Food safety culture was a cool concept to try and talk about all the incidentals in delivering safe food.

To me, it was when one employee was with another in the bathroom and one left without washing their hands, the culture would support the other employee saying, dude, wash your hands.

But the term was abrogated when Maple Leaf Foods started talking about their culture, rather than offering a clear time-line of who-knew-what-when, making Listeria test results publicly available, and putting warning labels on their deli meats, as Publix has done.

It jumped the shark.

If there’s any further proof required, Fonterra of New Zealand’s response to the latest inquiry on the botulism (not) in raw milk was, “The reason we’re welcoming it, is because it’s hugely important to raise the prominence of the food-safety culture with our food processes here in New Zealand.”

Uh-huh.

According to media accounts, Fonterra focused on profits at the expense of a food safety culture, damaging New Zealand’s international reputation.

Earlier this year, Fonterra was fined $300,000 for the incident, which saw milk-products pulled off shelves when it emerged they were potentially contaminated with Botulism. 

Fonterra was late in notifying the correct authorities and it caused an international scare, particularly in China, with Fonterra unable to confirm for several days where the products, which had been produced more than a year earlier, were around the world.

Further testing showed that the risk of botulism never existed, although the false alarm prompted a review of New Zealand’s food safety system.

The last of a series of independent reports was released today, and the inquiry, led by Queen’s Counsel Miriam Dean, found a number of errors were made. 

While food-safety protocols were in place, the culture of care around food safety had not been fostered.

Problems dated back to May 2012, when Fonterra reworked some of its concentrated whey using temporary pipes and hoses at the Hautapu plant in Waikato in a way not approved by regulators, which increased the risk of bacteria.

Hoses were cleaned using a caustic (rather than acid) solution, which failed to eliminate all contamination.

The report also found that having notified the ministry, days late in August 2013, Fonterra had no well-prepared group crisis plan to implement, including crisis communications (particularly in social media).

“Fonterra took until 18 August to trace all the affected products, a seriously deficient effort.

“Fonterra did not effectively co-ordinate its actions with those of the ministry, Danone and the Government during the crisis,” the report said.

The Ministry for Primary Affairs did not escape unscathed.  

“The ministry had no single, coherent (or reviewed or rehearsed) crisis plan for a food incident that it could implement straight away after receiving notification of C. botulism.

But Dean noted the ministry’s response was hampered by Fonterra’s late notification and overstating the certainty botulism, as well as Fonterra’s drawn-out and deficient tracing.

Dean described the incident as a “watershed moment”. 

“Fonterra realized in a most profound way that food safety was the one thing without which it was impossible to achieve any other company priority, whether continued sales and profits, a sound reputation, strong consumer confidence or a secure future on the world stage,” she said.

Labour immediately called for an independent food safety authority (New Zealand used to have one; good folks).

“It’s the only way that we can ensure the very highest levels of food safety and an independence that reassures our customers in the international market,” primary industries spokesman Damian O’Connor said.

New Zealand needs a “world-leading” food safety regime, he said. “This report has been a sad indictment of what has taken place… The culture, right from the farm through to the market-place has to improve.”

Fonterra chief executive Theo Spierings acknowledged the report and said the co-operative would study its findings and recommendations.

“Food safety and quality are our number one priority. At the time of the recall, we did what was right based on the evidence we had. It was subsequently confirmed that the recalled WPC80 did not present a health risk.”

Uh-huh.

Stop the nonsense about culture: Food producers should truthfully market their microbial food safety programs, coupled with behavioral-based food safety systems that foster a positive food safety from farm-to-fork. The best producers and processors will go far beyond the lowest common denominator of government and should be rewarded in the marketplace.

They should pay attention.

I coach hockey in Australia, where 5-year-olds and 10-year-olds are on the ice at the same time, and I say, pay attention. Because that 10-year-old can wipe you out.

Just like some unexpected bug or a false positive.

Culture is nice, but pay attention and serve your consumers the data to back up the bullshit statement that every food CEO makes during an outbreak: food safety is our top priority.

Stop making people barf.

And it was nice the work of me and Chapman and our collaborators was cited throughout the report.

Government Inquiry into the Whey Protein Concentrate Contamination Incident

Preface

Six months have passed since the Inquiry began stage two of its examination of New Zealand’s biggest food safety scare. That scare, as most people will vividly remember, was sparked by suspicion that infant formula and possibly other products, too, were infected with botulism-causing C. botulinum. In this final stage, the Inquiry has looked closely at the causes of the incident, together with the responses by Fonterra and the Ministry for Primary Industries and the roles of others. The distance of time has enabled the Inquiry to take a considered view of just how it was that the extraordinary events came to pass. At all times, it has endeavoured to do so through the lens of food safety, including its examination of the state of readiness of key participants to respond to unfolding events. The contributions of those who assisted, from providing documents, briefing papers and written submissions, to participating in long interviews, are gratefully acknowledged. All were prepared to review the events in question openly and honestly. The Inquiry is particularly appreciative of the assistance from

the core participants: Fonterra, the ministry, AsureQuality, AgResearch and Danone. The Inquiry is indebted to Kelley Reeve, Ned Fletcher, Sally Johnston and Annette Spoerlein as the secretariat and to Simon Mount as legal advisor; also our scientific advisor, Dr Lisa Szabo, chief scientist of Australia’s NSW Food Authority, and our independent peer reviewer, Professor Alan Reilly, chief executive of the Food Safety Authority of Ireland. We cannot thank Peter Riordan enough for his enormous contribution in assisting with the writing of this report. Also, Susan Buchanan for editing and proofing; Jacqui Spragg as designer; Jill Marwood and Maria Svensen for secretarial and administration assistance; and finally staff at the Department of Internal Affairs. As with the first stage, it was a pleasure to work with them all. It took this incident to raise awareness that food safety cannot be taken for granted. Lessons learned from the incident provide an opportunity for all participants in the dairy food safety system – and indeed wider – to step up and meet the challenges ahead. Consumers expect no less. But the Inquiry hopes that this final report can draw this particular chapter to a close, in the knowledge that all participants will continue to work together to ensure New Zealand remains a world leader in dairy food safety.

Overview

The news in August 2013 of potential Clostridium botulinum contamination made global headlines. In New Zealand, it was received with something approaching disbelief, in part because the country prided itself on exporting food of the highest quality. The truth is, our food was, and still is, safe, wholesome and among the best in the world. But the botulism scare, as many call the WPC80

incident, led to a review of the dairy industry’s food safety framework, a matter dealt with in the Inquiry’s first report. That report concluded that the

regulatory framework was fundamentally sound, but recommended improvements. Underlying many of these was the idea that the dairy industry must anticipate future risks as well as counter existing known threats. Now, in stage two, the Inquiry has turned to a detailed examination of what began with a simple breaking of a torch lens in a Waikato dairy factory and ended in the recall of millions of product items. How did something so insignificant come to have

consequences so enormous? This report answers that question. The Inquiry is tempted to describe the account as fascinating – and certainly it is likely

to be so for those at arm’s length from New Zealand’s biggest food safety incident. However, for those involved, or who felt its serious financial repercussions, the word grim might be more apt. Between the torch breakage on 1 February 2012 and Fonterra’s notification of C. botulinum on 2 August 2013, numerous people made decisions that, one by one, added their small contribution to the building momentum of events. Sometimes, those events seemed to take on a life of their own, but they were entirely avoidable – if a strong food safety culture had thrived in the workplace. Some readers will wonder why the various individuals involved did not heed the warning signs or take the precautions that were so apparent afterwards. But to yield to that temptation would be to underestimate the complexity of the events and also to undervalue the good intentions of all those involved (many of whom, the Inquiry can vouch, worked days on end after the crisis broke, trying to regain control of the situation).

The key immediate causes are relatively easy to determine (although the findings on pages 7-8 give a comprehensive list). They are:

• The Hautapu plant’s improvised reprocessing of WPC80, without a risk assessment and in breach of its risk management programme

• The Fonterra research centre’s encouragement of C. botulinum testing without sufficiently considering its purpose, justification and potential implications

• The decision to approve “toxin testing” without appreciating that this meant authorizing C. botulinum testing

• Fonterra’s failure to advise both the Ministry for Primary Industries and its customers much sooner of a potential food safety problem. The direct causes do not tell the whole story. Wider factors had an influence on the crisis as a whole. Identifying those enabled the Inquiry to understand more fully why the incident happened and to compile a lessons section especially for the industry (see pages 10-11).

Contributing factors included:

Organisational pressures: Fonterra’s workplace culture exhibited an entrenched “silo” mentality that robbed the company of some of the cohesion so vital in an organisation of its size. Both internal and external pressures also contributed to missed opportunities to correct the course of events. Communication, both within and between parts of the organisation, was often unclear – symbolised most starkly by a manager’s unwitting authorisation of C. botulinum testing. And there was also a lack of adequate escalation procedures to deal with possible food safety problems.

OVERVIEW

Testing: Fonterra and AgResearch, the research institute that tested Fonterra’s WPC80 samples, approached this work from different perspectives.

Communication lacked the precision and formality that might have halted testing or shifted it to a diagnostic laboratory and produced a different result.

Readiness: The ill-prepared inevitably pay a heavy price in a crisis. Fonterra was not ready for a crisis of this magnitude. It lacked an updated, wellrehearsed crisis plan to implement, as well as a crisis management team that could spring into

action. The ministry also lacked a single, coherent food incident plan to implement straight away.

Responses: The WPC80 incident had a long and largely unobserved prelude, followed by a short, very public conclusion. The second phase placed most of the main participants in the crisis, but particularly Fonterra, under intense pressure to act swiftly, decisively and in concert. This did not always happen. Partly, the underperformance was the result of insufficient preparedness and partly, Fonterra’s tracing problems.

With a single phone call on 2 August, the ministry was confronted with a raft of public health, trade, market access, tracing, infant formula supply and media problems. Many aspects of its response deserve credit, especially its decision to put public health first and urge a recall, knowing that more definitive test results would be weeks away.

Its decision-making, however, could have been more rigorous and science-based. All parties could also have co-ordinated better during the crisis.

Tracing: This was an undeniably complex task. The 37.8 tonnes of WPC80 manufactured in May 2012 had, by August 2013, made their way into thousands of tonnes of products in various markets.

Nonetheless, Fonterra’s tracing efforts were, for different reasons, seriously deficient. That, in turn, hampered both the ministry and Fonterra’s customers in their tracing of the affected production. Fonterra’s initial estimate was well off

the mark. It would take the company a further 16 days, and numerous amendments, before it arrived at a final, conclusive figure that enabled all

suspected production to be identified.

Food safety culture: A food safety programme and a food safety culture are entirely different. One is concerned with documentation and processes, the other with employee behaviour and a top-to-bottom commitment to putting food safety first.

The Inquiry has explored this in detail, because if Fonterra had possessed a strong food safety culture, this incident would probably not have happened.

But good can come out of bad. The WPC80 incident has spurred Fonterra into a series of comprehensive changes, from boardroom to factory floor, especially aimed at strengthening food safety and quality and crisis management capability. The ministry, too, has taken matters swiftly in hand. During the past 12 months, it has created a regulation and assurance branch devoted more or less solely to food safety. No one now can be in any doubt about where responsibility for food safety sits.

The ministry is also preparing a new crisis response model for implementation in 2015.

All those changes are welcome and will put the ministry and the country’s biggest dairy company on a better footing in the event of another food safety incident (as well as protecting consumers and New Zealand’s economy and reputation).

Other changes may follow, too. This report contains recommendations specifically for consideration by the Government and the ministry, which would, among other things, strengthen scientific expertise, auditing, crisis planning and non-routine reworking procedures. The report also draws lessons from the WPC80 incident that could be useful for the dairy industry and wider food manufacturing sector. These would strengthen the food safety cultures, manufacturing processes and crisis planning of other companies, as well as clarify laboratory testing processes.

But perhaps the most important lesson here is one of attitude. As United States food safety expert Debby Newslow puts it: “We can no longer learn

from our mistakes; we cannot allow mistakes to happen. In today’s world of food safety, we must be proactive and prevent mistakes from occurring.”