The recall of beef and beef products began on 4 September 2012 at the Brooks, Alberta beef processing plant operated by XL Foods due to E.coli O157:H7.
There was a “weak food safety culture” at the Brooks plant, shared by both plant management and CFIA staff, said the independent review.
The panel, appointed by the Governor in Council to analyse the incident, said it was their view that equipment maintenance and sanitation were “significant problems” at the plant.
Incomplete record keeping and confusing communication with the public were other areas that exacerbated the recall.
“Food safety is a journey, not a destination”
The union representatives of both plant and agency workers expressed concern about line speed at the plant, said the report.
“They noted that the processing establishment was reluctant to slow down line speed unless absolutely necessary; slim profit margins in the industry mean that higher line speeds need to be maintained to maximize production and profits.
“If the line speed is too fast, workers would have little time to examine and trim off visible contamination from carcasses before being moved to the next processing station. Staff would also have insufficient time to properly sterilize their knives between trimmings.”
However, it said line speed was slower than that at comparable US plants and the production line had been stopped 39 times between January and September 2012 to address food safety issues.
It criticised CFIA inspectors for not identifying deficiencies in recordkeeping of monitoring activities, validation of procedures and equipment maintenance and inconsistent sampling techniques.
Responding to the report, Gerry Ritz, Canadian agriculture minister, said: “Since this recall, our government passed legislation to strengthen Canada's food safety system which will improve inspections, strengthen food safety rules, and improve communication with Canadian consumers.”
Minister Ritz announced that the Harper Government will invest nearly $16m over the next three years to establish Inspection Verification Teams (IVTs) to oversee the performance of Canada's entire food inspection system.
IVTs will conduct unannounced spot checks of plants across the country to ensure that the food safety system is effective and that food safety rules and standards are consistently and thoroughly followed and enforced.
The report also found six days elapsed before XL Foods provided agency staff useful information on distribution of product and identification, meaning contaminated product continued to be produced and shipped.
High event periods (HEPs), caused by results for E.coli 0157:H7 exceeding a level of the 10% set by XL Foods, were being recorded but not analysed for trends so contaminated beef was not bracketed and likely found its way out of the plant, said the review.
By October 15, beef processed at the plant and contaminated with E.coli O157:H7 had made 18 consumers sick and 1,800 products had been removed from the market in Canada and the US.
Normal operations resumed at the Brooks plant on 14 January under the new ownership of JBS Food Canada.