Normalisation of Deviance (Diane Vaughan)

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