SKYTRON
Received Aug 7, 2007 · Event occurred Jul 19, 2007
Report 1825014-2007-00008 · MDR key 893497
Device
Product problems
- Device Emits Odor
- Replace
- Smoking
Patient
YR
- Unknown (for use when the patient's condition is not known)
Narrative
Description of Event or Problem
PT WAS ON A SKYTRON 3600B TABLE WHEN IT STARTED TO SMELL LIKE SMOKE. THE PT WAS ANESTHETIZED AND WAS MOVED TO ANOTHER TABLE.
Additional Manufacturer Narrative
THE TABLE WAS EXAMINED IN 2007. UPON INSPECTION, IT WAS IMMEDIATELY NOTICEABLE THAT THERE WAS DAMAGE TO THE LOW VOLTAGE (24 VOLT) CIRCUIT CONDUCTORS. THESE CONDUCTORS CAN BE FOUND NEAR THE ELECTRICAL CONNECTOR THAT PLUGS INTO THE TABLES RELAY BOX ASSEMBLY. THE EXTERIOR INSULATION OF THE CONDUCTORS EXHIBITED SIGNS OF DAMAGE FROM HEAT (SLIGHTLY MELTED). ADDITIONAL INVESTIGATION REVEALED THAT THE CAUSE OF THE FAILURE WAS A SHORT TO GROUND. IT IS APPARENT ON THE RED (+24 VOLT) CONDUCTOR THAT IT WAS PINCHED AGAINST A METAL BRACKET CREATING A RESISTANT POINT. THIS IS EVIDENT BECAUSE THE IMPRINT OF THE METAL BRACKET IS SHAPED INTO THE OUTER JACKET OF THE CONDUCTOR. DAMAGE TO THE RELAY BOX CONTROL CIRCUIT RESULTED FROM THE SHORT WHICH MADE THE TABLE INOPERABLE. IT APPEARS THAT THE LAST INDIVIDUAL WHO SERVICED THE TABLE OR REMOVED THE ACCESS COVER DID NOT EXERCISE CARE TO ROUTE THE WIRE HARNESS CORRECTLY AND CREATED A PINCH POINT.