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.
N. G. Leveson and C. S. Turner, "An Investigation of the Therac-25 Accidents," in Computer, vol. 26, no. , pp. 18-41, 1993.