The factory manager received a phone call from the council over a complaint regarding the company’s product bought from a nearby supermarket. It was my first week serving the role of a cookie manufacturer. The factory manager informed me about the bad news and assigned me the task of investigating the incident and preparing a strong defense, for she believed the council would most likely decide to prosecute. 

The report received by the council stated that a 12-year-old boy had bought the company’s choc chip cookie and got admitted to the hospital over a metal that lodged his esophagus. The foreign object looks like a small metal shaving, a few millimeters in length. At the time of the report, the child was undergoing general anesthetic surgery aimed at recovering the object. Although there is not yet solid proof that the metal came from the cookie, the child first felt pain when eating the cookie, and it is, thus, believed to be the source. Based on the batch code, the cookie had been manufactured two weeks ago.

Areas of Investigation

During cookie manufacturing ingredients are collected, mixed, and prepared at different points within the factory, hence several areas must be covered in this investigation. The investigation, thus, considers all activities that happen from the supply side and throughout the distribution chain. The Fishbone diagram shows the concerned areas.

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Figure 1: Fish bone diagram

Cause of Incident

As the preparations for investigation into the incidents were under-way, the Factory manager got another phone call from the council saying that the anesthetic surgery had enabled recovery of the metal shaving. Upon request, the council sent the metal piece to the factory. It looked like copper wire pieces the maintenance team had used a few days ago to correct wiring issues with the dough mixture. Further investigation, thus, focused on finding out the areas in which maintenance activities happened about two weeks ago.

It was discovered that copper wire had been used in the storage area to repair problems with lighting. Some of the ingredient containers were not fully closed, and there is a possibility that the small piece of copper wire dropped into one of those. The maintenance staff did not conduct any safety checks after cleaning the area on Tuesday morning. He was not aware that such checks should be done after repair. Chefs were not aware of this maintenance activity, and went ahead to use these ingredients which they had inspected earlier on.

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Recommended Preventive and Corrective actions

Corrective Actions

  • Steps to solve the identified root cause
  • Actions to manage the incident and related failures
  • Preventive steps for future operations

The table below shows the correction plan. It identifies the people in charge of various activities, what the people will do, where it will be done, how, and when it will be done. The table also identifies the monitoring process and frequency, as well as the evidence to show the effectiveness of the corrective process.




Incident Details


A piece of metal shaving got lodged into the esophagus of a 12-year-old boy who was eating a cookie made by our company. The child was admitted to the hospital, where the metal was successfully recovered. The council delivered the metal piece to the factory to aid investigation. It was discovered to be a piece of copper wire that possibly dropped into the open ingredient containers while maintenance staff completed wiring repairs in the storage area. He was not aware of the food safety checks to conduct after such activities, hence he only cleaned the place and left. The chefs, who had earlier on checked the ingredients, were unaware of the maintenance process and went ahead to use the ingredients without further inspection. These revealed weaknesses in several areas in the manufacturing process, especially the maintenance department. Even more, there were concerns over the packaging area, as they did not detect the metal while they packaged the cookie. The possibilities are that no checks were done at this point or the metal detector failed.

Corrective action

After uncovering the root cause of the incident, all the concerned departments were notified and a meeting was urgently arranged. The agenda of the meeting was to inform the staff about the breached food safety procedures and to inform all employees about the rules. Every department had to participate in upholding the safety of food manufactured by our company.


Cookies bearing the identified batch code were recalled from distribution points and supermarkets. Furthermore, operators in these areas were informed about the incident and requested to update the company on any similar incidents they hear elsewhere


A training program was scheduled for the maintenance staff to ensure they know the safety practices required in the food production area, for future safety


Further analyses would be conducted to determine any lack of knowledge on food safety practices, and relevant guidance be provided


Changes to inspections were also made to ensure that chefs inspect the ingredients at the point of use to avoid the recurrence of the incident


Experts would be invited to assist the company staff to select the most appropriate technologies for promoting food safety, especially the highly sensitive metal-detecting devices


To arrange for training programs to help staff learn to use any new equipment that the company purchases


The corrective measures will be checked at least once a week


Persons in charge include: quality assurance personnel, food safety team and their leader


3:00 pm

Preventive actions

The following measures were put in place to avoid the re-occurrence of the incident:

  • Contractors should ensure that all food containers are covered tightly before commencing maintenance work in a given area
  • A supervisor must be present on-site to monitor how the maintenance work is performed
  • A contractor must receive food safety training to work for the company
  • Safety checks be conducted in the area where maintenance activities took place to ensure that no metallic objects remain on the floors on the covers of the containers
  • A food safety officer to inspect the ingredients and the work environment before food manufacturing commences
  • Every check that Is performed should be recorded
  • All machines, especially metal detectors, be tested for effectiveness before work commences

Maintaining hygiene in the mixing area