Beyond human error: the butterfly effect

Paul Pegg on how life-altering events can be caused by tiny actions, and offers advice on more effective health and safety best practice

 It’s sometimes hard to believe that tiny things can have such large effects. But the recent BP Deepwater Horizon drilling rig disaster has shown that a small gas leak can lead to a spill so large.

Scientists have gone one step further and developed a theory to explain how life-altering events can be caused by tiny actions. The “butterfly effect” states that it’s possible for a hurricane in Jamaica, for instance, to be caused by a butterfly flapping its wings in Mexico. Just one small flutter can create a chain of events that could have devastating consequences.

Paul Pegg

When it comes to the logistics industry, the ‘butterfly effect holds true. Small slip-ups can create catastrophes. Take the Buncefield oil storage depot disaster in Hertfordshire, UK, for example. A series of explosions caused a fire of massive proportions – the largest in peacetime Europe. Nearby properties were wiped out, including Keystone’s Hemel Hempstead Distribution Centre.

After a lengthy series of investigations, the initial culprit was found to be a faulty gauge on one of the storage tanks. This small fault led to a chain of events that caused more than 40 people to be injured.

It’s clear that the consequences of health and safety breaches can be wide and far reaching. But being safe is about more than buying the best machinery and ensuring the parts are optimally maintained. Safety starts with people. And it’s up to people to take responsibility for creating a safe working environment.

The flipside is that the small actions that each member of a safety-conscious workplace carries out can make a huge difference – creating a ripple effect of good feeling, not to mention a safe workplace. This can lead to a shared sense of trust, co-operation, loyalty and commitment among employees.

Human error will always be an unavoidable by-product of the logistics industry, but there are several steps that companies can take to create an optimal safety culture.

In many companies, if you ask people to recite their organisation’s mission statement, they’ll be hard-pressed to convey the gist, let alone remember it word-for-word. Yet, the company’s stance on safety is often outlined in the mission statement.

And if you ask these same employees, who is in charge of safety, they’ll usually point to the person who has the words “health” or “safety” in their job title. So, the safety culture seems to get lost somewhere between the mission statement and the Health, Safety, Security and Environment Manager.

Health and safety is more about attitude and behaviour than procedure. It’s all very well having management systems, policies and comprehensive procedures that cover work activities. But safety procedures only work if people follow them correctly and fully understand the consequences of any unsafe shortcuts.

Always remember that people are the best sources of creativity, flexibility and problem-solving ability. Keep this in mind with every health and safety procedure you implement. Don’t be too rigid and allow individuals to feel free to work effectively within certain guidelines.

If you’re in a hurry, it’s easy to get into your car and forget to put your seatbelt on. Often, your dashboard will start beeping and/or flashing to let you know your mistake. But even if it doesn’t, your subconscious usually tells you something doesn’t feel right.

Most employees have come across that feeling at work, when they’ve tried to cut corners or, perhaps, deliberately done something unsafe. It’s vital for them to pay attention to this feeling, because things usually go wrong when they don’t. Simply communicating health and safety information via plasma screens, briefings and workshops can bring safety to the forefront of employees’ minds. And this can help them to listen to their internal impulse to keep safe and well.

Explicitly tell employees that they have the right to question others if they see them carrying out an unsafe act. Work on actively developing a culture in which safety is valued above employee hierarchy. This helps create an atmosphere in which people know that their comments count, and helps them feel empowered to speak up.

The trouble with safety is that you never quite know which safety behaviour prevented which particular accident or injury – the butterfly effect doesn’t work backwards. There’s little fame and glory in being safe, but creating a safety culture will pay dividends.

Paul Pegg is VP of Keystone – Distribution Europe

Banksmen, stevedores and air cargo handlers: the safety net in your supply chain

Bearing a responsibility often misunderstood or undervalued, the importance of appropriate training for this key group in the logistics workforce cannot be underestimated, believes James Tillyer  

When considering safety in the supply chain, one might think of procedures relating to the loading or packing of goods, or perhaps maintenance and condition of equipment. Maybe storage facilities and their inherent hazards. Typically, the focus will be on safety at the site and the welfare of workers, contractors and visitors within it.

The overwhelming reason why most UK-based companies have a safety system in place is to ensure legal compliance, coupled with corporate and social responsibilities. When you consider the corporate manslaughter and homicide legislation, it’s easy to see why companies are addressing this with renewed vigour.

James Tillyer

Supply chains can be enormous, involving a huge array of people from across the world, working on a wide range of activities with the ultimate goal of achieving profitable delivery of goods, on time and in perfect condition.

There is a key group in the logistics workforce that has a responsibility often misunderstood or underestimated; often with responsibility for ensuring site safety during vehicle or load movements, the securing and optimal positioning of loads, providing assistance to vehicle or machine operators and for ensuring the safety of others during these processes.

This group is most commonly known as banksmen, stevedores and air cargo handlers.

Among other responsibilities, banksmen assist a driver during reversing manoeuvres. But if, for instance, a trailer unit is curtain-sided, it is less likely that a banksman will be needed for reversing duties as the goods may be unloaded using a fork-lift from the side. However, the banksman may be used to oversee the loading/unloading process to ensure a safe procedure.

The importance of their role cannot be understated and the fear is that, in this current economic climate, some companies may reduce costs by delegating the traditional banksman role elsewhere. Recent figures show the number of non-fatal injuries where a banksman has been present is lower than the number of non-fatal injuries for the industry as a whole – and bear in mind that over one-third of these injuries involve a moving vehicle.

Stevedores work exclusively in ports and docks. Their primary role is to assist in the loading or unloading of containerships, often involving the use of derricks, cranes and other marine equipment. Stevedores will usually work closely with a ship’s crew, one or two of whom will oversee container placement and safety on board.

The pressures placed on a stevedore are usually very different to those of a banksman. Amid an increasingly fervent and competitive industry attitude, the pressure to provide swift and efficient service has been borne by the stevedore, which in turn presents greater risk of injury and damage to often high-value goods.