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Summary of Food/Feed Safety Incident Root Cause Analysis (RCA) informationRoot Cause Analysis data received in March 2022

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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
I-002-648	01/03/2022	Allergens	Nuts / Nut Products / Seeds	Multiple Allergens	Incorrect product went to the labeller and was therefore incorrectly labelled	Two different products with same packaging run through the same equipment, and manually sorted onto labelling lines. Product hadn't been dried the previous day following pasteurisation	Product was removed from the line prior to drying equipment	No procedure in place for handling of WIP stock to direct staff to remove after the dryer	Lack of controls in place for non-standard processes	Lack of controls in place for non-standard processes	Operations Manager has held a briefing with production co-ordinators and all labelling area team leaders regarding the issue, the cause and instructions not to use the same conveyor for different products at the same time. Further training to follow, see below. The incident has been risk assessed and determined that a recall is required for the product production which has been dispatched to customers. Recall team will be assembled and all activities logged for the recall. See full timeline of events/actions and all documentation and evidence is available in the folder.	Process: Quality Control Checks - inadequate Method: Work Instructions - inadequate
I-002-801	01/03/2022	Allergens	Meat & Meat Products (other than poultry)	Milk	Incorrect labelling of Lactose in the ingredient list with no reference to the source MILK	Insufficient understanding by the supplier to include the source of Lactose being obtained from MILK.	Labels not approved by FBO prior to importing product.	Blank	Blank	Source: Material - Labelling - absent / incomplete / incorrect No reference to MILK being the source of Lactose on the product label. Labels not approved by FBO prior to importing product. Insufficient understanding by the supplier to include the source of Lactose being obtained from MILK.	An approval process for product labels has been implemented which will allow review against the accepted UK labelling requirements for Allergens. Label check sheet and completed example supplied.	Process: Labelling Verification Checks - absent / failure