was found in
the Level I report″. (Presidential Commission Report, 1986, p. 147, Vol. I,
Ch. VΙ)
During both the Challenger and Columbia missions, managers were concerned with
following and maintaining the flight schedule, a persistence that led to overlooking
several opportunities that could have reversed the negative outcome3. Their primary
goal was to achieve the agency’s predefined objectives and increasing escalation of
commitment to continue launching was cultivated. More specifically, in the case of
Challenger, the decision to go ahead with the launch was merely a management one
that was based on criteria other than firm engineering data.
″The Commission concluded that the Thiokol Management reversed its
position and recommended the launch of 51-L, at the urging of Marshall and
contrary to the views of its engineers in order to accommodate a major
customer″. (Presidential Commission Report, 1986, p. 104, Vol. I, Ch. V)
To that end, information that would result in delaying launch was disregarded or its
importance was normalised and emphasis was given to those that were in favour.
This is a clear indication that management chose to be selectively exposed to
information depending on its suitability in regards to the agency’s goals.
″Communication did not flow effectively up to or down from Program
managers. As it became clear during the mission managers were not as
concerned as others about the danger of the foam strike, the ability of
engineers to challenge those beliefs greatly diminished. Managers’ tendency
to accept opinions that agree with their own dams the flow of effective
communications″. (CAIB, 2003, p. 169, Ch. 6)
Similar behaviours are identified during Columbia’s flight. NASA’s persistence in
meeting the schedule influenced decision-making towards accepting risk so as to
continue flying.
3 See appendix 4
41
″The agency’s commitment to hold firm to a February 19, 2004, launch date
for Node 2 influenced many of decisions in the months leading up to the
launch of STS-107, and may well have subtly influenced the way managers
handled the STS-112 foam strike and Columbia’s as well. When a program
agrees to spend less money or accelerate a schedule beyond what the
engineers and program managers think is reasonable, a small amount of
overall risk is added. These little pieces of risk add up until managers are no
longer aware of the total program risk, and are, in fact, gambling. Little by
little, NASA was accepting more and more risk in order to stay on
schedule″. (CAIB, 2003, p. 139, Ch. 6)
The escalation of managers’ commitment to the course of the predefined action
regarding Columbia bares similarities with Challenger. In both cases, NASA
accepted erosions, which were not expected and regularly altered the flight
requirements and criteria so as to fit certain circumstances and be able to meet the
increasing flight rate and not deviate from the schedule.
″The phenomenon of accepting … flight seals that had shown erosion and
blow-by in previous flights is very clear ... But erosions and blow-by are not
what the design expected … The O-rings of the Solid Rocket Boosters were
not designed to erode. Erosion was a clue that something was wrong … If a
reasonable launch schedule is to be maintained, engineering often cannot be
done fast enough to keep up with the expectations of originally conservative
certification criteria designed to guarantee a very safe vehicle. In these
situations, subtly, and often with apparently logical arguments, the criteria
are altered so that flights may still be certified in time″. (CAIB, 2003, p.
130, Ch. 6)
The intensification of commitment to achieving the so promoted Challenger mission
and the highly important “Node 2” goal had an impact on decision-making in both
incidents. During the former, NASA and its contractor accepted escalating risk
because erosion was observed in several flights and no problems were recorded.
Thus those events were considered to be within their “experience base” and further
action was taken so as to address its cause and resolve it. As a consequence and since
nothing disastrous has happened before, they lowered their standards and erosion as
42
well as blow-by became an minor issue that was known and later on was
characterised as acceptable risk.
This led to a situation where:
″As Commissioner Feynman observed, the decision making was: "a kind of
Russian roulette″. (Presidential Commission Report, 1986, p. 148, Vol. I,
Ch. VΙ)
Similarly, during the Columbia mission, the opinion that is safe to fly with potential
foam loss was established and all managers were in favour of such rationale as it was
congruent with the agency’s goals. The pivotal decision of accepting the foam strike
of STS-113 as not a safety-of-flight issue influenced the subsequent decision-making
process and therefore STS-107 [Columbia] flight. Changing or questioning a
rationale that was accepted from the management as a whole just one flight before
Columbia, while management was so vigorous to meet the schedule, would be seen
as it had fail to address and efficiently resolve a safety issue. Consequently,
managers escalated their commitment to the launch decision.
″It is here that the decision to fly before resolving the foam problem at the
STS-113 Flight Readiness Review influences decisions made during STS-
107. Having at hand a previously accepted rationale – reached just one
mission ago – that foam strikes are not a safety-of-flight issue provides a
strong incentive for Mission managers and working engineers to use that
same judgment for STS-107. If managers and engineers were to argue that
foam strikes are a safety-of-flight issue, they would contradict an
established consensus that was a product of the Shuttle Program’s most
rigorous review – a review in which many of them were active participants″.
(CAIB, 2003, p. 150, Ch. 6)
43
4.4 Conclusion
The themes that derived from the analysis of the reports revealed the existence of
certain information behaviours and highlight their impact on the Challenger and
Columbia space shuttles’ disasters.
A culture was prevalent in NASA that promoted an image of a capable, safe, healthy
and self-confident agency as well as a myth of NASA as the “best organisation”, one
that could make the access to space “routine and economic”. Furthermore, the
pressures the agency faced both political and production, subconsciously forced
managers to lower their standards and treat information concerning potential
problems in a way that would not pose delays and allow them to achieve a
predefined goal. Information that was seen as threat to the flight schedule and
subsequently to NASA’s launch goals and its image was ignored or avoided.
On the other hand, information that supported the dominant position was accepted
and acted upon. It can be, thus, argued that NASA’s “can-do” culture in conjunction
with the political and production pressures imposed to the agency cultivated the
existence of behaviours of information avoidance and selective exposure to
information, influencing the way in which information was treated and consequently
the outcome of the disasters.
Furthermore, the communication was in many cases hampered by the strictly
hierarchical chain of command. This had as a result the creation of informal channels
of communication and dissemination of information, and thus its rejection and
treatment as not valid. Additionally, flawed communication contributed to an equally
flawed decision-making, as information regarding the potential disaster was available
but not effectively communicated through the proper channels of command to all
levels of decision-makers. Moreover, the informal communication and dissemination
of information allowed certain behaviours to be cultivated, which in turn enabled
unwanted and inconsistent with the prevailing position information to be ignored or
avoided. Consequently, actions were taken based on insufficient and biased
information.
Moreover, the analysis revealed an escalation of commitment to the “myth of NASA
as the best organisation”. Since its establishment and the inception of the human
44
space shuttle program everyone was committed to the notion that space flight was
safe, routine and cost-effective. To accept information supporting that this is not
feasible would mean losing face and shuttering NASA’s image. Conversely,
avoiding such information and accepting only what is congruent with the predefined
goals would support the myth and lead to decisions that enabled it to be maintained.
Such situation makes it clear that escalation took place for a long period of time and
cultivated behaviours of information avoidance and selective exposure to information
which led to information failure and thus the disasters. These behaviours, informed
by the escalation of commitment to the myth surrounding NASA, led to ineffective
information dissemination and gradual loss of awareness of the catastrophic
consequences.
45
5. Discussion
The findings of the analysis performed on reports investigating the Challenger and
Columbia space shuttles’ disasters revealed several aspects of information behaviour
and its impact on information failures. Information avoidance behaviours were found
to be significant contributing factors to both disasters. Furthermore, the findings are
consistent with what the theories of information behaviour, that is Affective Load
and Face Threat, suggest. It also became clear that in both disasters the same
information behaviours and escalation of commitment to the course of launching
took place, despite the 17-year time frame between the two incidents, and the
recommendations for changes imposed by the Rogers Commission after the
Challenger accident. Moreover, NASA’s culture played an important role and
contributed to the ongoing cultivation of information behaviours. The organisation’s
strong “can-do” culture that was mirrored in its personnel’s decision-making made it
harder for the agency to become a learning organisation and thus avoid the second
disaster.
5.1. Framework
The culture surrounding NASA was a major contributing factor in both disasters.
Since its establishment, the space shuttle program promised to make the access to
space routine and economic. In order to get approval for more funding, NASA
promoted an image of “a capable of achieving everything organisation” and created a
myth around its mission and the exploration of space. Throughout the years this
image cultivated and established a strong “can-do” and over-confident culture, which
was also adopted by the people working within the agency (Deninson, 1990).
Consequently, the organisation’s “face” became an “accepted public norm” and got
ingrained in the personnel’s and public’s notion as a fact. As a result, any
information that would jeopardise or disturb this image was treated as threat and was
either ignored or avoided (Mon, 2005).
“Affective Load” (Nahl, 2005) and “Face Threat” theories (Mon, 2005), explain why
such behaviours took place. During the course of NASA’s progress, “learned
affective norms” were developed which placed an emphasis on information that
supported the agency’s statement regarding the ease and safety of space travel and its
46
ability to make it “routine and economic”. Such statement became a norm according
to which information was judged (Julien & McKechnie, 2005).
Additionally, a need to present the space shuttle’s flight as safe and cost-efficient to
the government, with the aim of ensuring its support and funding, led to the
development of information behaviours in order to sustain the image and myth that
NASA had created (Mon, 2005). This resulted in the creation of a cultural narrative
that drove information behaviours and the way in which information was shared and
communicated (Thatcher, Vasconcelos & Ellis, 2015). Moreover, in both incidents
there is a clear correlation between the two theories. The cultural narrative, “Face
Threat” theory, contributed to the establishment of certain learned affective norms,
which are informed by what “Affective Load” theory suggests, in that norms are
present and affect how information is assessed; and result in information avoidance
behaviours.
During their investigation, both the Rogers Commission and the CAIB, found that
apart from the technical causes, cultural elements also contributed to the catastrophic
outcomes. In the aftermath of the Challenger accident, several recommendations for
changes were made by the Rogers Commission, one of which concerned NASA’s
overconfident culture. Yet, 17 years later and after Columbia’s disaster had occurred,
the CAIB investigation revealed that not only the organisational culture had not
changed but it had evolved to a “culture of invincibility” that permeated the
management (CAIB, 2003, p.199). This had a result the interpretation of events and
the related information according to the agency’s cultural frames. Mahler and Hogan
Casamayou’s (2009) definition of NASA’s culture, as a ″deeply held, widely shared
beliefs about... the mission, the identity of the workforce and the legacy of the
organisation’s founders″ mirrors perfectly CAIB’s findings.
Furthermore, the cultural attitude of “the way things are done” and the “taken for
granted” (Martin, 2002) success hindered the possibility of a cultural change and
contributed to the development of behaviours of information avoidance. More
specifically, information that did not fit the cultural frames or may damage the
organisation’s image were avoided, rejected or ignored (Johnson, 2009; Case, 2012).
NASA could not afford losing face or support by either the public or the government
and therefore relied on what knew best about “how things are done” and discarded
47
information that opposed to that method. Consequently, the information
communicated and promoted to all parties was incomplete leading to the cultivation
of certain information behaviours and thus resulted in information failure (Westrum,
1992; Maclntosh-Murray & Choo, 2002)
In addition to NASA’s strong and resistant to change culture, the political and
production pressures posed to the agency played a key role in the disasters. NASA
suffered significant budget cuts. Several goals were set in order for the agency to
prove its ability to meet its funders’ requirements for further financial support. This
situation led to the creation of significant internal production pressures to meet the
schedule. In both cases, management was in a way forced to go ahead with
launching, despite the fact that concerns were raised and information regarding
potential hazards existed, so as not to delay and meet the increasing flight rate
schedule.
NASA was driven by its need to stay on track and therefore the information
processing and interpretation was made accordingly (Grunig, 1989; Atkin, 1973).
In the case of Challenger, one day before the launch, Thiokol’s engineers voiced
their reservations and raised strong concerns about the low temperatures and the
impact they may have on the O-rings. However, those along with the data presented
were minimised and subsequently disregarded by the management (Vaughan, 1997).
To accept such information, would mean that the flight would have to be delayed and
NASA automatically not being able to meet the schedule. To that end, Thiokol’s
leading engineer, during the teleconference pause, was strongly urged to “put off his
engineer hat and put on his management one”.
Clearly, the decision to proceed with Challenger’s launch was a management
decision driven by the agency’s need to survive (Atkin, 1973). It was made on the
grounds that O-ring erosion was observed during previous flights where nothing has
happened. Consequently, partly due to previous success, the ingrained cultural “can-
do” attitude, and the need to stay on schedule, information regarding the engineers’
concerns were avoided or ignored. More specifically, “any suggestions that it would
be difficult to meet that launch date were brushed aside”. (CAIB, 2003, p. 117,
Ch.5). Conversely, information that was congruent with the dominant position of
launching was accepted and promoted (Mon, 2005).
48
The reluctance to accept inconvenient facts and the tendency to avoid disturbing
information is a frequent event (Perrow, 1999; Forgas & George, 2001). A similar
situation to Challenger’s was repeated 17 years later, during Columbia’s mission.
Although foam shedding was formally precluded from the shuttle’s specifications,
relevant events were seen as common and treated as maintenance or turnaround
rather than safety-of-flight issues (CAIB, 2003). Information and concerns about the
foam-debris strikes were repeatedly minimised and ignored. Instead, information in
favour of proceeding were accepted and acted upon. Subsequently, the rationale of
flying with foam-loss was promoted and seen as safe.
From a management point of view, such decision meant that the so important “Node
2” schedule goal would be achieved. ″This pattern of avoiding the rigorous
application of safety procedures...mirrored the events seen before the loss of the
Challenger″ (Mahler & Hogan Casamayou, 2009, p. 66). It can be, thus, argued that
the strong political and production pressures contributed to the development of
behaviours of selective exposure and avoiding information, and hence to information
failure.
Flawed communication and subsequent biased decision-making also contributed to
both disasters. Due to the strictly hierarchical structure of NASA’s chain of
command (Daft, 2003), informal channels of communication emerged, which had as
a result information coming through them not to be acknowledged or be rejected as
invalid This situation affected the efficient and timely flow of information to
decision-makers (Turner & Pigeon, 1997) and enabled behaviours of information
avoidance, as if it was considered to be unwanted and inconsistent with the dominant
position it was ignored or rejected (Markoulides & Heck, 1993).
Accordingly, the pattern of decisions made during both the Challenger and Columbia
disasters reveal escalation of commitment to the course of the predefined by NASA
action, in that meeting the flight schedule. The agency’s culture also contributed to
the intensification of commitment towards launching (Schein, 1985). To accept the
concerns regarding the low temperature and the foam-debris strikes would result in
delaying or worse cancelling the launch, which in both cases would be seen as failure
of NASA’s behalf to achieve the desirable goal. Consequently, the organisation
would lose further funding and support and its myth would be chattered. Thus, in
49
order to avoid such possibility, NASA escalated commitment to its current course of
action with information that supported the decision to launch (Staw & Fox, 1997).
Conversely, information that was inconsistent with the predefined course was
avoided, ignored or distorted (Drummond, 1999).
Furthermore, changing a previously accepted rationale, in that flying with recorded
O-ring erosion and foam shedding is safe, would be seen as the management was
incapable of addressing and acting upon potentially sources of hazard and may have
resulted in permanent termination of the program. Therefore, intensification of
commitment to completing the mission took place by avoiding or distorting the
discomforting and inconsistent information (Staw, 1981).
The escalation took place for such a long period of time and became so ingrained to
NASA’s culture and the way it operated that such behaviour was normalised; it was
almost impossible for those in the chain of command to recognise it occurred and
then change it. Moreover, in both incidents decision-making was subject to
unanimity. During stressful situations, where important decisions have to be made,
individuals are under great pressure to conform to the dominant position (Whyte,
1993). Additionally, collective decision-making require simplified assumptions,
which result in the creation of “blind-spots”. Consequently, collective erroneous
perceptions are generated, and thus distinctive information may be ignored and
signals of hazard may be missed (Weick, 1998).
50
Framework diagram
: Information behaviours are consistent with the theories
: Information behaviours informed by the themes
: The decision-making trajectory
: Interaction between the themes
: The interrelation between the culture and information behaviours
Culture
Myth Image
Image
Flawed
communication
& decision-
making
Pressures:
political &
production
Information
behaviours.
Information seen as
threat to image/myth
is avoided or ignored
“Face Threat”
“Affective
Load”
Theories
Information behaviour
of selective exposure.
Information consistent
with dominant opinion
accepted
Information
inconsistent with
dominant opinion:
avoidance & selective
exposure
Escalation of
commitment
51
6. Conclusion
6.1. Contribution to knowledge
Challenger and Columbia’s space shuttle disasters constitute prime examples of the
impact information behaviours have on an organisation leading to information failure
and ultimately to catastrophic outcomes. This research highlighted the actors
involved in the two disasters and revealed the existence of certain information
behaviours within NASA that affected the way in which it operated, treated and
communicated information. More specifically, information avoidance, selective
exposure to information and escalation of commitment to a predefined course of
action were found to be significant influencing factors in decision-making during
both incidents.
In addition to these behaviours, the agency’s culture played an important role
throughout NASA’s history and in the course of the events in particular. A pattern of
similarities derived from the analysis of the official reports shows a strong
correlation between the information behaviours followed during both incidents.
Moreover, these behaviours were found to have significant impact on the decision-
making process leading to a trajectory and eventually to the disasters.
NASA’s management can be seen as the protagonist of the incidents, as in both cases
it employed certain information behaviours and insisted in following the predefined
course rather than acknowledge and act upon its engineers’ concerns and
recommendations. During both Challenger and Columbia, managers were found to
be in the centre of the events being unable to fully grasp the importance of the
information communicated by the engineers. Due to the pressures, political and
internal, they were in a way forced to follow a certain path so as to meet the schedule
and thus achieve the agency’s goals, in that to fulfil the governments requirements
and ensure further funding and support. It could be, hence, argued that the
government is as much responsible for the disasters as NASA. Had not had the
organisation experienced political pressures, it would not have insisted on meeting
the schedule and information behaviours would not have been developed.
Additionally, the agency’s culture was found to be over-confident and with a “can-
do” attitude. A sense of invincibility was cultivated over the years, which resulted in
52
the creation of “blind spots” and enabled the establishment and adoption of an
erroneous perception that NASA could achieve anything. Consequently, an image of
a “great organisation” was built, which NASA was determined to promote and
sustain. This resulted in the agency’s culture being more resistant to change. Due to
the intensification and continuous denial to accept that goals might not be met,
behaviours of selective exposure to and information avoidance were developed and
got ingrained in NASA’s culture. From that point onwards, avoiding and ignoring
information that would jeopardise the organisation’s image and goals was acceptable.
Furthermore, a pattern of similar information behaviours was identified in both
incidents. Information regarding the hazards of low temperature and foam-debris
strikes existed and concerns about their potential catastrophic consequences were
voiced. They were, however, systematically ignored and avoided. On the contrary,
what was consistent with the agency’s goals was accepted and promoted. In addition,
in both disasters, intensification of commitment to the decision of launching took
place and led to information failure.
The research also revealed an interrelation between the organisation’s culture and the
aforementioned behaviours. It became clear that the adopted information behaviours
were informed by the agency’s culture. Α strong organisational culture is seen as
integrated patterns of meaning, which guide relationships and operations within an
organisation and provide a reference point based on which actions are taken and
decisions are made. Consequently, certain taken-for-granted cultural assumptions
were espoused and NASA became constrained within a certain way of thinking and
acting. This resulted in a decision-making trajectory leading to information failure
and ultimately to the disasters.
Moreover, the framework that was developed delineates the connection between the
organisation’s culture and the information behaviours that were identified. It also
depicts the impact it has on all aspects of the agency as throughout the course of both
disasters, culture was a powerful yet subliminal driver. It can be, thus, argued that a
strong and resistant to change culture leads to the adoption of certain information
behaviours which in turn may result in information failure.
53
6.2. Limitations of the study
This research was limited by the scarcity of official reports other than the ones of
NASA regarding the two disasters. Their analysis might have provided diverse
perspectives on the incidents and a point of reference for the results of the research as
well as a measure for comparison on how third parties perceive and deal with such
situations.
6.3. Further research
The results of this research suggest that during both incidents certain information
behaviours were adopted leading to information failure. In addition, an interrelation
between the organisation’s culture and these behaviours was identified as
contributing factor to the disasters. Although a great number of literature deals with
organisational culture and information behaviour as two separate subjects, no
extensive research has been conducted regarding their connection and potential
consequences to the organisational environment. With the above limitations removed
a more in depth study of their relationship and impact on decision-making and
information failure within organisations can be performed, resulting in the
establishment of a better understanding.
(Word count: 14.214)
54
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8. Appendices
Appendix 1 Themes
Theme 1:
Label: NASA’s Culture
Definition: The basic values, norms, beliefs and practices that define an
organisation’s functioning and its employees’ assumptions.
Indicators: Coded when the report states “cultural traits”, “program culture”
or “organisational culture”.
Differentiation: Occasionally “history” is treated as intertwined with
“culture”.
Theme 2:
Label: Political and production pressures
Definition: The idea that an organisation must move from one status
(expectations) to another (achievement of goal).
Indicators: Coded when the report states “pressures to stay on schedule”,
“schedule pressures” or “pressures to meet the schedule”, “faster, better, cheaper”,
“pressing need to launch”,.
Theme 3:
Label: Communication and decision-making
Definition: The dissemination of information throughout all levels and lines
of authority, and the process of selecting a logical choice among available options
that is followed by individuals and/or organisations.
Indicators: Coded when the report states “communication of information”,
“communication failures, incomplete and misleading information”,
“communication difficulties”, and “decision-making”, “decision-making process”,
“managers accepted”, “management judgement”.
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Appendix 2 Research classification
Notification sent via e-mail concerning the classification of the research.
Research ethics risks assessment
Information School Research Ethics
Dear Stavroula,
I am writing to inform you that your dissertation proposal has been re-assessed, and
it has been confirmed that your dissertation is actually no risk. As such, you are not
required to apply for ethics approval.
Instead, you should include a statement in the Methods section that indicates that the
research has no risks, and you should indicate why, illustrating that you understand
research ethics implications. If you have re-used data collected by another person,
you must indicate that the data was ethically collected, that is, you should know
whether you are using viable data.
You are advised to keep a copy of this email for your records.
With best regards
63
Appendix 3 Definitions of foam-loss events classification
In-Family: A reportable problem that was previously experienced, analyzed, and
understood. Out of limits performance or discrepancies that have been previously
experienced may be considered as in-family when specifically approved by the Space
Shuttle Program or design project.8
Out-of-Family: Operation or performance outside the expected performance range
for a given parameter or which has not previously been experienced.
Accepted Risk: The threat associated with a specific circumstance is known and
understood, cannot be completely eliminated, and the circumstance(s) producing that
threat is considered unlikely to reoccur. Hence, the circumstance is fully known and
is considered a tolerable threat to the conduct of a Shuttle mission.
No Safety-of-Flight-Issue: The threat associated with a specific circumstance is
known and understood and does not pose a threat to the crew and/or vehicle.
(CAIB, 2003, p. 122, Ch. 6)
64
Appendix 4 Missed opportunities
1. Flight Day 4. Rodney Rocha inquires if crew has been asked to inspect for
damage. No response.
2. Flight Day 6. Mission Control fails to ask crew member David Brown to
downlink video he took of External Tank separation, which may have
revealed missing bipod foam.
3. Flight Day 6. NASA and National Imagery and Mapping Agency
personnel discuss possible request for imagery. No action taken.
4. Flight Day 7. Wayne Hale phones Department of Defense representative,
who begins identifying imaging assets, only to be stopped per Linda
Hamʼs orders.
5. Flight Day 7. Mike Card, a NASA Headquarters manager from the Safety
and Mission Assurance Office, discusses imagery request with Mark
Erminger, Johnson Space Center Safety and Mission Assurance. No action
taken.
6. Flight Day 7. Mike Card discusses imagery request with Bryan OʼConnor,
Associate Administrator for Safety and Mission Assurance. No action
taken.
7. Flight Day 8. Barbara Conte, after discussing imagery request with Rodney
Rocha, calls LeRoy Cain, the STS-107 ascent/entry Flight Director. Cain
checks with Phil Engelauf, and then delivers a “no” answer.
8. Flight Day 14. Michael Card, from NASAʼs Safety and Mission Assurance
Office, discusses the imaging request with William Readdy, Associate
Administrator for Space Flight. Readdy directs that imagery should only be
gathered on a “not-to-interfere” basis. None was forthcoming.
(CAIB, 2003, p. 167, Ch. 6)
65
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