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Root Cause Analysis data received in March 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-002-648	01/03/2022	Allergens	Nuts / Nut Products / Seeds	Multiple Allergens	Incorrect product went to the labeller and was therefore incorrectly labelled	Two different products with same packaging run through the same equipment, and manually sorted onto labelling lines. Product hadn't been dried the previous day following pasteurisation	Product was removed from the line prior to drying equipment	No procedure in place for handling of WIP stock to direct staff to remove after the dryer	Lack of controls in place for non-standard processes	Lack of controls in place for non-standard processes	Operations Manager has held a briefing with production co-ordinators and all labelling area team leaders regarding the issue, the cause and instructions not to use the same conveyor for different products at the same time. Further training to follow, see below. The incident has been risk assessed and determined that a recall is required for the product production which has been dispatched to customers. Recall team will be assembled and all activities logged for the recall. See full timeline of events/actions and all documentation and evidence is available in the folder.	Process: Quality Control Checks - inadequate Method: Work Instructions - inadequate
I-002-801	01/03/2022	Allergens	Meat & Meat Products (other than poultry)	Milk	Incorrect labelling of Lactose in the ingredient list with no reference to the source MILK	Insufficient understanding by the supplier to include the source of Lactose being obtained from MILK.	Labels not approved by FBO prior to importing product.	Blank	Blank	Source: Material - Labelling - absent / incomplete / incorrect No reference to MILK being the source of Lactose on the product label. Labels not approved by FBO prior to importing product. Insufficient understanding by the supplier to include the source of Lactose being obtained from MILK.	An approval process for product labels has been implemented which will allow review against the accepted UK labelling requirements for Allergens. Label check sheet and completed example supplied.	Process: Labelling Verification Checks - absent / failure
I-002-992	01/03/2022	Allergens	Meat & Meat Products (other than poultry)	Mustard	Pork product for sale in Retailer store should have been alternative pork product. (Allergens and ingredients are different, Mustard and Sulphites also being present in the pork product). Therefore, incorrect product, allergens, ingredients.	These incorrect product had a specific motif present upon the lid of each product packaging, whereas the other product has no motif and this was not identified at point of sale.	The manufacturere despatched a box of pies to Retailer in error this case was intended for a different customer/order. The order was packed (then despatched) on the specified date. This was/is not a normal order day for that Retailer.	The previous customers order had not been totally completed. One case of the product which was possibly labelled for the correct customer, was incorrectly added in with Retailer order. An outer label for the Retailer was added to the case (these outer labels are applied to a different part of the outer case). It is not 100% certain how many labels were on the case when it was delivered to the Retailer.	The order was not packed on one of the usual order days for the Retailer, and was an extra order packed on the specified date. Packing Supervisor and the High Care Supervisor were both attending a meeting at the time during which the preceding order and then Retailer order were being packed. Human error/lack of attention is the Root Cause.	Human error/lack of attention.	A new Standard Operating Procedure has been written for the packing staff/team, applicable to packing orders for the Retailer. An extra safeguard/step/check has been added this requires every case to be rechecked BEFORE case is sealed, metal-detected and palletised. The case will be initialled if satisfactory. This will guarantee that the quantity, contents and label are all correct before case is sealed. Packing Supervisor, High Care Supervisor, Q.A.Supervisor and all packing staff being trained against this new S.O.P.	People: Procedures not followed
I-003-021	01/03/2022	Allergens	Ices & Desserts	Milk	Undeclared allergen (milk) on the product	Traces of milk in one of the ingredients (coconut oil powder).	Blank	Blank	Blank	Traces of milk in one of the ingredients (coconut oil powder).	Affected lot quarantined. Product recall notice issued. Availed technical specification of all raw materials. Prepared allergen matrix for raw materials.	Material: Ingredient Cross-contamination