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Project 7: Case Study With ICT :computer Failures

This case study examines a computer failure involving a radiation therapy machine called the Therac-25. The Therac-25 suffered from software bugs that allowed the machine to deliver massive overdoses of radiation, resulting in patient injuries and deaths. An investigation found issues including reused software that was not properly tested, weak operator interfaces, and inadequate safety testing. Responsibility was assigned to both the manufacturer for software and design flaws, and hospitals for using the defective machine. The case highlights the importance of software engineering practices, user interface design, and regulatory oversight to improve safety for systems involving human lives.

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aliancista12345
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736 views

Project 7: Case Study With ICT :computer Failures

This case study examines a computer failure involving a radiation therapy machine called the Therac-25. The Therac-25 suffered from software bugs that allowed the machine to deliver massive overdoses of radiation, resulting in patient injuries and deaths. An investigation found issues including reused software that was not properly tested, weak operator interfaces, and inadequate safety testing. Responsibility was assigned to both the manufacturer for software and design flaws, and hospitals for using the defective machine. The case highlights the importance of software engineering practices, user interface design, and regulatory oversight to improve safety for systems involving human lives.

Uploaded by

aliancista12345
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PPT, PDF, TXT or read online on Scribd
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Case Study on Computer failure

Errors, Failures, and Risks

By Nelson Perez

What We Will Cover


Failures and Errors in Computer Systems Case Study: Computer failure Increasing Reliability and Safety Dependence, Risk, and Progress

Failures and Errors in Computer Systems


Most computer applications are so complex it is virtually impossible to produce programs with no errors The cause of failure is often more than one factor Computer professionals must study failures to learn how to avoid them Computer professionals must study failures to understand the impacts of poor work

Failures and Errors in Computer Systems (cont.)


Individual Problems: Billing errors Inaccurate and misinterpreted data in databases Large population where people may share names Automated processing may not be able to recognize special cases Overconfidence in the accuracy of data Errors in data entry Lack of accountability for errors

Failures and Errors in Computer Systems (cont.)


System Failures: AT&T, Amtrak, NASDAQ Businesses have gone bankrupt after spending huge amounts on computer systems that failed Voting system in 2000 presidential election Denver Airport Ariane 5 Rocket

Case Study: The Therac-25


Software and Design problems: Re-used software from older systems, unaware of bugs in previous software Weaknesses in design of operator interface Inadequate test plan Bugs in software Allowed beam to deploy when table not in proper position Ignored changes and corrections operators made at console

Case Study: The Therac-25 (cont.)


Why So Many Incidents? Hospitals had never seen such massive overdoses before, were unsure of the cause Manufacturer said the machine could not have caused the overdoses and no other incidents had been reported (which was untrue) The manufacturer made changes to the turntable and claimed they had improved safety after the second accident. The changes did not correct any of the causes identified later

Case Study: The Therac-25 (cont.)


Why So Many Incidents? (cont.) Recommendations were made for further changes to enhance safety; the manufacturer did not implement them The FDA declared the machine defective after the fifth accident The sixth accident occurred while the FDA was negotiating with the manufacturer on what changes were needed

Case Study: The Therac-25 Discussion Question


If you were a judge who had to assign responsibility in this case, how much responsibility would you assign to the programmer, the manufacturer, and the hospital or clinic using the machine?

Increasing Reliability and Safety


What goes Wrong? Design and development problems Management and use problems Misrepresentation, hiding problems and inadequate response to reported problems Insufficient market or legal incentives to do a better job Re-use of software without sufficiently understanding the code and testing it Failure to update or maintain a database

Increasing Reliability and Safety (cont.)


Professional techniques: Importance of good software engineering and professional responsibility User interfaces and human factors Feedback Should behave as an experienced user expects Workload that is too low can lead to mistakes Redundancy and self-checking Testing Include real world testing with real users

Increasing Reliability and Safety (cont.)


Law, Regulation and Markets: Criminal and civil penalties Provide incentives to produce good systems, but shouldn't inhibit innovation Warranties for consumer software Most are sold as-is Regulation for safety-critical applications Professional licensing Arguments for and against Taking responsibility

Dependence, Risk, and Progress


Are We Too Dependent on Computers? Computers are tools They are not the only dependence Electricity Risk and Progress Many new technologies were not very safe when they were first developed We develop and improve new technologies in response to accidents and disasters We should compare the risks of using computers with the risks of other methods and the benefits to be gained

Dependence, Risk, and Progress Discussion Questions


Do you believe we are too dependent on computers? Why or why not? In what ways are we safer due to new technologies?

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