Learning from near disasters
Don’t ignore the lessons that can be learned from those near disasters
An article in the Globe and Mail in early August about learning from incidents which, if they had occurred, would have been disasters, served to remind me of incidents that I had experienced in the past that taught me valuable food safety lessons. I’ll tell you about two.
Bags look alike
Not long after I was hired into a large multi-national company as their director of QA/R&D, I was asked to audit a large ingredient supplier. Let’s call them Company A. Since the position I had recently assumed had been vacant for some time, it had been a while since this company had had an audit.
The supplier audit had been going smoothly for a couple of hours when the president of Company A approached me to come into the board room to meet the company’s executive team and have coffee. Wow, I thought, they are really rolling out the red carpet!
Upon entering the board room, the president introduced me to his executive team — none of whom were smiling. I sat down to enjoy my coffee and expected the president to launch into a speech about how much his company appreciated doing business with my new employer. That didn’t happen.
He cleared his voice and then slowly and carefully explained that it had just come to his attention that a wrong ingredient had been mistakenly used in making one of my company’s key products. This had been happening for a couple of weeks. When I asked the president how his company found out that they were using the wrong ingredient, he took his time to answer. It turned out that Company A was alerted by the company that supplied this ingredient (Company B). During an inventory audit at Company B, it was discovered that the wrong ingredient had been shipped to Company A. Company B immediately notified Company A of the mistake. On investigating, Company A discovered empty bags from the “wrong ingredient” beside the equipment used to prepare one of my employer’s key products.
I won’t get into the details of all the frantic activities that followed the board room meeting but I did not finish my audit of Company A that day. Given the serious nature of the incident and the implications to my company, I was given complete freedom to engage anyone I thought could help assess the food safety risk and to help me deal with potential regulatory action.
In the end, it was shown that although the “wrong ingredient” was not intended to be used as a food ingredient, it was approved for “food contact” which means that it did no harm when in contact with food. The final amount of the “wrong ingredient” in the finished product was also extremely low. Disaster averted.
Lesson learned: The ingredient problem arose because both the right and wrong ingredients were packed in similar brown craft-paper bags and stored adjacent to one another in Supplier B’s warehouse. As a result of this experience, I have, without exception, insisted that those responsible for receiving ingredients always verify that what has been received is what was ordered. Likewise, those using the ingredients must check the labels to verify that the correct ingredients are being used.
Taking efficiency too far
At the end of the day, restaurants and food processing companies are left with varying amounts of ingredients and food that can’t be stored overnight. In most cases, these items end up being composted. However, in some cases, these items find their way back into manufacturing and on to consumer plates.
My company was pushing to recover a high-value-added ingredient from a prepared food at the end of each day and then incorporate it into other items such as soups and sandwiches the following day(s). In theory, this should work but when this concept was tested in several locations, microbial test results were extremely concerning. We abandoned the idea.
Lesson learned: Unless the processes for using recovered ingredients can be validated as food safe over an extended period of time, don’t do it.
Don’t ignore the lessons that can be learned from those near disasters.