What was the Therac 25? - Answers A medical linear accelerator used to treat cancer patients in order
to remove tumors
What happened with the Therac-25? - Answers In Tyler, TX a patient complained about a bright flash
of light and hearing a frying, buzzing sound; signs of radiation overdoes after cancer treatment
sessions; two patients died; more accidents occurred
How did the Therac-25 accidents happen? - Answers In texas, Operator selected x-rays by mistake and
used cursor keys to change to electrons; Causes a malfunction 54 trip; in documentation this is a
"does input 2" error; In washington, Operator used hand controls to rotate table to field-light position
and check alignment; Set machine but forgot to remove film; Turned beam on and machine showed
no dose
What were the roots of the Therac 25 accident? - Answers Software code was not independently
reviewed; AECL did not consider the design of the software during its assessment of how the machine
might produce the desired results and what failure modes existed; The user manual did not explain or
even address the error codes; The engineer has reused software from older models
What with Boeing 737-MAX? - Answers The planes malfunctioned due to reuse of code and usage of
new system MCAS to resolve a minor problem; manuals were not updated to include info
What are Leveson's Casual Factors? - Answers Overconfidence in software, confusing reliability with
safety, lack of defensive design, failure to eliminate root causes, complacency, unrealistic risk
assessments, inadequate investigation/follow-up on accidents, inadequate SW engineering practices,
Software reuse naivety, Safety vs friendly UI, user/gov't oversight
What is overconfidence in software? - Answers A feeling among nonsoftware professional that
software will not or cannot fail, which leads to complacency and overreliance on computer functions;
Also stems from engineers ignoring software in their safety checks
What is confusing reliability with safety? - Answers When you mistake the consistency of how many
times a software has worked to mean that it is safe
What is lack of defensive design? - Answers When software does not contain self-checks or error
detection/handling
What is failure to eliminate root causes? - Answers Protection could've been built into the hardware
and software to prevent the accident; Therac-20 hardware had interlocks to mitigate the error, but
those were removed in the 25 but the same software was reused; Shouldn't do band aid fixes for each
situation need to find the root cause of all the cases
What is complacency? - Answers Takes the event of an accident to alert people to the dangers
What are unrealistic risk assessments? - Answers When they underestimate the likelihood of a
software error or assume all errors are likely to occur
What is inadequate investigation/follow-up on accidents? - Answers when companies or regulators
don't properly investigate accidents or incidents nor do they inspect after changes are made
What are inadequate SW engineering practices? - Answers Not updating or keeping accurate
documentation; No QA practices
What is software reuse naivety? - Answers when companies don't update software when they make
changes elsewhere specifically to hardware
What is safety vs friendly UI? - Answers when they value use of ease over safety measures in UI
What is user/gov't oversight? - Answers When people don't report or act upon incidents
What is authoritarian in political artifacts? - Answers System centered, immensely powerful but
inherently unstable
What is democratic in political artifacts? - Answers Man-centered, relatively weak, but resourceful
and durable
What is the social determination of technology? - Answers The social or economic system in which
tech is embedded is what matters; Technologies are shaped by social and economic forces
What are the ways tech can have politics? - Answers by decision or by necessity
What does by decision mean? - Answers when tech arrangements are forms of order used to settle an
issue in the affairs of a community; Ex: long island bridge
What does by necessity mean? - Answers Inherently politically technologies; The choice to put
handles in the middle of park benches
What is subjective relativism? - Answers Each person decides right and wrong for himself or herself