The instruments subject of the reported event were reprocessed prior to use.A steris service technician arrived onsite to inspect the transfer carriage following the reported event.The technician was informed that as the employee was removing a load from the sterilizer, the front end of the transfer carriage collapsed.The technician inspected the transfer carriage and found that the transfer carriage remained on the floor in the position that it fell during the reported event.Per the technician's inspection, he identified that the position of the transfer carriage is consistent with not fully engaging the transfer carriage's front wheels with the sterilizer's docking station.Should the transfer carriage's front wheels be locked fully the transfer carriage would not have moved out of place or fell to the floor.In this event, the transfer carriage's front wheels were all the way back aligned with the back wheels indicating that the root cause is attributed to user error as the employee did not fully engage the transfer carriage to the sterilizer's docking station prior to removing the instruments from the sterilizer.The transfer carriage and loading car were removed from service and the customer is waiting for replacements.While onsite the technician counseled user facility personnel on the proper procedure for loading and unloading the sterilizer.No additional issues have been reported.
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