Skip to main content
Back to dataset

Root Cause Analysis data received in June 2021

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

You're previewing the first 4 rows of this file.

Download CSV Download
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-000-741 02/06/2021 Allergens Milk Confectionery The products are made by a subcontracted BRCGS certified site. A customer allergic reaction to the dark hazelnut chocolate spread identified the potential presence of milk protein. Susbsequent analysis confirmed presence of casein. Contamination was confirmed to be possible through cross contamination from milk containing formulations produced on the same line with the known inability (by the factory) to consistently achieve levels below 0.1% casein. The product was labelled Vegan and also No Dairy whilst also stating that it was made in a factory handling milk. Milk was routinely present in the product through cross contamination and the high levels were not fully understood by the brand owner leading to a belief that the statements on pack were sufficient to mitigate the risk i.e. - ‘No dairy’ was labelled to indicate that no milk ingredients were added, - ‘Vegan’ was labelled as no vegan ingredients were added and levels of cross contamination were acceptable to vegan societies - ‘Made in a factory handling milk’ was labelled to indicate the potential presence of milk The product had a potentially misleading on pack message ‘No dairy’ that could have been interpreted as indicating that the product was free-from milk / dairy The potentially misleading on pack message of ‘No dairy’ was signed off as part of the packaging approval process by the manufacturer and the brand owner. The ‘No dairy’ label was signed off as both parties did not fully understand the potential for this to be misleading to customers with allergy to milk A ‘No dairy’ on pack statement was approved by the manufacturer and brand owner of a Vegan product due to not understanding the potential for misleading customers with allergy to milk. Removal of misleading on pack labelling i.e. ‘No dairy’ Enhancement of allergen cross contamination through use of ‘Not suitable for…..’ labelling Approval of all labels by an independent legal labelling expert (in this case the amended labels have been approved by the Local Authority) Method: Labelling Declaration - incorrect
I-001-171 02/06/2021 Allergens Multiple Allergens Confectionery A formal sample found traces of milk and gluten within the product Our supplier of chocolate stated that the product may contain milk, and thus the alibi statement was presented on the customer specification, which was repeated on the customer packaging. Present as an ingredient is gluten-free rolled oats. We tested this product for presence of Gliadin and our results show that its presence was <5ppm. The formal test stated 3.6ppm. and EU Law states anything less than 20ppm is declared gluten free. Blank Blank Blank Continue to test gluten-free rolled oats for Gliadin to ensure the product remains gluten free. Alibi labelling to remain on the pack as, we have always done. Finally as a precautionary measure we advised our customer to sign-off an alternative chocolate Source: Material – Other As a plant-based site we do not handle milk. The chocolate that our customer signed-off for this job stated that it may contain the presence of milk, and, from our risk assessment, we stated on the finished product specification that “Alibi Label prompt - Risk Of Cross Contamination” for milk. As our supplier, although fully cleaned down, could not guarantee no milk presence. Continue to test gluten-free rolled oats for Gliadin to ensure the product remains gluten free. Alibi labelling to remain on the pack as, we have always done. Finally as a precautionary measure we advised our customer to sign-off an alternative chocolate which is manufactured in a dairy free facility. Customer to sign off an alternateive chocolate which is manufactured in a dairy free facility. Source: Material – Other This chocolate was only used for the 1 customer in question, and as of their complaint we advised to transfer over to our standard dark chocolate, and, while it is more expensive, it is manufactured in a dairy free site. And so the alibi labelling can be removed. Material: Ingredient Specification - incorrect
I-001-201 02/06/2021 Pathogenic Microorganisms Salmonella Meat & Meat Products (other than poultry) Blank Blank Blank Blank Blank Source: People Staff Illness - There were no staff absences reported during the manufacturing period related to infectious disease. Training - All staff receive induction training that includes the control of microbiological hazards and legal food handler responsibilities. Training records are in place for staff involved with the production of this product. Source: Environment - Temperature Control - Temperatures recorded on the day of production (morning and afternoon) were reviewed and found to be within specification. Source: Method Meat is minced and mixed with spices before being put in to sausage casings. The sausages are then packed for retail or placed in bulk bags for sale at Markets. The sausages are sold as a raw product with the point of safety being after cooking by the consumer and as such there is no specific process that would eliminate the risk of Salmonella contamination at the manufacturing facility. Possible cross contamination at laboratory – Analysis was conducted at a UKAS approved facility and although the initial detection method was not UKAS accredited the confirmation was conducted using UKAS and Campden BRI approved methods. There is no evidence that the result was due to cross contamination at the laboratory. Source: Plant Hygiene records were reviewed for the sausage manufacturing area and these show that cleaning was conducted as per schedule. As part of the investigation post hygiene swabs were taken of both mincers, fillers and food contact production surfaces – No Salmonella was detected. Source: Equipment Temperature probe verification records demonstrate that the accuracy was verified to schedule. Source: Material – Contaminated product The product was produced to specification using approved suppliers with a long history of supplying the company. Most likely source is from raw meat from one supplier although no out of specification results have been notified to us. EU data from 2009 suggests that 10 to 20% of pig carcasses are contaminated with Salmonella hence the raw meat is considered the most likely root cause. Five further samples of sausage were submitted and tested for Salmonella – All results were within specification. The risk of Salmonella contamination of raw pork through the supply chain is an industry wide issue that cannot be eliminated at site for raw products. The business will continue to monitor finished product microbiological results and ensure that all other possible vectors of Salmonella contamination continue to be controlled. The products are labelled with cooking instructions that if followed, are sufficient to eliminate the risk of Salmonella prior to consumption. Undetermined
I-000-306 04/06/2021 Allergens Mustard Egg & Egg Products Another variety of egg products produced were packed inside traditional egg product packaging. This egg product is not easily identifiable from the traditional variety and also contains MUSTARD which is not contained in the traditional variety. The packer responsible for packing this batch of egg products did not follow company procedure It is possible that the Egg product variety from Kitchen 2 (where the egg products are cooked) were put in a white tray (which are only meant to be used for a traditional Egg product) and the tray was not marked to identify them (with a large X). Alternatively, the packer may not have checked that the tray was specifically marked before packing as traditional. The operatives in Kitchen 2 may not have marked the tray for the Egg product variety correctly. Alternatively, the packer did not follow company procedure and check the tray for markings identifying the variety of Egg product before packing. Blank Human error. Additional label check step added to packing process ensuring that the product details (e.g. barcode) on each label is checked against sheet. This will allow mistakes such as this to be identified at this stage, where they can be rectified. People: Procedures not followed - one-off operator error