$225,000,000 typo

To err is human.  But to err to the tune of $225 million because of a single typo?  Ouch!

News headlines last week included what may be the single costliest Fat Finger error in the financial markets’ history. 

Fat finger error occurs by pressing the wrong buttons on a keyboard.  Just last week, a Japanese stock broker entered 610,000 shares at 1 yen (less than a penny) per share instead of 1 share at 610,000 yens for a company going public. 

$225 millions gone – just like that. 

I bet the idea that it’s OK to learn from your mistakes just went out the window at this fat-fingered employee’s company.  Maybe they even adopted a new slogan: “to err is human and to forgive is against company policy.”

In our industry, human error is the largest contributing factor to accidents and loss. 

According to the ASM consortium, 42% of all accidents are due to human error and the cost of industrial accidents in the USA alone exceeds the GNP of many countries.  These errors come from both taking the wrong action and failing to take action. 

The “Fat Finger” is a common cause of taking the wrong action.  I have seen a process unit nearly came to a disastrous conclusion after an operator had entered 47% instead of 4.7% as the setting of a very critical slide valve.  The chance for reoccurrence of this error was minimized by adding some software for smarter data entry checking, but this surely can’t be done for every single entry – even though that unfortunate trader in Japan may sure wish that to be true…

Failing to take action is quite something else, and generally comes from inadequate training or operator overload.  Training is an ongoing priority for almost every company in the process industries and handled quite well by friends like those at TTS Performance Systems. 

Failing to act from operator overload is often the result of too many systems, all of which were at one time implemented for good reasons of safety and improved performance.  However, when it rains it pours, and often the alarms from these systems all demand operator attention at the same time to correct a critical situation. 

Here at PAS we have seen far too many operator overloads.  Since ‘94, we have focused on improving operator effectiveness by providing the right tools for early fault detection and also solutions for avoiding alarm system overload.  Accidents such as the one at the Texaco Pembroke refinery in the UK and, more recently, at BP Texas City could have been mitigated had the alarm system been properly designed and maintained. 

I am proud to be a part of a company that has led the industry in creating awareness and developing technologies to address the alarm management issue. 

Too bad for our friend in Japan that he didn’t have all the safeguards available to our process plants, but at least there wasn’t any human life at risk in that case. 

The moral of the story:  Drive defensively and type carefully.