Isn't there a saying about the impossibility to make something idiot proof because there will always be a bigger idiot. At the same time we as engineers need to be trying to do all we can to make everything work as much as possible.
Quite often in a case like this it's people working hard and doing the best they can that struggle with something that should be easy to do. But under the wrong set of circumstances it doesn't perform the way it is expected.
Yes, a feedback loop would have done wonders to correct the design. Given the wider acceptance of collaborative tools, it looks like feedback loops -- that could have helped here -- are beginning to sprout. It will be interesting to see if news from the field begins to alter design.
Again, the concept of switching to a nonstandard plug/socket on medical equipment is precluded by the fact that almost all medical devices must be able to be used in almost any environment...for convenience, economic, and safety reasons.
The high placement of outlest iwas the real issue, and in most patient stations these are only used for permenently installed monitors. The new NICU was/is a highly device intensive environment...maybe more than they planned for. Research hospitals are always pushing the edge of technology for patient care...which can mean more equipment.
One change that I see now that could have made a small difference is the orientation of the outlets. In the past the outlets were installed so that the ground pin was on the botom. At that time the concern was to maintain the contact with the ground if the plug was partially pulled by tilting. This was for preventing electrical microshock to patients. Now the outlets are installed with the ground pin on the top. The power pins are the last to lose contact if the plug is tilted downward.
I like the lights in the plugs. I see them in "cheap" extension cords at Home Depot. It sometimes amazes me how nickle-and-dimey manufacturers can become on $50K-100K devices.
Good job on the go and see approach to solving the problem. In a previous job, we had a similar problem with power supplies on bench weigh scales that would suddenly stop functioning. The warranty held on the first few units, but after three failures, the scale company said that we had a problem as their units typically do not fail. Review of the systm showed that some of the plugs were to be used only for industrial fans and these had a hard wired power monitoring / controlling circuit designed to minimize power usage while using the fan. When a scale was plugged into this plug, the monitor would effectively drain the power supply and cause it to fail. We changed the plugs for the fans to a round 120 V plug which eliminated the possibility of plugging the scale into that plug.
I have come across these types of "improvement parts" and similar problems. From time to time the developers will provide a notice to the end-user as a warning so such events don't happen. Sometimes the smallest change or improvement can cause big problems.
This case includes two examples of the "it seemed like a good idea at the time" syndrome. The first being to put the outlets at a non-ergonomic height. Above head height is certainly a very poor choice for anything except plug in permanent lighting fixtures. The second poor choice was selecting receptacles without specifying the insertion force. Different levels are available from some suppliers.
Of course, having an "AC present" indicator on all of the battery backedup devices would have immediately indicated the problem, and it should always be provided.
The mention of twist-locking connectors is certainly a good comment, and it is applicable in a wide realm of applications. OF course, in some areas the equipment would need to have loss of power alarms to instantly allert the users to the problem.
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For industrial control applications, or even a simple assembly line, that machine can go almost 24/7 without a break. But what happens when the task is a little more complex? That’s where the “smart” machine would come in. The smart machine is one that has some simple (or complex in some cases) processing capability to be able to adapt to changing conditions. Such machines are suited for a host of applications, including automotive, aerospace, defense, medical, computers and electronics, telecommunications, consumer goods, and so on. This discussion will examine what’s possible with smart machines, and what tradeoffs need to be made to implement such a solution.