Food Safety Culture and Resilience: A Systems Analysis of the UK Pennington 1996 and 2005 E.coli Outbreak reports

Rounaq Nayak

R.S.Nayak@lboro.ac.uk

Introduction• 2nd year of study

• Sponsored by Loughborough University Graduate School

• Publication:Nayak, R. and Waterson, P.E. (2016), ‘When Food Kills’: A sociotechnical systems analysis of the UK Pennington 1996 and 2005 E.Coli O157 outbreak reports. Safety Science, 86, 36-47. http://dx.doi.org/10.1016/j.ssci.2016.02.007

• Supervisor: Dr. Patrick Waterson

Safety culture• Concept originated after the Piper Alpha oil

and gas explosions that occurred twenty-eight years ago resulting in 167 deaths

• ‘Culture complacency’ and relaxed attitudes towards safety were regarded as the chief factors that led to the accident

• There are multiple definitions for safety culture and hence there is a confusion between safety culture and safety climate

• Safety culture: ValuesSafety climate: Perception of culture in the business

• In organisational safety, safety culture is defined as ‘combination of those behaviours which either increase or decrease the risk of harm, with safe denoting protected from harm, and unsafe at high risk of harm’

Food safety culture• Griffith states that food safety culture

provides staff with a common sense of food safety purpose.

• A business with a good safety culture would be one where staff are aware of the possible risks, where appropriate tools are used to assess food safety (HACCP, FSMS, FHRS, SALSA, etc.) and where staff are encouraged to practice good safety practices (rewards, positive reinforcement, incentives).

SYSTEMS ANALYSIS OF THE UK PENNINGTON 1996 AND 2005 E.COLI OUTBREAK REPORTS

Example of Accimap: 1996 Outbreak Accimap

Public unaware of dangers

Authorities reluctant to

enforce guidelines

10. Cross-contamination 11. E.coli O157

outbreak

EHOs not motivated5. Outcomes

9. Inefficacious layout and design

of plant and equipment

Raw and cooked meat not separated

Temperature monitoring and controlling less than

ideal

Skinned and non-skinned carcasses hung too close to

each other

Untrained helpers at church halls and

community centres

4. Physical/Individual events, processes and

conditions

Distribution chain difficult to trace

8. Hardly any product recall

systems in place

Legal requirements to carry out hazard analysis not met

No documented system in place

Operator responsible for food safety

Too expensive to carry out routine

testing

Not an offense to present dirty animals for slaughter

Food prepared in non-registered premisesRejected animals

accepted at other abattoirs except in

NE Scotland

OVS lowered quality check

standards

3. Organizational/ Workplace

2. 1995 Regulations less prescriptive

Regulations too complex to understand

3. Loopholes such as Codes of

Recommended Practices and

GuidanceMixed

transportation standards

4. No legal authority for Meat

Hygiene Service (MHS)

5. High demand on the limited resources of

EHOs

No symptoms exhibited by infected

animals

6. Inadequate number of EHOs

dispensed with many tasks

7. Move to unitary status2. Government

1. Media difficulties Commercial pressures1. External

Underestimating the importance of detailed

regulation

Underestimation of transport risks

Not enough support for EHOs

Key

Precondition

Direct Cause

Indirect Cause

COMPARING THE OUTBREAKSSimilarities between both outbreaks

‘Macro’ factors

Complacency in food safety HACCP absent (not mandatory)

Loopholes in Codes of Recommended Practices and Guidance

Faulty audits

‘Light touch’ approach

Ill-defined roles for authorities

Inadequate support provided to Environmental Health Officers

Provincial budget cuts

‘Micro’ factorsMeat served to highly vulnerable population

Compliancy failures

Blatant disregard for food hygiene and safety (e.g. cross-contamination, lack of training, erroneous approach by food business operators and food businesses)

Prioritization of production and profits over hygiene and safety

Interaction between ‘macro’ and ‘micro’ factors

• Both outbreaks involved a complex interaction between macro and micro-level contributory factors

• Some factors were specific to the food industry at the time of the outbreaks (e.g. fragmentary and poorly managed regulation, commercial pressures)

• Few factors could have also affected other industries, had it happened there (e.g. government budget cuts)

• Both categories of factors were upper level factors in the Accimap and had a role to play in the existence of lower level phenomena and behaviour (e.g. lack of compliance with rules and procedures and development of complacency over time)

• Factors such as widespread complacency and prioritization of production over safety are examples of ‘whole system’ phenomena

PERCEPTION OF FOOD SAFETY CULTURE AND THE GREENSTREET BERMAN TOOLKIT

Toolkit• Post the 2005 E.coli outbreak, the Food Standards Agency (FSA) commissioned a study to

develop a toolkit that could evaluate safety cultures and behaviours in businesses and enforcement bodies

• The contractor, Greenstreet Berman, reviewed existing food safety culture research and tools available in the public domain; as no tool dedicated to assess safety culture existed, they developed one

• The government approved toolkit (only one for the food industry in the UK) is a 32-page document!

Most common issues with the toolkit (as voiced by EHOs, academics and food and beverage managers)

1. Too wordy

2. Repetitive

3. Titles used for categorizing businesses too complicated to understand without the explanation

• Development of a user-friendly yet comprehensive and effective tool/toolkit

• The objective of this tool/toolkit would be to help assess the safety culture in food businesses without making the process much of a hassle for EHOs and food and beverage managers

• EHOs and food and beverage managers already know the importance of assessing safety culture and the link between safety culture and safe food; the challenge would be to get them to use an ‘additional’ tool/toolkit

ANY QUESTIONS?

R.S.Nayak@lboro.ac.uk