An investigation of the Therac-25 accidents
Leveson, N.G.; Turner, C.S.
Computer
Volume 26, Issue 7, Jul 1993 Page(s):18 - 41
Digital Object Identifier 10.1109/MC.1993.274940
Summary:Between June 1985 and January 1987, the Therac-25 medical electron
accelerator was involved in six massive radiation overdoses. As a
result, several people died and others were seriously injured. A
detailed investigation of the factors involved in the software-related
overdoses and attempts by users, manufacturers, and government agencies
to deal with the accidents is presented. The authors demonstrate the
complex nature of accidents and the need to investigate all aspects of
system development and operation in order to prevent future accidents.
The authors also present some lessons learned in terms of system
engineering, software engineering, and government regulation of
safety-critical systems containing software components
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