
The Race Condition That Killed Two Patients
In the 1980s, a radiation therapy machine called the Therac-25 delivered massive overdoses because of a software timing bug invisible to its makers. This is the story of how a single misplaced assumption in code became a lesson every safety engineer still learns.
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The Therac-twenty-five replaced physical hardware interlocks with software controls that failed to prevent lethal radiation overdoses.
A race condition occurred when experienced operators corrected input errors in less than eight seconds.
Cryptic error codes like Malfunction fifty-four failed to warn staff that patients were receiving massive radiation doses.
An arithmetic overflow in a single-byte counter allowed the machine to bypass critical safety checks.
The Food and Drug Administration grounded all machines in February nineteen eighty-seven following three patient deaths.
Modern medical software standards now require defense-in-depth to prevent single-point failures in physical environments.
- 01Intro1 min
- 02The Invisible Failure2 min
- 03Malfunction 543 min
- 04The Denial of Failure2 min
- 05The Legacy of Defense in Depth3 min
- 06Outro1 min
- Therac-25
- Therac-25 - Ethics Unwrapped
- Therac-25 Radiation Therapy Accidents
- An Investigation of the Therac-25 Accidents - Columbia CS
- An Investigation of Therac-25 Accidents - I
- Therac-25 radiation therapy accidents - Charter
- [PDF] An Investigation of the Therac-25 Accidents - UC Irvine
- An Investigation of the Therac-25 Accidents -- Part II - MIT
- The Therac-25 — What Really Happened - VastBlue Innovations
- The Therac-25: 30 Years Later - IEEE Computer Society
- An Investigation of the Therac-25 Accidents -- Part IV
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