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PEXiS - performance experts in safety - behind human error

THERAC 25 case

This accident report details how a radiation machine delivered dangerous levels of radiation. When you are finished reading it, collect your thoughts, and respond in the quick-write form at the tbottom of this page.


THERAC 25 Accident Report (.pdf, acrobat reader required)



quick-write 4

A quick-write is a writing exercise meant to free your thinking and writing and to get some discourse going about a topic. To do it, think about the THERAC 25 case, and your reactions to the way it was handled relative to the concepts from the 'conceptualize' submodule. Try to draw parallels between how the events occured, and how similar events have ocurred in your world.

Then open a word-processing document, put your fingers on the keyboard, and write freely, nonstop, for a specific amount of time - about 5 minutes, in this case. Do not censor your thoughts or judge your writing. If you can not think of a precise word or phrase, leave a blank and go on. Whatever you write will not be criticized or graded. The key is to write continuously for 5 minutes, while reflecting on the exercise.

When you have finished writing your quick-write in your word-processing program, spell check, grammar check, save a copy, and then copy and paste your quick-write into the form provided below.







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