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Root Cause Analysis data received in July 2021

Summary of Food/Feed Safety Incident Root Cause Analysis (RCA) information

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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-001-284	01/07/2021	Pathogenic Microorganisms	Listeria Monocytogenes	Milk & Milk Products	Listeria monocytogenes was discovered in a batch of cheese following lab testing but some of the batch had already gone to retailers	Suspected contaminated raw milk used to make unpasteurised cheese	Blank	Blank	Blank	Suspected contaminated milk Not following positive release procedure	Farmer identifying signs for listeria in cows, ensuring pre-requisite cleaning in place for cows and equipment. Raw milk and or fresh cheese being tested for each batch for listeria (and other microbes). Further batches will not be released until a clear result is received, i.e. positive release.	Material: Ingredient Hygiene Controls - inadequate
I-001-464	01/07/2021	Pathogenic Microorganisms	Salmonella	Meat & Meat Products (other than poultry)	Salmonella Detected in product produced using raw materials slaughtered and processed at site before being sent to company for further processing and packing for retailer	Cannot identify root cause on site We reviewed carcase swabs and no salmonella was detected. Streaky was also sampled, with no salmonella detected. Daily Lairage reconciliation documents were reviewed for the kill dates of these products and no high grade soiled pigs were noted on intake on these days. Additionally, hygiene pre-op checks were reviewed for specified weeks and no issues were found.	We dont believe that the root cause of the issue originates on our site.	As above	As above	Do not believe salmonella positive originated on Site.	Continued focus on process hygiene to ensure that we produce to the highest standards.	Undetermined
I-001-455	02/07/2021	Foreign Body	Plastic	Prepared Dishes & Snacks	Small pieces of blue plastic/nylon and metallic dust potential surface contamination of baked finished product.	Spiral belt became misaligned resulting in internal fabric damage to spiral chiller wear strips and runner damage. Resulting in small fragments potentially falling on to product.	Roller moved out of usual position causing belt to lift and therefore mistrack.	Component bearing failure	Blank	Belt misaligned in spirial chiller causing damage to plastic wear strips and some metal on metal contact Source: People Product not all contained on site once the incident was identified. Source: Plant - Machinery failure Spiral damage creating potential foreign bodies as per 5 Whys	All wear strips, damaged belt sections , and belt rods and rollers have been changed opportunity taken to conduct full PPM Full hygiene clean conducted following major works intervention. Line started up with spotters on line for two complete rotations to ensure all performing as intended. Line released by Senior Management and is now fully operational. Source: People Time between incident being identified and product being quarantined meant some orders had already been picked and left site destined for specified depot Review of quarantine procedure and responsibilities / follow up action to be undertaken Internal actions to be clarified and communicated. Assessment to be carried out. Withdrawal procedure to be reviewed and confirmed. Post incident review being conducted by Group Governance function. Source: Plant - Machinery failure Component failure.	Equipment: Machinery - damage
I-001-331	05/07/2021	Allergens	Peanuts	Confectionery	Blank	Blank	Blank	Blank	Blank	SOURCE: Material -COMPOSITION - incorrect ingredients / substitution. Peanut presence detected within specified batch. Elisa allergen screening idendified peanut level at >40 ppm within the chocolate dip. Peanuts not declared within the ingredients declaration. Customer recall for all Best Before codes	Re-labelling in consideration for remaining warehouse stock that has a confirmed peanut presence, to declare peanuts within the ingredients list and Allergen update front of pack statement. Will review re-labelling with enforment authority Further documentary evidence secured from supplier. Additionaly analysis to be undertaken on stock in transit from China. Re-labelling will also be considered if peanut or other undeclared allergens identified, before stock is placed on sale. No further orders placed and buyer considering an alternative supply	Method: Labelling Declaration - absent Material: Composition - incorrect ingredients