Fault Tree Analysis

1. Fault Tree Analysis Anna DiRienzo, Katelyn Lesk, Amber Loree, and Jude Menie

2. Device Failure Mode D C B A

3. Mechanical Failures A Device not sensitive enough for small pressure changes Device cannot support load Incorrect vertical Tracking system Failure of L-plate Incorrect calculation of center of gravity Failure of Gooseneck to support Incorrect alignment and/or attachment with iSCAN Inaccurate weight distribution

4. B Operator Errors Haphazardly Stored Incorrect Sterilization Incorrect Positioning Improper cleaning Too far away from patient’s eye Too close to patient’s eye Contaminated Device Missing parts Device broken

5. DesignErrors C Attachments Movement of base while device is in use Tipping of structure Operator leans on device improperly Locking wheels not utilized by operator No enough weight on base Center of gravity off-balance Large adjustment to small adjustment Large adjustment to IV pole Small adjustment to device Material failure Loose screws Improper Attachment by Physician Loose screws Material failure

6. Material Failure D Destabilization More wear and tear than expected Fatigue Gooseneck Small adjustment Repetitive use