Normalisation of Deviance
(Diane Vaughan)
Cleaning
• Schedule "a joke" ( Prof Griffiths)• Nothing about cooked meat area or details for vac
packer• No sanitizer ( TFR 1 Alpha Traffic Film Remover)• Cloths changed every 14 days• Freezer not cleaned for 12 years
HACCP Plan
"Member of National Association of Catering Butchers"!
"A number of quality awards for excellent service
and hygiene standards"!
No analysis of operation of processing ready-cooked meats
Vac packing analysis inadequate (shelf life etc)
Vac Packer
• Use for raw and cooked "a bit like playing Russian roulette" (Brian Curtis)
• In raw meat area next to mincing machine
• Cleaned twice/week at most
Inspections of John Tudor & Son
Date Risk Score Risk Rating
April 2001 75 B
July 2001 100 A
Feb 2002 100 A
July 2002 65 C
Jan 2004 No Report -
July 2003 85 B
Groundhog Day is a 1993 comedy filmdirected by Harold Ramis, starringBill Murray and Andie MacDowell.
In the film, Murray plays Phil Connors,an egocentric Pittsburgh TV weathermanwho, during a hated assignment coveringthe annual Groundhog Day event(February 2) in Punxsutawney,finds himself repeating the same dayover and over again. After indulging inall manner of hedonistic pursuits, hebegins to re-examine his life & priorities.
FSA Audit
• Not designed to identify Tudor-type problems
PROCUREMENT
Latent Conditions
• Shortfalls in training
• Inadequate equipment
• Bad practices
Important Outbreaks
1993 Jack in the Box Burgers Western US 732 Cases 4 Deaths
1994 West Lothian Milk Scotland 100 Cases 1 Death
1996 Wishaw Meats Scotland ca 500 Cases
17 Deaths
1996 Sakai City Schools
Radish Sprouts
Japan ca 8,000 Cases
3 Deaths
1999 North Cumbria Milk England 114 Cases 3 HUS
2000 Walkerton Town Water
Canada ca 2,300 Cases
7 Deaths
2006 US Nationwide Spinach US, Canada 200 Cases 3 Deaths
‘What experience and history teach is this -
that people and governments never have
learned anything from history, or acted
upon the principles deduced from it’
Hegel