参考资料

Therac-25 の使用によって引き起こされた事故は,オペレータが誤って「x 」キー(X線照射モードの設定)を押し,「8秒以内」に「↑」キーを押すことで電子線照射モードに変更した場合にしばしば生じるものであった. 問題となる機器の異常動作は発生しなかった

The Therac-25 is a computer-controlled radiation therapy machine produced by Atomic Energy of Canada Limited (AECL) in 1982 after the Therac-6 and Therac-20 units (the earlier units had been produced in partnership with Compagnie générale de radiologie (CGR) of France). [1]The Therac-25 was involved in at least six accidents between 1985 and 1987, in which some patients were given massive

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