Killed by a Machine: The Therac-25

The Therac-25 was not a device anyone was happy to see. It was a radiation therapy machine. In layman’s terms it was a “cancer zapper”; a linear accelerator with a human as its target. Using X-rays or a beam of electrons, radiation therapy machines kill cancerous tissue, even deep inside the body. These room-sized medical devices would always cause some collateral damage to healthy tissue around the tumors. As with chemotherapy, the hope is that the net effect heals the patient more than it harms them. For six unfortunate patients in 1986 and 1987, the Therac-25 did the unthinkable: it exposed them to massive overdoses of radiation, killing four and leaving two others with lifelong injuries. During the investigation, it was determined that the root cause of the problem was twofold. Firstly, the software controlling the machine contained bugs which proved to be fatal. Secondly, the design of the machine relied on the controlling computer alone for safety. There were no hardware interlocks or supervisory circuits to ensure that software bugs couldn’t result in catastrophic failures.

The case of the Therac-25 has become one of the most well-known killer software bugs in history. Several universities use the case as a cautionary tale of what can go wrong, and how investigations can be lead astray. Much of this is due to the work of [Nancy Leveson], a software safety expert who exhaustively researched the incidents and resulting lawsuits. Much of the information published about the Therac (including this article) is based upon her research and 1993 paper with [Clark Turner] entitled “An Investigation of the Therac-25 Accidents”. [Nancy] has since published updated information in a second paper which is also included in her book.

Continue reading “Killed by a Machine: The Therac-25”