Malfunction 54
The Therac-25 was a computer-controlled radiation therapy machine produced by Atomic Energy of Canada Limited (AECL) in 1982 after the Therac-6 (neptune) and Therac-20 units (the earlier units had been produced in partnership with Compagnie générale de radiologie (CGR) of France).
The Therac-25 was involved in at least six accidents between 1985 and 1987, in which some patients received overdoses of radiation. Because of concurrent programming errors (also known as race conditions), it sometimes gave its patients radiation doses that were many times greater than normal, resulting in death or serious injury. These accidents highlighted the dangers of software control of safety-critical systems.
The Therac-25 has become a case study in health informatics, software engineering, and computer ethics. The incidents highlight the dangers of engineer overconfidence after the engineers dismissed end user reports, leading to severe consequences.
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