| Recurring |
one_organization |
(a) The software failure incident having happened again at one_organization:
The software failure incident related to the outdated technology and system crashes in the organ transplant system has been reported to have occurred multiple times within the United Network for Organ Sharing (UNOS), the nonprofit agency that operates the transplant system. The system has experienced periodic failures, mistakes in programming, and overreliance on manual data input, leading to the conclusion that the mechanics of the entire system need to be overhauled [130083].
(b) The software failure incident having happened again at multiple_organization:
There is no specific mention in the articles about the software failure incident happening at multiple organizations or with their products and services. The focus of the articles is primarily on the issues within the organ transplant system operated by UNOS. |
| Phase (Design/Operation) |
design, operation |
(a) The software failure incident related to the design phase is evident in the outdated technology and aged software used in the transplant system, as highlighted in the confidential government review obtained by The Washington Post [130083]. The review pointed out mistakes in programming, periodic system failures, and overreliance on manual data input, indicating design flaws that have contributed to system crashes and inefficiencies.
(b) The software failure incident related to the operation phase is reflected in the reliance on manual data entry, which can lead to mistakes and narrow the timing window for successful organ matches. The need for hospitals to modernize to automate data entry also suggests operational challenges impacting the efficiency of the system [130083]. |
| Boundary (Internal/External) |
within_system, outside_system |
The software failure incident related to the transplant system for organs can be categorized as both within_system and outside_system.
(a) within_system: The failure was attributed to factors originating from within the system itself, such as aged software, periodic system failures, mistakes in programming, and overreliance on manual input of data [130083].
(b) outside_system: The failure was also influenced by factors originating from outside the system, such as the lack of federal audits for security weaknesses, the outdated technology used, and the resistance from the United Network for Organ Sharing (UNOS) to modernize the operations of the system [130083]. |
| Nature (Human/Non-human) |
non-human_actions, human_actions |
(a) The software failure incident occurring due to non-human actions:
The software failure in the organ transplant system was attributed to aged software, periodic system failures, mistakes in programming, and overreliance on manual input of data. The system experienced crashes for hours at a time, with one outage lasting about three hours in February 2021. Additionally, a firewall failure was blamed for one of the crashes. These issues point to failures caused by technical deficiencies and system vulnerabilities rather than direct human actions [130083].
(b) The software failure incident occurring due to human actions:
Human actions were also implicated in the software failure incident. The report highlighted that UNOS had allowed a programming error to push some lung patients lower on the priority list than they should have been, which was eventually caught by a different federal contractor analyzing patient data. This indicates that human errors in programming and data management contributed to the failure incident [130083]. |
| Dimension (Hardware/Software) |
software |
(a) The articles do not provide information about a software failure incident occurring due to contributing factors originating in hardware.
(b) The software failure incident reported in the articles is primarily due to contributing factors that originate in software. The system for getting donated organs to patients experienced crashes for hours at a time due to aged software, periodic system failures, mistakes in programming, and overreliance on manual input of data [130083]. The software system was described as clunky, requiring manual data entry that could lead to mistakes or narrow the timing window for successful organ matches. Additionally, the software's organizational structure was criticized for being slow to reflect policy changes, taking up to a year for a single change in priority policy to be implemented in the code [130083]. |
| Objective (Malicious/Non-malicious) |
non-malicious |
(a) The articles do not provide any information indicating that the software failure incident was malicious in nature, i.e., due to contributing factors introduced by humans with the intent to harm the system [130083].
(b) The software failure incident discussed in the articles is non-malicious in nature. It is attributed to out-of-date technology, aged software, periodic system failures, mistakes in programming, overreliance on manual data input, and an overreliance on human intervention for critical processes within the transplant system [130083]. |
| Intent (Poor/Accidental Decisions) |
poor_decisions, accidental_decisions |
The software failure incident related to the transplant system's technology issues can be attributed to both poor decisions and accidental decisions:
(a) poor_decisions: The failure can be linked to poor decisions such as overreliance on manual data input, aged software, mistakes in programming, and the lack of modernization efforts despite complaints from transplant doctors about outdated technology [130083].
(b) accidental_decisions: The incident also involved accidental decisions or unintended consequences, as highlighted by the reliance on outdated technology, system failures, and the lack of proper oversight and regulation by federal agencies, leading to vulnerabilities in the system [130083]. |
| Capability (Incompetence/Accidental) |
development_incompetence, accidental |
(a) The software failure incident related to development incompetence is evident in the article as it highlights various issues with the outdated technology and processes in the organ transplant system. The system relies on aged software, periodic system failures, mistakes in programming, and overreliance on manual input of data [130083]. The report from the U.S. Digital Service recommended breaking up the current monopoly held by the United Network for Organ Sharing (UNOS) due to the lack of incentives for modernizing operations and improving technology [130083]. Additionally, the article mentions that UNOS considers its code to be a trade secret and would require $55 million if the contract were to be given to someone else, indicating a lack of transparency and potential barriers to technological advancement [130083].
(b) The software failure incident related to accidental factors is also apparent in the article. For example, it mentions a three-hour system crash in February 2021 attributed to a firewall failure, which could be considered an accidental technical glitch [130083]. Furthermore, the article discusses a case where a programming error pushed some lung patients lower on the priority list, indicating accidental mistakes in the system that affected patient care [130083]. These incidents highlight how accidental factors can contribute to software failures in critical systems like the organ transplant network. |
| Duration |
temporary |
The software failure incident related to the transplant system for organs was temporary. The system experienced crashes for hours at a time, with one specific outage lasting about three hours in February 2021. The three-hour crash was attributed to a firewall failure [130083]. |
| Behaviour |
crash, omission, other |
(a) crash: The software failure incident mentioned in the articles involved crashes of the system, where the critical computers connecting the transplant network crashed for a total of 17 days since 1999, with one outage lasting about three hours in February 2021 [130083].
(b) omission: The software failure incident also involved omissions by the system, as there were difficulties in getting the surgeons to a very sick woman in the ICU on life-support systems after an organ was offered, leading to delays and ultimately the woman's death [130083].
(c) timing: The software failure incident did not specifically mention failures related to timing issues where the system performed its intended functions correctly but too late or too early.
(d) value: The software failure incident did not specifically mention failures related to the system performing its intended functions incorrectly.
(e) byzantine: The software failure incident did not specifically mention failures related to the system behaving erroneously with inconsistent responses and interactions.
(f) other: The software failure incident also highlighted issues with manual data entry leading to mistakes or narrowing the timing window for successful organ matches, as well as the clunky organizational structure of the software that made changes in priority policy take a full year to be reflected in the code [130083]. |