Siemens has completed an investigation of the reported event.The root cause was determined to be an individual work error.At the end of a procedure, the display ceiling suspension (dcs) carriage was moved by the operator towards the patient's foot end.The ceiling carriage is used to move the entire ceiling pendant, including the monitor.To do this, the user manually pulls the dcs into the desired position.If the dcs is pulled to the end of the rails it is stopped by a mechanical end stop.In the given case, this mechanical end stop was not attached correctly, which ultimately caused the ceiling carriage to slip out of the rails on this side.Only the front rollers left the rails and the other rollers remained in the rails.Therefore, the carriage did not fall completely to the floor, but the carriage tilted due to gravity and bent the carriage.No one was injured in the given event.In this condition, the system is no longer operational and service intervention is necessary to repair the dcs.The cause for the incident was found to be two completely loose allen screws and two loose allen-head set screws that fix the end stop.However, it could not be determined why the screws were not tight.No anomalies were found during the review of the installation protocol dated 01/17/2016.Unfortunately, the maintenance protocols could not be reviewed because the customer performs the maintenance themselves and refused to provide the protocols.The maintenance instructions explicitly state to check that the end stops are mounted correctly.Both the on-site investigation and the detailed investigation at the factory revealed that this was neither a design problem nor a systematic problem.The occurrence rate of the error pattern was checked.A possible error accumulation or even a systematic error, which would lead to a corrective action of the installed base, could not be determined by the investigation.
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