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Root Cause Analysis data received in October 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-001-982	01/10/2021	Non-Pathogenic Microorganisms	Mould	Other Food Product / Mixed	Customer complaint of mould in the packet of microwavable Basmati Rice	This type of product is classed as commercially sterile, meaning no microorganisms are present and grow can only occur if the seal or pouch has been compromised in some way, in this instance this seems to be the case. There may have been a tiny hole in the packaging.	This individual bag may have been damaged during storage and distribution, or during transport with the other shopping from store to the customers home.	Blank	Blank	This individual bag may have been damaged during storage and distribution or during transport with the other shopping from store to the customers home. This type of product is classed as commercially sterile, meaning no microorganisms are present and grow can only occur if the seal or pouch has been compromised in some way, in this instance this seems to be the case. There may have been a tiny hole in the packaging.	The process is monitored during each cook, details recorded and verified by a QA every 12 hours. Samples are routinely sent to an external lab for microbiological testing, there have been no fails to date. There have been several site improvements made and further investment is being made with the introduction of online seal checkers, which adds closer monitoring to ensure pouch integrity. There have been no other complaints for this batch of product	Process: Packaging - defective
I-001-842	05/10/2021	Pathogenic Microorganisms	Not Determined / Other	Poultry Meat & Poultry Meat Products	n/a	n/a	n/a	n/a	n/a	Following an investigation at the slaughterhouse, the root causes identified are ageing evisceration equipment, uneven size of birds within the same batch causing difficulty to eviscerate them properly, and inadequate staff training and FBO management supervision, all leading to inadequately eviscerated birds leaving the slaughterhouse and entering production.	The management at the slaughterhouse have commissioned a review of their evisceration equipment by the manufacturer to determine whether it can be upgraded or requires complete replacement (the report is expected). In the interim they have adopted and implemented other mitigating actions, including training and supervision of staff, increase in the number of monitoring and verification checks to ensure all carcases are properly eviscerated and changes to their food management procedures to prevent further contaminated product being placed in the market; they are also liaising with their producers to reduce bird size variation. The FBO has temporarily stopped exports to the EU. Review carried out in liaison with the slaughterhouse operator and management actions implemented, including a review of the performance of plant inspection assistants (PIAs), an increase in the levels of supervision at the co-located cutting plant and verification of the corrective actions put in place by the food business operator (FBO), taking robust enforcement action as necessary to ensure compliance.	Equipment: Other - Incorrect machinery specification Process: Quality Control Checks - inadequate
I-001-827	06/10/2021	Pathogenic Microorganisms	Salmonella	Soups / Broths / Sauces & Condiments	We were informed by our supplier that Salmonella had been detected in a related batch of product when testing.	Salmonella has entered the product via fertiliser, poor Agricultural practices, or sub standard factory GMP	There are a variety of vectors for Salmonella in the open agricultural production of Tomato and to some extent during the manufacturing processes the actual root cause of this contamination has not been identified in China - The Chinese factory has subsequently stopped communicating with our German supplier to allow us to obtain a full investigation closure..	Blank	Blank	Blank	Blank	Material: Ingredient Cross-contamination
I-001-969	06/10/2021	Pathogenic Microorganisms	Salmonella	Feed Additives	The customer had positive notifications for Salmonella contamination from two loads supplied by our facility the serotype identified by the customer has not been identified at the site to date.	We completed the required detailed investigation and identified that at the time the meal was produced and loaded, we had just restarted the crush plant following a planned maintenance shutdown.This shut down involved extensive cleaning and the consensus is that some older meal had been dislodged during the cleaning process which included treatment with both wet and dry biocides.	Blank	Blank	Blank	Older meal dislodged during cleaning process	We will put a step in place that ensures the first few tons of meal produced are segregated,we will monitor this new start up procedure after the next planned shutdown.	Equipment: Contamination - cleaning failure