The Therac-25 Software Disaster

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The Therac-25 Software Disaster

The Therac-25 is a computerized medical radiation therapy machine for cancer patients. During the time span of June 1985 to January 1987, it was the source of six fatal or near fatal overdoses. These incidents were a result of a combination of factors that can be viewed as unethical actions made through the ranks of hierarchy, from the manufactures to the FDA.
The Therac-25 is a medical dual-mode linear accelerator that is used to target the less sensitive cancer cells of patients. The Therac-25 was not the first generation of this product. The previous versions, Therac-6 and Therac-20, were very similar, however the Therac-25 used more advanced technology. Compared to the Therac-20, the Therac-25 is more compact, versatile, and easier to use. All these added features are consequences of its dependence on software, instead of hardware. In this paper, I will evaluate the problematic actions that lead to the poor design of the product (“Death and Denial”).
The leading factor contributing to the poor design can be found in the programming of the software. The first mistake made was that a single programmer was responsible for the software in all three different versions of the Therac. Because the single programmer was negligent of his or hers responsibilities, many issues arose within the software. Examples of the programmer’s unethical behavior include him not informing his supervisor of the possible dangers of having no safely catches outside of the software. The programmer also used unprotected memory, improper initialization, and did not test the software properly. Since a single programmer designed all three generations of the product, the new iterations reused the same software. (“System Safet...

... middle of paper ...

... placed on one individual; however, the actions of all involved failed to properly address the right problems.

References

Leveson, Nancy G., Turner Clark S. “An Investigation of the Therac-25 Accidents.” Online Ethics Center for Engineering and Science. National Academy of Engineering. 16 Feb. 2006. 15 April 2014. http://www.onlineethics.org/Resources/Cases/therac25.aspx

Leveson, Nancy G. “Medical Devices: the Therac-25.” Massachusetts Institute of Technology. 19 April 2014. http://sunnyday.mit.edu/papers/therac.pdf

Porrello, Anne Marie. “Death and Denial: The Failure of the THERAC-25, A Medical Linear Accelerator.” 22 April 2014. California Polytechnic State University. http://users.csc.calpoly.edu/~jdalbey/SWE/Papers/THERAC25.html

“System Safety.” 22 April 2014. Computing Cases.org. http://www.computingcases.org/case_materials/therac/analysis/Safety.html

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