A traversing gantry fail on (b)(6) 2017.Handicare tech.Service (b)(4) went on-site dec.4, 2017 to evaluate the gantry system in use since sept.2010.The installation consists of a ceiling lift that moves on a traversing gantry attachment plate.The gantry is attached to the plate with 4 bolts, 2 on each end with 4 bolts, 2 on each end, to a gantry attachment plate in a sandwich configuration.The entire assembly is held by vertical supports mounted to walls with fasteners.The gantry rail showed no abnormal damage or deformation of the ends.The coating is worn through the bottom of the gantry where it contacts the attachment plate on the end that detached, indicating long-term friction/movement between the gantry and the attachment plate.This suggests the bolts weren't t adequately tight.The bolts continued to be attached to the gantry attachment plate after the gantry fell.The fall occurred on the end of the fixed rail closest to a vertical support.Some lateral movement of the vertical support was visible during (b)(4) 's visit.The analysis indicates that double failure modes must occur in order for the gantry to become detached: the bolts in the traversing gantry must be loose.The gantry must either move away (horizontally, not side to side) from the attachment plate it sits on or the fixed rail and attachment plate must move away from the gantry or a combination of both.Maintenance has been performed on the installation as recent as september 2017.Root cause: the gantry fell because there was lateral movement of the vertical support which allowed the gantry to move off the attachment plate because the bolts were not adequately tight.Corrective action: (b)(4) test ceiling track systems to confirm: · toggle bolts that affix the wallmount post to the wall are installed and tightened.· bolts on bracket of above mount gantry are tightened to manufacturer recommended torque: 30.9 ft-lbs.· load test all ceiling track to 125% load capacity of ceiling lift.· pre-drilled holes along the upright support have a correctly installed toggle bolt fixing the support to the wall.
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