Lying on the cold metal table, Voyne Ray Cox knew the drill. This was his ninth round of cancer treatment – which is why he was certain that what happened next couldn’t be right. He heard a sizzling sound and saw a blue flash. And then – agony. It was like someone had thrust a hot skewer through his shoulder. He cried out in pain, but the operator was down the corridor and she couldn’t hear him. She blasted him again and again with the red-hot radiation beam.
Ray wasn’t the first patient to be burned by the Therac-25 therapy machine, and he wouldn’t be the last. Its dual-purpose design, controlled by a software programme, was supposed to offer hospitals more bang for their buck. But as patient after scorched patient suffered ulcerated skin and yawning lesions, it should have been clear that something was horribly wrong. Why did it take so long for anyone to put this awful puzzle together?
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Further reading
Nancy G. Leveson and Clark S Turner “An Investigation of the Therac-25 Accidents” Computer 1993
Nancy Leveson “Medical Devices: The Therac-25” in Nancy Leveson Software: System Safety and Computers 1995.
Steven M. Casey Set Phasers On Stun
Supplementary sources include
Charles Huff “Therac-25 Case Narrative” Online Ethics Center 2003 and Adam Fabio “Killed By a Machine” Hackaday 26 October 2015
Helen Nissenbaum. 1994. Computing and accountability. Commun. ACM 37, 1 (Jan. 1994), 72–80.
“Lethal Doses Radiation That Kills” The Plain Dealer, Cleveland 16 December 1992
James Reason Human Error
And
Tom Standage 1843 Magazine “What we can learn from the world’s first computer bug” 1843 Magazine 4th Sep 2019