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Disabled Alarm Blamed for Ohio Fertility Center Failure that Destroyed Around 4,000 Eggs and Embryos

posted by martyb on Wednesday March 28 2018, @11:00AM   
from the cracked-some-eggs...-noggins-next? dept.

takyon writes:

In a letter to nearly 1,000 patients, University Hospitals in Ohio says that a tank's remote alarm system, meant to alert an employee to temperature swings, was disabled for an unknown length of time. That led to the destruction of around 4,000 frozen eggs and embryos, double the original estimate:

Hospital officials say they doesn't know who turned the remote alarm off or how long it was disabled. They also said they were aware the tank in question needed preventative maintenance. Some of the eggs and embryos had been stored there since the 1980s. The hospital's investigation is ongoing.

"Right now we do not know whether it's mechanical or human or [a] combination," said James Liu, chairman of the department of obstetrics and gynecology at University Hospitals.

He says he doesn't think anyone intentionally disengaged the alarm. "Because it is a computer, we think it's unlikely that there was any kind of external force that was working to hack the computer or anything like that. We think it's unlikely," Liu said.

Previously:
Freezer Malfunction May Have Damaged Up to 2,000 Frozen Eggs and Embryos
Two Fertility Clinic Freezer Failures Occurred in a Single Day

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Original Submission

• 256 MiB in th 1990s probably larger surface area. 256 MiB in th 1990s probably larger surface area. (Score: 0) by Anonymous Coward on Wednesday March 28 2018, @11:14AM (2 children)

  by Anonymous Coward on Wednesday March 28 2018, @11:14AM (#659442)

  I wonder what the numbers are now.

  I suppose we're mostly getting errors in non-essential data, such as video streams.

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• Re:256 MiB in th 1990s probably larger surface are (Score: 3, Informative) by c0lo on Wednesday March 28 2018, @11:52AM

  by c0lo (156) on Wednesday March 28 2018, @11:52AM (#659453) Journal

  With the transistors getting smaller, I think is reasonable a cosmic ray incident will cause more extensive damage by flipping more transistors. The frequency may stay the same, just the damage is more intensive.

  Now, I don't know how much of that study looked into the isotopic composition of the materials around. E.g the chips are covered in plastic and ¹⁴C (in 1 ppm abundance) is radioactive. ⁴⁰K - potassium - will be present in the concrete that makes the building - half chances to decay in energetic gammas that penetrate the chips.

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  https://www.youtube.com/watch?v=aoFiw2jMy-0 https://soylentnews.org/~MichaelDavidCrawford

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• Re:256 MiB in th 1990s probably larger surface are (Score: 3, Informative) by c0lo on Wednesday March 28 2018, @01:11PM

  by c0lo (156) on Wednesday March 28 2018, @01:11PM (#659473) Journal

  A more recent (2003) article (PDF) [iaea.org]

  Neutrons produced in cosmic-ray spallations reach on the ground of the earth. Fig. 1 shows the particle ffight path. The rates of secondary cosmic-rays are summarized in Table 1. Muons consist about 60% of secondary cosmic-rays and neutrons consist about 40% of them. Electric charge in a semiconductor cell by a deposit energy from a cosmic-ray muon induced is negligible. However, heavy nuclei fragments produced by a nuclear reaction between a neutron and a
  silicon nucleus deposit huge amount of energy that brings about a single event upset. Thus, about 99% of soft-errors by secondary cosmic-rays are caused by cosmic-ray neutrons.
  ...
  We calculated an expected soft error rate on a 1 Mbit SRAM device caused by neutrons generated from cosmic rays... We assumed that the injected neutron flux is
  12 n/cm2/hour, which is the experimentally measured neutron flux in Tokyo shown in Table 2.
  ...
  We generated 1.04e+9 neutrons in the Monte Carlo simulation. It corresponds to the real time of 8.67E+11 hours by using the generated area of LE-4cm² and the flux of 12n/cm2/hour. ... Assuming that the soft error threshold is 30fC (0.68MeV) 7 events are observed as an energy deposition
  greater than the threshold in the depletion layer by an#alpha;-particle. From this result, the soft error rate is derived as 8.4E-12 errors/hour/cell. Therefore, the soft error rate of the 1Mbit SRAM device is expected to be 8.4E-6 errors/hour ...

  256 MB is 2048 Mbit - thus apple-to-apple comparison would say 0.0172032 errors/hour at the level of 2003 memory. Or 1 soft error every 58h = 2.6 days in 2003

  That was 2003. The today transistors are much easy to upset (lower charge thus incident energy required) thus I expect that the number upset events to be increased.
  Supplementary, the amount of memory cells in the same silicon volume increased zillion-fold - Moore's law hold quite strong. I wouldn't be surprised to hear of multiple soft errors per hour today.

  Other stories
  The Invisible Neutron Threat [lanl.gov] - SEU - single event upset

  On October 7, 2008, an Airbus A330-303 operated by Qantas Airways was en route from Perth to Singapore. At 37,000 feet, one of the plane's three air data inertial reference units had a failure, causing incorrect data to be sent to the plane's flight control systems. This caused the plane to suddenly and severely pitch down, throwing unrestrained occupants to the plane's ceiling. At least 110 of the 303 passengers and 9 of the 12 crew members were injured. The injuries of 12 of the occupants were serious, and another 39 occupants required treatment at a hospital. An SEU was the only potential cause for the malfunctions not ruled out. All potential causes were found to be "unlikely," or "very unlikely," except for an SEU. However, the Australian Transport Safety Board (ATSB) found it had "insufficient evidence to estimate the likelihood" that an SEU was the cause.

  Google: DRAM error rates vastly higher than previously thought [computerworld.com] 2009

  The study (download .pdf), which used tens of thousands of Google's servers, showed that about 8.2% of all dual in-line memory modules (DIMM) are affected by correctable errors and that an average DIMM experiences about 3,700 correctable errors per year.

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  https://www.youtube.com/watch?v=aoFiw2jMy-0 https://soylentnews.org/~MichaelDavidCrawford

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