
New interview with the physicist who discovered the infamous Therac-25 failure condition
KLTV (East Texas) recently interviewed Fritz Hager, the medical physicist at the East Texas Cancer Center who investigated the 1986 radiation overdoses with the Therac-25 radiotherapy machine. Although the technical causes of the Therac-25 have been documented for decades, this interview adds valuable first-hand historical detail from one of the key people involved.
A few things that stood out to me:
- Hager describes how he and a technician spent hours after work trying to reproduce the infamous "Malfunction 54" error.
- After successfully reproducing it, he measured a dose of about 15,000 centigray delivered in one-tenth of a second (far beyond a therapeutic dose.)
- He then asked MD Anderson's Dr. Robert Shalit to independently verify the measurement before reporting the findings.
- Rather than waiting for a coordinated response, Hager personally called every known Therac-25 site in the U.S. to warn them. Within hours, physicists at other hospitals were able to reproduce the same fault and connect it to injuries they had already seen.
- The article also includes what appears to be a photograph of the brief Cherenkov flash observed during one of the reproduction tests. I'd never seen that image published before.
One detail I found particularly striking is Hager's explanation that the earlier Therac-20 would simply blow a fuse if a similar operator sequence occurred because it still had hardware interlocks. The Therac-25's reliance on software in place of those interlocks is, of course, one of the central lessons of the case.
If you've only read Nancy Leveson's classic paper or watched the various YouTube explainers, this interview is a worthwhile complement.
I'd be interested to hear from anyone in medical physics or radiation oncology: is the Cherenkov photograph included in this article already well known within the field, or is this the first time it's been published so prominently?