Controlling for a compliance breach

Happy Baby (Pty) Ltd. is a fictional, medium-sized enterprise that manufactures food products for babies and children. These products include teething biscuits, baby formula, flavoured rooibos-based iced teas, cereals, cookies, and fruit purees. The company employs 225 staff in the food production operations of the business, with an additional 30 staff members in logistics, administration, HR, compliance, and senior executive positions.

During the national lockdown as a result of the COVID-19 crisis, Happy Baby was permitted to continue partial operations, as it was certified as an essential food production service. However, it was only permitted to allow 40% of the total workforce to work on the premises to reduce the risk of spreading the virus. All non-production roles were required to work from home during the lockdown, with only production-based employees able to work at the factory in Paarden Eiland, Cape Town.

To facilitate this without reducing production, the CEO implemented a rotating schedule of teams, allowing the factory to remain operational over 24 hours. The workforce was divided into four teams with each group working a shift lasting 8 hours and 30 minutes, and the teams rotating through a 3-shift day. No overtime would be allocated, but it meant that employees would not experience a pay reduction.

Each team was led by an operational manager; following the lockdown regulations, that same manager also acted as the compliance officer to ensure compliance. While no formal COVID-19 testing was done on-site, the operational manager performed essential daily screening before each shift. Any employee who reported symptoms was tested at the expense of the company. Employees were also asked to self-report and self-isolate if they developed any symptoms of the virus.

While staffing each team, it became necessary to appoint two new operational managers. There was no formal training given, due to the swiftness with which the company needed to prepare. It was assumed that the newly appointed managers would know what was required, as they had been long-term employees of the business.

During a particularly chilly April morning, there was a low-temperature alarm from one of the baby formula hydrolysis tanks, which was ignored at 3:30am during the Saturday early morning shift. The machinery is set to run at very precise temperatures, and the ambient temperature is considered when doing so. As a result of the low outside temperatures, the temperature in the tank dropped.

In these cases, an alarm sounds but due to the revised shift plan, the incident report was only seen on Tuesday morning.

When questioned about why the alarm had been ignored, the newly appointed operational manager on shift at the time responded: "Nobody knew what it was for. Someone said it was a false alarm because the temperature was controlled by the computer systems and it had never happened before. After about half an hour, the alarm turned off. We had another problem in a different area of the factory that the team and I were addressing at the same time. We couldn't do it all, so we focused on what we could fix quickly."

Questions Below

Imagine that you are the compliance officer consulted on the manufacturing incident at Happy Baby. Considering that the affected batch of hydrolysed baby formula had already been packaged and dispatched, it is likely stocked on store shelves or already purchased. It will be incredibly difficult to track the production batch numbers to specific stores. The general health and safety executive has asked for your insight on the situation. In preparation for your response, address the following questions:

1) Why were the existing controls ineffective in relation to the risk they were meant to mitigate?

2) What new controls can be implemented in order to avoid the incident happening again?

3) Discuss your thoughts on the incident.