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Root Cause Analysis data received in February 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-002-335 03/02/2022 Allergens Milk & Millk Products Multiple Allergens The application of English unit labels not applied to the products Operation moved to new facility and new people employed to carry out work Rework Team at new facility not trained sufficiently and the support team from existing warehouse operation could not support due to holiday, staff absence and sickness levels (Covid) Re-work moved to night shift at the new site and not fully supported Blank Move to new facility, training of new people, lack of experienced staff to support new team • Working photographic bible detailing what work is required for products to be reworked implemented – Completed • Staff from site 1 reinstated at site 2 to assist with training and rework requirements, this includes printing of outer case labels from site 1 and transferring them to site 2.- Ongoing • Formal documented training for all team members involved in rework process including the checking of labels - Completed • Procedure for changes in the product line and requirements to be implemented between different sites – Completed? • Only members of the QA team / Customer Relationship manager to have authorisation for releasing product into good stock – Completed • Dedicated rework area put in place – Completed • Unit/Barcode labelling to be photographed start, middle and end of rework – Ongoing • Unit labelling only to be carried out on days where there is more support – Ongoing • Full review between different sites to cover all rework SKU for sign off – TBC February People: Training - incomplete
I-002-873 03/02/2022 Pathogenic Microorganisms Prepared Dishes & Snacks Listeria Monocytogenes Listeria spp detected by enrichment at end user No Listeria detected at production site in either finished goods or environment Blank Blank Blank Posp production contamination No Listeria detetcted in finished product or environment however thorough cleaning of plant and production area was carried out and area swabbed extensively after, no Listeria detected. Undetermined / Inconclusive
I-002-890 04/02/2022 Allergens Confectionery Nuts Cocoa Dark Chocolate Pistachio product arrived to consumer mixed with Cocoa Dark Chocolate Almonds Product issue originating from supplier - both products packed in the same day - OR Our staff picked wrong product when decanting and mixed the 2 very similar looking products Blank Blank Blank Product issue originating from supplier - both products packed in the same day - OR Our staff picked wrong product when decanting and mixed the 2 very similar looking products Re-training of the staff on allergens and labelling / picking packing as well as product identification (Picking product based on outer case label and order being processed – opening and checking that bag label matches outer case label – visually inspecting product for any differences in shape / size as per training and product specifications). - Supervision of the production line to observe if any staff disregards or does not pay attention to labelling when picking / packing product - A Poster / booklet of chocolate products to be created and displayed in production. - Warehouse supervisor will provide one product at the time only for packing. - After opening the bag, a sample can be taken and/or product cut open for positive release. - Organoleptic tasting can be done to verify that the product for packing is correct if needed. - After the order is complete and the product is not needed, the warehouse supervisor MUST take the surplus of the product back to its original storage in the warehouse before starting to pack a different product. - Cleaning to be performed between products using FAD and following cleaning instructions. - Updated the Quality Control document to include time stamp and signature for the removal of product and clean down between runs Supplier also confirmed addressing the gap in their cocoa dusting process and updating their process, paperwork and sign off. Process: Assembly Error Process: Labelling Verification Checks - failure
I-002-833 07/02/2022 Pathogenic Microorganisms Meat & Meat Products (other than poultry) Salmonella Blank Blank Blank Blank Blank Source: Material - Contaminated Product. Routine microbiological surveillance conducted on site on a weekly basis of mince and meat preparations in line with legislative requirements. On this occasion Salmonella was detected in 25g of a pooled sausage sample from specified batch. Brand of 80/20 trim supplied & kill date specified. Seasoning supplier specified - Batch of seasoning was quarantined and tested. Most likely source determined as 80/20 Pork Trim. Specied separation procedures are in place at the site so cross-contamination of trim unlikely pre-production – additionally trim would enter directly into mincer without pre-cutting so contact minimal. Seasoning results came back as Non detected in 25g for Salmonella. Full investigation launched supplier. Carcase analysis showed that Salmonella was not detected in carcase swabs taken, however trend analysis of 50 samples shows that Salmonella was detected on 2 occassions across 50 swabs(2/50). Which whilst within threshold suggests an on-going low level presence. No trim was retained on the occasion, so further analysis could not be undertaken to be certain of root cause but it is the suspected cause. Product brand requested not to be supplied as an interim measure. Additionally 80/20 trim now being sought from an alternative supplier on a regular basis. Trim samples retained in the freezer for all routine surveillance microbiologial testing in order that further testing can be conducted in the future if an issue if found. Internal Audit of specied separation also conducted as a precaution. Material: Ingredient Hygiene Controls - inadequate