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Root Cause Analysis data received in January 2022

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-002-290 04/01/2022 Pathogenic Microorganisms Salmonella Feed Materials We have been advised of a a Salmonella Positive analysis result received by end user End user as part of their usual procedures conducted a salmonella analysis which was returned positive From leaving our site the product was purchased & stored by our customer until being purchased by the end user. In addition to our usual monthly aggregate Salmonella Testing We have conducted further analysis on our retained sample of the product supplied which has been confirmed as Salmonella Not Detected In addition we have conductyed numerous retesting of our stocks and all have been found to be Salmonella Not Detected. Root cause has not been identified Root cause has not been identified Blank Blank Undetermined / Inconclusive
I-002-539 07/01/2022 Pathogenic Microorganisms Salmonella Feed Materials The customer had positive salmonella notifications for salmonella contamination from loads supplied by our facility We have conducted a thorough investigation and reviewed all the plant conditions during the periods in question and we found that all the relevant manufacturing conditions on plant were stable although including the dosing of liquid biocide the environmental temperatures were fluctuating due to seasonal change this can lead to an increase in the chances of condensation forming providing suitable conditions for the growth of Salmonella. Blank Blank Blank Fluctuating moisture levels in the system caused by condensation forming on metal surfaces We followed our standard procedure when we have any isolations , namely, extra sampling, reviewing our liquid biocide dosing, additional treatment of a solid biocide and continued optimisation of manufacturing conditions. The daily monitoring samples from the days in question were clear Swab and sampling exercises were carried out on the specified dates - all samples were tested and found to be clear we also initiated two “end to end “deep cleans of the process, on the specified dates followed by an additional sanitize procedure of the likely problematic areas during this period. We continue with the daily analysis of out loaded samples for the monitoring of Salmonella in rape meal as a part of our good manufacturing practice controls. We will continue to adjust our moisture control to optimise the level and minimise the fluctuations in moisture thereby helping prevent Salmonella. The combined methods of cleaning and control of moisture on an ongoing basis have been implemented Equipment: Other - condensation, due to seasonal temperature fluctations
I-002-544 07/01/2022 Pathogenic Microorganisms Salmonella Feed Additives The customer had positive salmonella notifications for salmonella contamination from loads supplied by a specified facility We have conducted a thorough investigation and reviewed all the plant conditions during the periods in question and we found that all the relevant manufacturing conditions on plant were stable although including the dosing of liquid biocide the environmental temperatures were fluctuating due to seasonal change this can lead to an increase in the chances of condensation forming providing suitable conditions for the growth of Salmonella. Blank Blank Blank Fluctuating moisture levels in the system caused by condensation forming on metal surfaces We followed our standard procedure when we have any isolations , namely, extra sampling, reviewing our liquid biocide dosing, additional treatment of a solid biocide and continued optimisation of manufacturing conditions. The daily monitoring samples from the days in question were clear Swab and sampling exercises were carried out - all samples were tested and found to be clear we also initiated two “end to end “deep cleans of the process, followed by an additional sanitize procedure of the likely problematic areas during this period. We continue with the daily analysis of out loaded samples for the monitoring of Salmonella in rape meal as a part of our good manufacturing practice controls. We will continue to adjust our moisture control to optimise the level and minimise the fluctuations in moisture thereby helping prevent Salmonella. The combined methods of cleaning and control of moisture on an ongoing basis have been implemented Equipment: Other - condensation, due to seasonal temperature fluctations
I-001-245 09/01/2022 Allergens Milk Prepared Dishes & Snacks By error, specified quantity of flavoured product were packed into incorrect flavour cardboard sleeves, leading to UNLABELLED MILK ALLERGEN Insufficient procedures to ensure right product is placed in right cardboard sleeve. Layout of re-packing zone is not clear enough Blank Blank Blank Insufficient procedures to ensure right product is placed in right cardboard sleeve. Layout of re-packing zone is not clear enough Improve process flow and layout of repack zone; improve procedures at warehouse and repack zone to ensure correct cardboard sleeves are selected and used; longer term, investigate use of handheld barcode scanning to identify right product and packing materials ENVIRONMENT: Design: inadequate layout METHOD: Work instructions: inadequate