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Therac-25

Radiation therapy machine made by AECL

Aftermath

AECL's Response

  • Problems resolved
  • AECL Medical dissolved
  • Programmer vanished

By Evan Laursen

  • "That's impossible"
  • Improved by five orders of magnitude
  • Misleading information

What we can learn

The Problem

Don't take shortcuts in safety

Don't be overconfident in your work

  • Two operating modes
  • Relied solely on software

Causes

  • The code was not reviewed
  • Useless error codes
  • Little testing

References

Worst Case Scenerio

  • Ray Cox
  • 180 or 15,000
  • http://www.ccnr.org/fatal_dose.html
  • http://en.wikipedia.org/wiki/Therac-25
  • http://hci.cs.siue.edu/NSF/Files/Semester/Week13-2/PPT-Text/images/Image3.png
  • http://www.thestar.com/opinion/editorials/2011/07/01/sad_end_for_a_canadian_success_story.html
  • http://aabb.multiview.com/userlogo/aabb/1185938v1v1.jpg
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