|
It was reported that the cable corrugated support has collapsed.Issue occurred outside of clinical use; there is no allegation of death or serious injury.However, it is uncertain whether this event is likely to recur and potentially cause serious injury.Based on the available information, this issue has been determined to be a reportable event.Philips has initiated an investigation into this complaint.
|
|
Issue description: philips received a complaint regarding the digitaldiagnost c50 system, reporting that the corrugated hose rail holder was out of space.The incident occurred while the device was not in clinical operation.There was no allegation of death or serious injury.Investigation findings: -the philips field service engineer (fse) conducted a thorough analysis of the ceiling suspension system and identified that the corrugated hose rail holder had become dislodged from its intended position.The fse addressed the issue by securing the holder with a replacement pressure nut.Subsequent testing confirmed that the device is functioning as intended.The philips r&d team performed a root cause analysis and identified the following: -the holder¿s nut and screw are intentionally designed without a locking mechanism, permitting free rotation during cs movement.Over time, repeated motion causes thread wear, loosening the screw-nut connection and eventually leading to detachment of the connection rod.However, even if detachment occurs, the cable hose remains securely suspended due to its natural elasticity, stiffness, and three-point fixation.The detached component poses no risk of personnel contact or wire exposure.Design evaluation: material selection: the screw (low-carbon steel) and nut (stainless steel) are known for their high hardness, rigidity, and wear resistance, which benefits in minimizing the probability of threads wore.Additionally, these materials are commonly used for screw and nut.Reliability testing: the cable hose holders are secured to the auxiliary rails of both longitudinal and lateral rail systems.Reliability testing for longitudinal and lateral movements has been successfully completed, with all results meeting specifications.The design fulfills the durability requirement for 10 years of operation.Root cause analysis: during normal operation, as the cs moved, the threaded connection rod rotated back and forth within the cable clamp pulley nut.This repeated movement caused severe wear on the nut threads.Preventive actions: the following preventive actions should be implemented to avoid recurrence of this issue.-according to pm (preventive maintenance) manual, during pm activities, cables and the corrugated hoses checking are required to be performed annually, which can reduce the potential issues that may cause hose holder fall.-in the instruction for use (ifu) it was clearly defined that this product requires proper operation, planned maintenance, and checks the user must perform routinely, which are essential to keep the product operating safely, effectively and reliably.Resolution: the philips field service engineer (fse)addressed the issue by securing the holder with a replacement pressure nut.Subsequent testing confirmed that the device is now functioning as intended.Final reportability assessment: -the reporting decision was re-evaluated based on the updated risk assessment.The system did not cause or contribute to a death or serious injury.The reported issue does not affect system functionality but presents a negligible risk due to the potential detachment of the hose holder, it would not be likely to cause or contribute to a death or serious injury if this were to recur.Therefore, this issue has been determined not to be a reportable event.
|