I think the Systems Theory Model is the most applicable in determining and explaining how everything went wrong at the Stinson Shipping Company. To begin with, the environment was extremely hectic. Tom Murphy was under considerable pressure to deliver the goods on time amidst the increase in business over the past three months. I think that it is quite possible that his supervisors had a “Git-R-Done” philosophy and Tom felt he had to adopt the same mentality to be a success in the position.
There may have been some training issues as well because Tom should have known that the mixing of caustic lye and Hydraulic fluid would be dangerous; instead he was more concerned about weather the fork lift could lift the load. Both problems needed to be considered because it was really the combination of the two that caused the disaster. The Hydraulic fluid leaking caused the fork lift to fail which in turn caused the pallets to fall resulting in the caustic lye mixing with the Hydraulic fluid.
There was really a failure to communicate on all ends. The equipment Manager, Mike Morello, jury rigged the fork lift and was no where to be seen. I would think at the least they all would have been observers making sure to spot for anything that could go wrong. When Bill Jefferson, noted drops of hydraulic fluid on the dock floor, he should have stopped and walked over to Tom instead of just waiving at him. The interaction of people machine and environment was dire but their was a breakdown. Even though information was collected, I don’t think the risks were really weighed out. I think the risk they were most worried about was should they risk holding up the shipment?
Ultimately, he decision that Tom made was wrong, but still the accident could have been avoided had Mike stood his ground, The two of them supervised the loading, had Bill done a better job of communicating. Now Bill is covered with the chemical and being rushed to the hospital. This...