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Summary of Food/Feed Safety Incident Root Cause Analysis (RCA) informationRoot Cause Analysis data received in April 2021
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Download this file| Incident Reference Number | Date RCA Received | Incident Type | Hazard Type | Product Type | Why 1 | Why 2 | Why 3 | Why 4 | Why 5 | Root Cause | Corrective Actions | ALPHA TEST: FSA RCA Categorisation | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| I-000-620 | 01/04/2021 | Foreign Body | Rubber | Poultry Meat & Poultry Meat Products | We chose to use the Fishbone method. | Blank | Blank | Blank | Blank | Human error in the visual inspection of dolly bins before use, to ensure it is free of contamination i.e an o-ring. PEOPLE: Procedures not followed - one-off operator error - A human error ENVIRONMENT: Adequate lighting and space are provided throughout the whole process of production of the product. Adequate facilities for washing and hygiene are available too. Not a likely root cause. METHOD: Work instructions on checking the O-rings position and integrity during equipment assembly are in place. Visual product standards on the line for the line inspectors / graders are available. Procedure to cover with blue liner all meat containing vessels is strictly adhered to throughout. Not a likely root cause. PLANT: There were no stops for maintenance at the front end of the line (where the issue occurred) during this run. The machines are relatively new; the last PPM was completed with no issues related to O-rings. The forming machine and the relevant O-ring, must have been assembled and used correctly at the start of shift, or the subsequent loss of pressure would have resulted in urgent engineering intervention none recorded to have taken place. Not a likely root cause. MATERIAL: All raw materials are subject to documented sampling visual inspections upon arrival, no issues recorded pertaining to physical contamination. All raw materials were accepted as these were found to be within specification. All raw materials are 100% x-rayed the records showed no issues. Not a likely root cause. | Mixing Teams, Hygiene Teams and Line Graders / Inspectors all debriefed to be more vigilant. All Hygiene and Meat Mixing operators, as well as Line Graders / Inspectors have been debriefed to be vigilant. O-rings now kept locked and control issued (Old-for-New) by Engineering. Working with equipment manufacturers to procure metal detectable O-rings where possible. | PEOPLE: Procedures not followed - one-off operator error | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set |
| I-000-843 | 05/04/2021 | Allergens | Milk | Cereals & Bakery Products | Blank | Blank | Blank | Blank | Blank | Apparently the supplier verbally verified that there is no milk in the cookies and thought it was a clerical error!! However, I forwarded the PA laboratory report to the FBO and made it clear that it was not an error and that there was scientific evidence to substantiate this incident and that it was not a mistake. He contacted them again and they carried out an investigation and realised that the cookies contain small % Butter, hence the presence of lactose and casein!!. So the supplier is now producing new labels with butter (milk) declared on the label and in the ingredients list as per the EC Regulation 1169/2011 with the name of the actual allergen after its processed product. The FBO has sent labels to all of his customers to add a milk warning to all of the packets with the old labels and then any new stock will have the correct ingredients and allergen declaration direct from the supplier. | We applied an additional labels for dairy/milk allergen warning. Also sent the stickers to the shops we supplied and asked them to stop selling if the dairy allergen warning sticker is not applied. The new stock from the producer will be with full allergen warning including milk/butter warning. | Material: Ingredient Specifications - incorrect Process: Labelling Verification Checks - failure | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set | Not set |