You are on page 1of 10

THE THERAC 25

Zainab Sada
149190
Spring 2016
ENGL 201
Group 33

WHAT IS IT
Radiation Therapy Machine
One Of The Most Serious Computer Related Accidents
In History

OVERVIEW
History And Background
a. History Of The Therac-25
b. The Design

What Went Wrong


a. Software Bug
b. Cases And Incidents

HISTORY AND BACKGROUND OF


THE THERAC-25
Medical Linear Accelerator Developed by Atomic
Energy of Canada, Ltd And A French Radiation
Company in 1970
Predecessors are Therac-6 and Therac-20

THE DESIGN
The Machine
a. Double Pass Linear Accelerator
b. Two Modes; Electron Mode and Photon(X-ray Mode)
c. Turntable

The Software
a. PDP-11 Assembly Language
b. Responsible For A lot Of Things

SOFTWARE BUG
Lack Of Proper Assessment
Recurring Issues Never Fixed Or Understood
Main Cause: Race Condition
Race Condition Is The Behavior Of An Electronic, Software
Where The Output Is Dependent On The Sequence Or
Timing Of Other Uncontrollable Events.

CASES AND INCIDENTS


Six Accidents Involving Massive Overdoses Between
1985 and 1987
A 61 Year Old Woman
Overdosed With 15,000 Rads Of Radioactive Energy
Machine Projected Beam Without Spreading
Resultant Hole In Her Chest And Paralysis In Her Left Arm

First Fatality
Technician Quickly Changed Mode From X-ray To Electron
Using The Cursor Up Key, Thus Activating The Race
Condition
Error Message And Dose Repeated
Paralysis In Both Legs And Arms
Death

REACTIONS AND CONCLUSION


AECL Were Contacted
Only After The 6 t h Case Were The Machines Recalled
Machines Still In Use Today
Conclusion
It Is Important That Everyone Does Their Job Properly
Everything Should Be Tested Properly Before Offi cial Use