Recent Feature Articles

Feb 2021

The Therac-25 Incident

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A few months ago, someone noted in the comments that they hadn't heard about the Therac-25 incident. I was surprised, and went off to do an informal survey of developers I know, only to discover that only about half of them knew what it was without searching for it.
I think it's important that everyone in our industry know about this incident, and upon digging into the details I was stunned by how much of a WTF there was.
Today's article is not fun, or funny. It describes incidents of death and maiming caused by faulty software engineering processes. If that's not what you want today, grab a random article from our archive, instead.

When you're strapping a patient to an electron gun capable of delivering a 25MeV particle beam, following procedure is vitally important. The technician operating the Therac-25 radiotherapy machine at the East Texas Cancer Center (ETCC) had been running this machine, and those like it, long enough that she had the routine down.

The Economic Problem

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One of the main tasks any company needs to do is allocate resources. Regardless of the product or the industry they're in, they have to decide how to employ the assets they have to make money. No one has really "solved" this problem, and that's why there are swarms of resource planning systems, project management tools, and cultish trend-following.

After a C-suite shuffle at James B's employer, one of the newly installed C-level execs had some big ideas. They were strongly influenced by one of the two life-changing books, and not the one involving orcs. A company needs to allocate resources. The economy, as a whole, needs to allocate resources. If, on the economic level, we use markets to allocate resources because they're more efficient than planning, then we should use markets internally as well.

Coming to Grips

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Regardless of what industry you're in, every startup hits that dangerous phase where you're nearing the end of your runway but you still haven't gotten to the point where you can actually make money with your product. The cash crunch starts, and what happens next can often make or break the company.

Nathan was working for a biotech company that had hit that phase. They had a product, but they couldn't produce enough of it, cheaply enough, to actually make a profit. What they needed was some automation, and laboratory robots were the solution. But laboratory robots were expensive, and for a company facing a cash crunch, "expensive" was too risky. They needed a cheaper solution.

Not-so-Portable Document Format

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Adrian worked for a document services company. Among other things, they provided high-speed printing services to clients in the financial services industry. This means providing on site service, which is how Adrian ended up with an office in the sub-sub-basement of a finance company. Adrian's boss, Lester, was too busy "developing high-end printing solutions on a Unix system" to spend any time in that sub-sub-basement, and instead embedded himself with the client's IT team.

"It's important that I'm working closely with them," Lester explained, "because it's the only way we can guarantee true inter-system compatibility." With disgust, he added, "They're mostly a Windows shop, and don't understand Unix systems, which is what drives our high-speed printing solution."