kyle-hill 39 years ago
science educator #Technology

Kyle Hill | History's Worst Software Error (1985)

In 1985, a state-of-the-art radiation therapy device called the THERAC-25 started blasting holes through patients' bodies, leading to the world’s first death by radiation treatment overdose. It killed two more people before anyone knew what was going wrong. Why?

The Therac-25 was a computer-controlled radiation therapy machine produced by Atomic Energy of Canada Limited (AECL) in 1982 after the Therac-6 and Therac-20 units (the earlier units had been produced in partnership with Compagnie Générale de Radiologie (CGR) of France).


It was involved in at least six accidents between 1985 and 1987, in which patients were given massive overdoses of radiation. 


Because of concurrent programming errors (also known as race conditions), it sometimes gave its patients radiation doses that were hundreds of times greater than normal, resulting in death or serious injury.


These accidents highlighted the dangers of software control of safety-critical systems, and they have become a standard case study in health informatics, software engineering, and computer ethics.


Additionally, the overconfidence of the engineers and lack of proper due diligence to resolve reported software bugs are highlighted as an extreme case where the engineers' overconfidence in their initial work and failure to believe the end users' claims caused drastic repercussions.

Kyle Hill
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