In the summer of 2008, 22 Canadians died from an outbreak of listeriosis, a bacterial infection. The bacteria was traced to contaminated meat products produced at a Toronto plant owned by Maple Leaf Foods. The tragedy fuelled a public backlash and criticism of Canada’s food safety system. In response, the government appointed an independent investigator to determine what went wrong in the plant and how similar events could be prevented in the future. On July 21, 2009, the investigator published her report. The key finding: Although Maple Leaf had an effective oversight system in place to ensure food safety, flaws in this system undermined its effectiveness and allowed the Listeria bacteria to breed for months on two of the plant’s production lines [Report of the Independent Investigator into the 2008 Listerios Outbreak (the Weatherill Report)].
THE PROBLEM
The Weatherill Report focuses on the systems companies in the food industry implement to prevent incidents such as a listeriosis outbreak. And in many ways, the management of a food safety system is similar to the management of an OHS system. Both systems use an array of engineering and work practice controls to detect and eliminate or control hazards. The breakdowns that occurred in Maple Leaf’s food safety system are similar to the failures that can undermine the effectiveness of an OHS system. These same weaknesses can result in worker injuries, illnesses and fatalities. Thus, companies like yours can apply the insights of the Weatherill Report to pinpoint and correct weaknesses in their own OHS systems.
THE EXPLANATION
Companies must have OHS systems to ensure the health and safety of their workers. But flawed or inadequate systems undermine this goal, exposing workers to hazards and the company to liability. So merely having an OHS system isn’t enough. The system has to be comprehensive and effective.
The same is true of food safety systems. The key lesson from Maple Leaf is that there’s more to a safety system than technology and procedure. Before the listeriosis outbreak, Maple Leaf was regarded as an industry leader in food safety. Its in-house safety system was comprehensive and included food safety procedures, a hazard monitoring and control program and worker training. The plant complied with regulatory requirements and passed government inspections and tests. In fact, Maple Leaf’s food safety efforts went beyond government requirements.
So why did Maple Leaf’s system fail? The report cites four problems:
1. The company didn’t consider the “big picture.” There were positive tests for Listeria on meat slicing machines in two of the plant’s production lines as early as the summer of 2007. The plant took steps to deal with the problem and assumed it had been resolved. But the pattern of positive tests on these lines continued into 2008. Although data was collected, no one at the plant or company headquarters analyzed the test results to detect trends or patterns that might indicate emerging problems. So the company missed the “big picture.”
2. The company didn’t talk to inspectors. The company didn’t report the positive test results for Listeria to government inspectors because it wasn’t required to do so. But if the company had shared its results with the government, the underlying problem may have been identified and resolved sooner, according to the report.
3. Nobody notified the CEO. Because the plant assumed that the problem had been resolved, nobody told the CEO about the pattern of contamination on these production lines. As a result, another opportunity to thoroughly investigate and prevent the outbreak was lost.
4. There was a disconnect between food safety and equipment design. Because of the way the slicers were designed, fully dismantling the machines to thoroughly clean them took days. As a result, the contaminated slicers weren’t fully dismantled to verify that the infection control measures implemented had been effective.
THE LESSONS
The Weatherill Report makes recommendations for preventing future contamination outbreaks. These recommendations could easily apply to an OHS system instead of a food safety system, including:
CEO oversight of safety. CEOs and senior management should accept oversight responsibility for ensuring that commitment to workplace safety is fully embedded in every level of the company.
CEO oversight of equipment design. CEOs and senior management should ensure the effective design of equipment and machinery with an eye towards workplace safety.
Updated safety plans. Workplace safety plans and rules should be updated regularly to ensure adequate attention to new hazards or changed procedures.
Verification of safety measures’ effectiveness. Don’t assume that the safety measures the company implements actually work. We need to verify the effectiveness of these measures.
Communication with government safety inspectors. The company should disclose safety hazards to government inspectors, whether or not disclosure is requested and required by law.
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