51–58 of 58 posts
I would add Therac-25[1] and the 500 mile email[2] to that list. [1]: http://www.ccnr.org/fatal_dose.html [2]: http://www.ibiblio.org/harris/500milemail.html
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Yep, also I would say that Heartbleed is definitely deserving of a place.
I agree, Heartbleed is a big miss. Before reading the article, the two that came to mind were Y2K and Heartbleed. Notwithstanding all the recent security breeches (e.g., Ashley Madison, Sony) that could be attributed to "bugs".
As others have noted, the big miss is the Therac-25 bug, which is pretty commonly taught in Software Engineering/Computer Science classes the example of how intangible software can kill people.
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My assumption is that you'd put the sensor behind the patient. After the beam has been through the body, you don't care if it's deflected or reduced. Obviously, it's too late at that point to prevent the beam from hitting the patient, but you'll know that something went wrong and can lock the system until the problem is found.
Many (most?) modern linear accelerators have imaging panels behind the beam path (see image [1]) which could be used for dose monitoring although they are primarily used for imaging purposes. I'm not sure whether any of these are currently used for dose monitoring. [1] http://tommytoy.typepad.com/.a/6a0133f3a4072c970b0147e2ed7f8...
As an aside, TLDs and IVD systems are falling out of favor for patient dose monitoring because AAPM TG 62 (referenced in the link in your other post) is not directly applicable to IMRT and VMAT modalities, which are pretty common these days.
[1]http://www.sunnuclear.com/medphys/patientqa/epidose/epidose....
[2]http://www.sunnuclear.com/snc_site/solutions/patientqa/perfr...
Earlier quoted context omitted.
Many (most?) modern linear accelerators have imaging panels behind the beam path (see image [1]) which could be used for dose monitoring although they are primarily used for imaging purposes. I'm not sure whether any of these are currently used for dose monitoring. [1] http://tommytoy.typepad.com/.a/6a0133f3a4072c970b0147e2ed7f8...
Yes, EPID panels are indeed used for dose monitoring and quality assurance of the dose delivery to the patient [1][2]. However, this is relatively new in the industry and is not universal. The fact that EPIDs have become so common (since Varian and Elekta like to offer them as standard) means that this will be used more as time goes on. As an aside, TLDs and IVD systems are falling out of favor for patient dose monit…
p.s. If you are employed in Med Phys allow me to make a quick plug for my open source Med Phys QA database project: http://qatrackplus.com/
There are a lot of bugs more infamous than this... this page is bullshit.
Wait a second, it says they had to destroy mass climate orbiter because the development and underlying software used different metric system ? It's bit hard to digest. ( Although just checked wikipedia, it also says so ) How can a high performance organisation like NASA could make such a simple yet fatal mistake ? Wikipedia page of Mars Climate Orbiter says that NASA was informed about this discrepancy by two people,…
So I went ahead and read the MCO Mishap Phase 1 report (linked here: http://www.icics.ubc.ca/~cics525/handouts/handout_MCO_report... ) and I'm having a hard time finding something that backs up the wiki summary of two navigators raising concerns and having them dismissed. The report does go ahead and state all sorts of organizational (and otherwise 'soft' issues) that contributed to the end failure. The report notes…
So had a look at the report.
There was one more problem actually. This machine, the MCO, had asymmetrical solar panels which would cause solar pressure ( force by sunlight ) to create a very mild spin ( angular momentum ). Now this angular momentum had to be desaturated time to time in order to keep this machine stable. Now, one module called SM_FORCES calculate this adjustment and feeds to AMD ( Angular Momentum Desaturation ). Now, this SM_FORCES & AMD uses different unit system, which was ignored by whoever wrote this connecting piece of program. Due to this error desaturation was not enough ( or more ) and it kept building over the period of 9 months.
Now, I notice that NASA has a separate team to navigate this machine to mars. There data showed this angular momentum adjustment event occurred 10-15 times more than expected. It was like a man walking with one leg shorter than another. It's a 9 months journey from mars to earth. They must have seen the first sign to inconsistency with in first few weeks only, just guessing though.
In this report, out of 8 possible contributing causes, at-least 3 are attributed to navigation team. I think success of such mission depends not only on meticulous planning but also on thinking on the feet ability of the team. ( Any Apollo 13 fans? :) )
I would add Therac-25[1] and the 500 mile email[2] to that list. [1]: http://www.ccnr.org/fatal_dose.html [2]: http://www.ibiblio.org/harris/500milemail.html
The 500-mile email was a configuration error. The software was working exactly as intended.