Intuitive Surgical da Vinci Xi software anomaly causes unexpected movement
Intuitive Surgical identified a software anomaly in the da Vinci Xi P5 software that could cause unexpected master and instrument tip movements. This led to a global Class 2 FDA recall affecting 677 devices.
Intuitive Surgical has identified a software anomaly in the da Vinci Xi P5 software that can result in unexpected master movement and potential instrument tip movement.
Key facts
- What
- Intuitive Surgical identified a software anomaly in the da Vinci Xi P5 software that could cause unexpected master and instrument tip movements.
- Incident date
- May 1, 2017
- Who
- Intuitive Surgical
- Failure mode
- Agentic Action Error
- AI surface
- Autonomous System
- Severity
- High
What happened
Intuitive Surgical identified a software anomaly in the da Vinci Xi P5 software that could result in unexpected master movement and potential instrument tip movement. The company issued urgent medical device correction letters to customers in October 2016 to notify them of the risk. A software upgrade was deployed in the first quarter of 2017 to fix the anomaly.
What broke inside the model
- 01 · TriggerAn agent plans a multi-step task.
- 02 · Model stepIt chooses a wrong or destructive action.
- 03 · Control gapNo confirmation gate guards the write.
- 04 · FailureThe action commits to a system of record.
- 05 · ConsequenceData is changed or destroyed irreversibly.
A wrong action commits, and the step is written before anything can stop it.
The failure was attributed to a software design error within the P5 software version of the da Vinci Xi system. This design flaw could trigger unintentional robotic movements under certain operational circumstances.
What it cost
Sources
- Reader-SubmittedClass 2 Device Recall da Vinci Xi Surgical Systemaccessdata.fda.gov
- Court Filingda Vinci Xi Surgical System : Biomedical Safety & Standardsjournals.lww.com
Cite this entry
https://failureindex.ai/failures/intuitive-surgical-vinci-software-anomaly-causesAI Failure Index. "Intuitive Surgical da Vinci Xi software anomaly causes unexpected movement" (FI-0377). Realm Labs. https://failureindex.ai/failures/intuitive-surgical-vinci-software-anomaly-causes (indexed Jun 9, 2026).Data fields CC-BY 4.0, prose citation permitted. Incident ID FI-0377. Full dataset at /data.
Note from Realm Labs, the Index steward
How Realm fits
- Prism
- OmniGuard
- AgentRealm
This entry sits in the index's predictive wing: a system that scores, ranks, perceives, or steers rather than generates. Realm's runtime layer is built for the generative and agentic systems now moving into these same decision seats, where it watches a model's internal state and holds an unsupported claim or an unchecked action before it commits. The control gap on this record, an automated decision that reached people with no runtime check in front of it, is the same gap. The index keeps predictive failures on the record because the pattern carries straight into the systems shipping today.