5 replies to this topic

[Baohan88]

Hi everyone, I recently received a customer complaint about a 1 cm metal fragment found in one of our finished products. My investigation revealed the contamination occurred during production due to a loose machine part. Although the operator adjusted the equipment and notified maintenance, they did not stop the line or hold the product. Instead, production continued as usual, even after the malfunction was discovered.
I plan to re-train all production operators on proper procedures when equipment abnormalities occur and also assign an additional supervisor to monitor processes during breakdowns.
Besides training and supervision, I would really appreciate suggestions on additional preventive that can help avoid similar complaints. Do you have any suggestions on improving the escalation process to prevent operators from bypassing critical steps? I would be grateful for any insights you can offer from your experience. Thank you in advance for your help!

[GMO]

Before you jump to retraining, was lack of training the problem?

 

I know it sounds stupid but SO often when it comes to an incident people jump to "train" or "brief" their teams rather than understand what went wrong first.

 

I'd use a combination of fishbone and five whys to first understand the issue then go to corrective and preventive actions.

 

So a few questions to ask yourself.

 

Why was the machine part loose?

What processes are in place to prevent the loose machine part?

What PPM does the machine receive? Was that to plan?

What knowledge do the team have on metal hazards and consumer risk?

How was the part repaired when it was found? (As presumably it wasn't just a contaminant linked to one person but also later repaired, probably by someone else.)

How much pressure are the team under to deliver production volumes?

How are people treated if they raise a concern?

Are team members overly reliant on metal detectors?

Does your metal detector detect this contaminant?

 

I'm sure you can think of more. Even if you decide training is the answer, you can then direct it to actual gaps.

[SHQuality]

I'm not so sure that the training was the actual root cause that needed addressing.

 

How did this piece of metal make it all the way to the customer?

Don't you have a metal detection system?

If you do have one, do you have records that show it was working correctly at the time of this incident?

 

A working metal detection system would've ejected this product from the line and the first thing I would ask if I was auditing your business or if I was this customer is how this could possibly have happened in the first place.

[GMO]

 

A working metal detection system would've ejected this product from the line and the first thing I would ask if I was auditing your business or if I was this customer is how this could possibly have happened in the first place.

 

Depends on if it was a long and thin piece of metal and orientation effects but yes, it's certainly worth looking into why it didn't. If there are issues with sensitivity. If settings have been changed. If timing is set up correctly. Are your failsafes working? Are staff even faking results for tests? (It happens.) Etc.

[Baohan88]

I would like to post a follow‑up to clarify the situation more accurately, as my initial description may have caused some misunderstanding.

 

After re‑checking the process flow and interviewing the production team, we confirmed that the contamination happened after the metal detector, not before it. In our line setup, the metal detector is positioned earlier, followed by the filling hopper, and then the final packing stage.

During production, the filling hopper became deformed. This deformation maybe a cause for a sharp metal piece to break off from the chute and enter the product stream. The filling hopper is normally inspected once per month during cleaning, but in this case, the operator noticed the abnormal condition and still allowed production to continue. They made a temporary adjustment and informed maintenance, but did not stop the line or hold the affected product for proper repair. Because the metal fragment entered the product after passing the metal detector, the detector had no chance to catch it.

[GMO]

Ok, when you do a fishbone, you focus on 6 topics. There are some variations but these are the 6 I often use:

 

Measurements:

 

How is it detected that the filler is damaged?

How did you consider this risk and the positioning of the metal detector in HACCP? What controls were put in place?

Are these controls after the metal detector clear to people who operate that machine and engineers, i.e. any damage after the metal detector WILL cause consumer harm? Is there visual management in the area not just in an SOP? Do people process verify these controls are in place on a regular basis?

How was the damage recorded? Is there any verification of operator records?

What verification activities do you have for metal control and are they more "leading indicators" than just complaints?

 

Materials:

 

Is the material the filler fabricated from prone to damage? Could it be made of anything else?

 

People:

Why did both the operator and the maintenance not twig about the food safety risk to the product?

What kind of response do operators get when they report issues?

How focused on production "at all costs" are your supervisors? 

Do your operators often see your supervisors during a shift?

Why did your supervisor not know about this issue? (Assuming they didn't.)

How present are quality team members in operations? Do operators find them easy to talk to?

Are operators clear about what food safety risks are in their zones?

 

Environment:

 

How busy was it on that day? Were people likely to have been distracted?

 

Machines:

 

How is the machine cleaned and could this contribute to damage?

How did the damage actually occur, do we know?

What is the mean time between failure for this part?

When was it last changed?

Do you have spare parts for any damage if it occurs?

 

Processes:

 

Is it clear when they do the check for damage what the immediate corrections should be to prevent food safety risk?

 

I have to admit I'm unclear on your product but it's unusual for metal detection to not be in pack or, if that's not possible for some reason, just before at the filling stage. But I hope the above helps. Remember Reason's "Swiss cheese model" that this, like any incident is likely to have had multiple contributory factors. While the operator and the maintenance person didn't escalate in the right way, I think it goes beyond that to why it broke in the first place, your line design, your methods etc etc.