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Summary of Food/Feed Safety Incident Root Cause Analysis (RCA) informationRoot Cause Analysis data received in November 2021

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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-002-113	02/11/2021	Allergens	Nuts	Confectionery	A limited amount of dark chocolate bars with hazelnuts were wrapped with a wrapper of dark chocolate with raisins and almonds	1.1. dark choc with hazelnuts present at the line 2.1. Checklist change over/start up barline: check line clearance was ok on checklist, but not in reality. 3.1. During currative maintanance interventions on the packaging machine, products are collected on another conveyer belt and put into grey bins. Products of the previous run were not put back on the line in the same run or have not been labelled after the production run. There was no communication towards the next shift or Teamleaders about this in the shiftbook on the shift.	1.2. Products of previous production were not used within the same production run (due to too many technical issues during this shift) as described in the procedure. If this is not possible these products should be identified and put away. 2.2. Grey bins with rest products of the bars dark choc with hazelnuts were overlooked at the start of the production run of the bar dark choc almonds and raisins 3.2. Grey bins with rest products of the bars dark choc with hazelnuts were overlooked	1.3.Grey bins with rest products of the bars dark choc with hazelnuts were overlooked 2.3.Unlabelled bins containing product of previous production run may be mistaken with empty bins. 3.3.Training manual of the operators, which includes how to stop on the end of a working day, does not describe the place where the grey bins were left.	1.4.There is a checklist for start up of production which includes checks for line clearance, which was completed. There is no written acknowledgement on a checklist when stopping the line at the end of the day. 2.4.Because the bins have been left unlabelled by the previous production shift. STEP 6: 1.5. There wasn't a prompt on checklist for stop production. There is no written acknowledgement on a checklist when stopping the line at the end of the day.	1. There wasn't a prompt on checklist for stop production 2. Because the bins have been left unlabelled by the previous production shift. 3. Training manual of the operators, which includes how to stop on the end of a working day, does not describe the place where the grey bins were left.	1. Revision of checklist change over/start up to include stopping the production run at the end of a working day 2. Training personnel how to use the revised checklist which includes stopping the production run at the end of a working day 3. Retraining personnel for how to use the shift book correctly 4. Retraining personnel for communication of the status of the production run towards the teamleaders. 5. Upgrade training manual to include the place were the grey bins were left when stopping the production run at the end of a shift/working day Retraining personnel according to upgraded training manual.	Environment: Ingredient / Product Storage Controls - inadequate Method: Work Instructions - inadequate	Not set