Annual Report of Incidents, Resilience and Prevention 2024/25

1 Summary

1.1 The paper provides an overview of the work the FSA does in managing and responding to incidents. It gives an insight into how we are working with organisations to reduce incident demand through prevention activities and improving the resilience across the food system. FSA Incident functions have responded effectively to a series of challenges throughout 2024/25, including increasing complexity of incidents and overcoming capacity issues in the system.

1.2 The type of incidents and foodborne disease outbreaks being managed are more complex, so the FSA is responding to more high and medium priority incidents. This can in part be explained by increased complexities in supply chains. Improved surveillance in partner agencies has also meant we are better able to detect and link incidents.

1.3 The incident triaging process has been improved to create some capacity to deal with the increasing complexity of incidents. In addition, a new IT case management system to improve the Agency's ability to respond, was designed with initial implementation. The focus for 2025/26 will be on continuing to evolve and embed the new system, improving FSA prevention capability and to manage the threats posed by foodborne disease.

1.4 The Board is asked to:

• note the trends and analysis of incidents we have dealt with this year,

• note the changes made this year to improve our priorities and systems, and

• agree the priorities for the coming year.

2 Introduction

2.1 FSA teams across England, Wales and Northern Ireland protect UK consumers by managing incidents ^{(footnote 1)} 24/7, 365, working with Food Standards Scotland (FSS) and Food Safety Authority of Ireland (FSAI) when required. We assess evidence and co-ordinate activities of local authorities (LAs) and businesses, working with other partners as needed, to respond to these food and feed safety incidents, which include foodborne disease outbreaks. We provide food and feed safety advice to enforcement authorities, businesses and consumers. We also provide advice that contributes to significant cross government incident responses and UK preparedness planning, such as H5N1(Avian Influenza) in US cattle, ensuring that any safety or national security risk presented by food or feed is considered and managed.

2.2 This paper includes:

• A review of incidents and foodborne disease outbreak response for 2024/25

• Changes that have been made to improve FSA and system effectiveness and handling

• A forward look and the priorities for improvement in 2025/26

3 Evidence and Discussion

Incidents and foodborne disease outbreak response review of 2024/25 ^{(footnote 2)}

3.1 In this section, we will look at the volumes of incidents and categories used to give insight into the themes of incidents reported for the UK in 2024/25.

3.2 The FSA was notified by others of 1825 food and feed safety incidents in England, Northern Ireland and Wales during 2024/25 (Fig A1).This is a reduction of 0.7% from 1837 last year. Whilst the volume of incidents this year has remained stable, the proportion classed as medium or high priority is increasing year on year (Fig A2).This is partly attributed to the increasing complexity of supply chains due to fiscal, climate and geopolitical events. These more complex investigations often require expertise from across the FSA, including policy, microbiologists, toxicologists, risk assessors, communication specialists and sometimes our Scientific Advisory Committees. Wider government and international partners can also be involved when required (for example overseas partners for peanut contamination in mustard: Case study: Peanut contamination in Mustard) to ensure the risks are identified, investigated and managed effectively.

3.3 In addition to direct incident notification, during 2024/25, the FSA monitored 12,504 food safety signals ^{(footnote 3)}. From that total, 810 were used in intelligence assessments, of which 36 were referred for investigations to LAs and other organisations. These signals generated 18 new incidents that required action and product withdrawal. Signal sources vary slightly year to year, with some no-longer available or offline for extended periods, or purposefully de- prioritised to avoid duplication. This has resulted in a decline in overall signal numbers for 202024/25.Work is ongoing to optimise sources and to seek alternatives. Signals and Prevention - case study examples.

3.4 Incident Handling- High and medium priority incidents require increased activity from LAs and Port Health Authorities (PHAs) to make sure food businesses take appropriate action to protect public health, understand the source of the incident and apply prevention strategies to stop reoccurrence.LA teams conduct critical activity and collate necessary information essential to managing incidents. They are required to undertake inspections and sampling, gathering food chain details and ultimately determining what action is required from a food business operator (FBO), based on FSA advice. They continue to face resourcing pressures, which impacts on their capacity to do this important work with a knock-on effect to the FSA response.

3.5 Food Alerts– FSA publishes Food Alerts to notify consumers and businesses of food safety risks with particular foods. Within this year’s published Food Alerts, (Fig A3) we saw a 55% increase in the Allergy Alerts, notably due to the peanut contamination in mustard incident at the end of 2024.There was an increase this year in the number of Food Alerts for Action (FAFA) issued ^{(footnote 4)}. This was due to 3 incidents that included counterfeit vodka, possible contamination of ‘food to go’ products and illegal meat on the market. FSA engaged on 1147 food safety notifications (includes inward, outward and follow-up notifications) with the International Food Safety Authorities Network (INFOSAN) ^{(footnote 5)}, an increase from 987 in the previous year.

3.6 Hazard Categories- The top four hazard types for incidents notified to the FSA in 2024/25 were Pathogenic Micro Organisms (436), Allergens (264),Residues of Veterinary Medicinal Products (133)and poor or insufficient controls (198) (Fig A4).The number of incidents related to poor or insufficient controls has risen from 136 to 198 compared to last year (45% increase), this is largely due to illegally imported products.

3.7 The leading incident hazard category, as with previous years, relates to Pathogenic Micro-Organism contamination of food, where out of the 436 incidents, 15 were linked to previously reported foodborne disease outbreaks. For food incidents reported, Salmonella was again the most recorded pathogen (Fig A5) (44%).The number of pathogen reports do not always correlate to severity or proportionality of scale of response. Less commonly reported pathogens can present the most severe illness, noting two Clostridium Botulinum ^{(footnote 6)} incidents recorded in the year and pathogens such as STEC and Listeria can cause severe disease and occasionally fatalities. A number of trends were detected from reported incidents that led to focused efforts across the FSA, for example, imported milk products (cheese) with 25% of these from France contaminated with Listeria or STEC which led to prevention strategies and enhanced scrutiny at border control.

3.8 The number of incidents related to novel foods has risen from 74 to 102 compared to last year (38% increase).There has been a gradual increase in the trend of international notifications mostly related to divergence in approaches to approval for Cannabidiol (CBD) products across EU and UK. The CBD team also raise incidents directly when made aware of situations that may pose a safety concern or risk, for example, the removal of products from the public list due to significant presence Tetrahydrocannabinol (THC) or CBD products being sold and advertised to children. The underlying causes of novel foods incident reports will be explored as part of future prevention activities in 2025/26.

3.9 Foodborne Disease Outbreaks- The number of outbreaks linked to the three pathogens most commonly associated with foodborne illness outbreaks reported to the FSA all increased (Fig A6). Listeria saw a rise to 17 outbreaks or clusters of interest (from 13),Shiga toxin-producing Escherichia Coli (STEC), 13 (from 12), and Salmonella, 11 (from 9).These account for 26%, 20% and 17% of the reported foodborne disease incidents respectively. This continues the increasing trend seen in 2023/24 which may to some extent be explained by developments in sampling and testing and our improved ability to link cases.

3.10 Many of these outbreak investigations are very complex. As a result, they are improving our broader understanding regarding the potential root causes which is helping us identify prevention strategies and work with partners to implement wider initiatives that will reduce the risks to consumers.

Case study:I-007-693 – E. coli STEC O145 linked to salad leaves

3.11 Notifiable Disease in Animals -The FSA plays a critical role working closely with APHA in managing notifiable diseases in animals ^{(footnote 7)}. There were 262 incidents of Bluetongue disease reported last year primarily impacting ruminants such as sheep, cattle and goats. The FSA records notifiable diseases in food producing animals to ensure slaughterhouses have the right approvals within the control zones. However, since the disease has no known direct public health or food safety implications, these cases are not included in the figures presented.

3.12 We continue to work across government and prepare for potential incidents such as the US Outbreak in Cattle regarding H5N1, African Swine Fever (ASF) and other relevant notifiable diseases that may have any potential food safety impact. Further risk assessments were completed on the risk to consumers of consuming dairy products (including raw drinking milk) and beef should the risk occur in the UK.

Changes made to improve FSA and system effectiveness and handling

3.13 This section sets out what has been done with industry and other partners including the UK Health Security Agency (UKHSA) to improve FSA incident handling, strengthen resilience and preventative work during the past year.

Detection and Prevention

3.14 UK Government detection capability is better than it was previously at identifying clusters of cases and potential outbreaks of foodborne disease which require investigation. This is primarily because of new systems and increased capacity in foodborne detection. This advancement means we can better protect consumers because we can connect cases, identify outbreaks and launch investigations to remove food risks. We are also starting to exploit digital technologies to conduct more food chain analysis to identify sources of contamination. This has enabled us to implement appropriate preventative risk management and communication interventions. This element of our work will need to continue increasing as our knowledge of surveillance and diagnostic techniques using Whole Genomic Sequencing (WGS) evolves.

3.15 We have improved the way we use intelligence across the FSA to tackle emerging or recurring risks before they lead to incidents through a number of cross agency and inter agency forums, such as the Intelligence Considerations Meeting (ICM) and the 4 Nations Working Group. These forums work in addressing the cases that fall into the low triage response to resolve the chronic symptoms rather than the need for a more immediate incident response to protect public health.

3.16 For example, we held a series of industry awareness and prevention events in grey market goods ^{(footnote 8)} to help manage and ultimately reduce the number of reported incidents. As a result, we have seen a reduction in the proportion of US grey market incidents reported from 5%, to below 3% of total annual incidents. We will continue to monitor this through border controls

Industry Engagement

3.17 We continue to improve our understanding of Root Cause Analysis (RCA) ^{(footnote 9)} by working closely with industry (Root Cause Analysis Breakdown). This year we received 283 RCAs from businesses, which is an increase from last year’s figure of 255.The main incident types covered by RCA are allergens (38%), pathogenic microorganisms (35%) and foreign bodies (16%).Labelling and cross contamination issues are the main causes of incidents related to allergens whilst contamination of source materials being the main issue for micro pathogenic microorganisms. Industry and FSA technical groups were established to learn lessons from the RCA analysis, with industry agreeing to lead on issuing communication for smaller businesses to prevent incidents linked to Salmonella in raw meat and poultry by September 2025.This will address a leading cause of microbiological incidents.

3.18 We have increased our industry engagement, exploring wider networks across the British Retailer Consortium (BRC) and the Institute of Grocery Distribution (IGD) with more representatives from across industry attending the FSA monthly Food Industry Liaison Group (FILG ^{(footnote 10)}). The regular updates at FILG on incidents, outbreaks and emerging risks allows key information to be relayed as soon as possible enabling industry to act rapidly and provide any insight.

3.19 Following the STEC outbreak affecting leafy salads in sandwiches, the FSA convened a group of affected 31 businesses, including growers, manufacturers and retailers in January 2025 to improve industry awareness, and agree common production standards. The collaboration outputs included the delivery of a webinar for over 180 LA Officers. The webinar which reflected recent grower training, addressed LA knowledge gaps and improved their awareness.

Internal FSA System Improvements

3.20 New triage processes were implemented in June 2024 to action high and medium priority incidents by reducing the impact of low priority notifications ^{(footnote 11)} and ensure the best use of our resource. This project helped to clarify accountabilities and understanding across LAs, industry and other organisations to ensure that incidents notified to us, meet the threshold for FSA involvement. This review in process and accountability (including the ND /Bluetongue reporting) saw a significant reduction in the number of low priority incidents managed by the FSA from 873 to 384 in the last year.

3.21 The FSA’s Risk and Crisis Management (RCM) Programme that was established in spring 2023 aimed to strengthen resilience and emergency preparedness, has now concluded. The programme has delivered outcomes that ensure the FSA is better prepared to respond to large scale crises and non-routine incidents. The outcomes include:

• the development of FERST (FSA Emergency Response and Support Team) a system for mobilising personnel who will form a skilled incident response capability that can be deployed at pace in a non-routine incident.

• a comprehensive programme of tactical and strategic crisis management training and exercising that has resulted in an increased number of Strategic Incident Directors and Incident Management Chairs across the agency building resilience and capability.

• clarity of incident response governance structures that are set out in supporting standard operating plans and procedures and an updated approach to the collection and management of situational awareness during an incident.

4 Forward Look and Priorities

In the coming year, the FSA will continue to:

4.1 Improve our processes and systems through the use of modern data and analytics tools, including Artificial Intelligence (AI), prioritising those changes that will drive efficiency and effectiveness to shift our activity to where it is most useful in managing complex incidents and establishing prevention strategies. In doing this we will need to be conscious of the changing context and considering the end-to-end risk management process (from what is raised to us through to what is actioned).We will also pay need to pay particular attention to the evolving position on Sanitary Phytosanitary measures (SPS) as this evolves.

4.2 Embed the new case management system and manage the transition from the legacy technology this replaces, with the priority being to further improve how we approach incident management and risk across the FSA. To support this, we will maintain a rolling programme of training and exercising activities across the Agency and government to improve and test FSA and system resilience.

4.3 Work with UKHSA to understand the impacts of our improved collective ability to detect foodborne disease outbreaks. This will support our activities to strengthen how we monitor and respond to trends in foodborne illness. ^{(footnote 12)}

4.4 Grow our prevention capability within the FSA and with partners, including industry, by exploiting the opportunities and improved data capture and analysis that the new case management system will provide. The expectation is that, once embedded, this will release capacity to deliver more in-depth analysis of data trends, findings from complex incidents, and root cause analysis outputs to further inform prevention strategies.

4.5 Assess the impacts of the geopolitical landscape, including the World Health Organisation (WHO) and INFOSAN, following the withdrawal of US funding support for INFOSAN. We are working with international food regulators who rely on the system to facilitate safe trade of foods and will look for ways to mitigate the risk of a reduction in INFOSAN capacity.

4.6 Engage with the cross government National Security resilience network and develop the food-system preparedness for major events. Exercising is planned for 2025/26.

Does the Board agree with the areas of priority for the coming year as set out in paragraphs 4.1 to 4.6?

5 Conclusions

5.1 We have responded to more high priority incidents and outbreaks that by their nature are becoming more complex. We have done this whilst establishing new processes and implementing a new case management system that will improve our ability to respond to future outbreaks and use data to better inform our prevention capabilities. We will need to continue reforming our approach to incident management with an emphasis on addressing risk in the system in the coming year as UKHSA and partner agencies improve their ability to detect and link foodborne disease outbreaks.

5.2 We will continue to work even more closely with industry and government partners such as LAs to improve our detection and prevention capabilities. We will use the information we hold on signals to better direct where resources could be deployed in the case of LAs and to improve how we assess root cause analysis with industry.

5.3 However, we do remain concerned about the complexity of incidents and outbreaks as with previous years; therefore, reforms to our approach to incident and risk management will be crucial. This includes a focus on improved data analysis and reporting, stakeholder engagement, processes and governance, and we will assess the opportunities afforded to us by modern data analytics tools, including AI.

Annex A: Incidents Data 2024/25

Fig A1 Total number of incident notifications received by the FSA, by the reporting year

Fig A1 Total number of incident notifications received by the FSA, by the reporting year

Fig A2 Incidents by Priority, by the reporting year.

Fig A2 Incidents by Priority, by the reporting year.

 

Fig A3 Number of alert notifications issued by the FSA, by the reporting year.

Fig A3 Number of alert notifications issued by the FSA, by the reporting year.

 

Fig A4 Top nine incident notifications, by the reporting year

Fig A4 Top nine incident notifications, by the reporting year

 

Fig A5 Pathogenic break down for 2024/25

Fig A5 Pathogenic break down for 2024/25

 

Fig A6 Outbreaks and Clusters of Interest (COI) received by the FSA, by the reporting year.

Fig A6 Outbreaks and Clusters of Interest (COI) received by the FSA, by the reporting year.

Annex B1: Signals and Prevention - case study examples

Risk	Action
Market place referral: A signal from Canada on recall of a Noodle Nissin brand Big Cup Noodle recalled due to undeclared shrimp and Nissin brand Big Cup Noodle Curry Flavour recalled due to undeclared peanut	The Signals Team contacted the eBay regulator which resulted in the removal of 11 listings from sellers outside the UK.
Emerging issue: A number of signals concerning behavioural changes in dogs with possible links to dog chews originating from China, including RASFFs (Rapid Alert System for Food and Feed) and linked EU recalls/withdrawals in Finland, Netherlands and Germany. Although no confirmed distribution to the UK or reported cases, intelligence received indicated that products may have been available online in the UK via an online retailer. Recalls published in other countries also received UK media coverage. Social media monitoring showed growing concern from UK pet owners. Subsequent investigations showed shipments of product to UK.	Businesses were contacted to check for any goods on the market and precautionary advice to dog owners and vets to avoid these products issued:https://www.food.gov.uk/news-alerts/news/precautionary-advice-issued-to-pet-owners-on-dog-chews-linked-to-illness
Incident referral: A signal from UK media on a chocolate snack sold at TK Maxx and Home Sense stores, recalled in the UK due to undeclared milk. Signal validation found that the FSA had not been notified and identified that a separate recall had been issued in the Republic of Ireland (who we informed of the recall)	The signals were referred the Incidents team who issued an Allergy Alert https://www.food.gov.uk/news-alerts/alert/fsa-aa-12-2025
Incident Prevention of an emerging risk: Imported food sampling for 2022/2023 identified 26 baked goods/snack products from Bangladesh, India and Pakistan containing undeclared milk and some with undeclared egg at levels presenting a risk to hypersensitive consumers. Difficulties: products sold across the country, compliance levels are unknown, sold in micro grocers, catering to minority groups & purchase, consumption and hypersensitivity rates relating to these products was not understood. Action taken: Incident management, including allergy alerts issued and one FBO prosecuted; Discussion at the Intelligence Considerations meeting (ICM); Dedicated Task & Finish Group established; Escalation to BDG; Consumer survey undertaken to understand consumer habits relating to these products; Link letter sent to LAs requesting action and action by LAs monitored; Letter to importers for action. Next Steps: possible further sampling; further discussion at BDG; possible consumer and small business messaging; communication with Countries of Origin. Examples of products found to be a possible concern to hypersensitive consumers: Kerala Murukku, Boondi Masala, Nan Khatai Cookies, Farali Chevdo, Nimki Biscuits Chethi Chekkalu rice crackers, Papad Chavana.

Annex B2: Case study: I-007-693 – E. coli STEC O145 linked to salad leaves

Summary of the incident response approach amongst a multi-organisational, food industry and Local Authority collaboration

In May 2024, the Food Standards Agency (FSA) was alerted by the United Kingdom Health Security Agency (UKHSA) to a concerning rise in severe STEC (Shiga toxin-producing E. coli) infections. These cases, identified through routine surveillance, involved a particularly dangerous gene profile—stx2a and eae+—known to cause serious illness, including Haemolytic Uraemic Syndrome (HUS), which can lead to kidney failure and even death. Similar patterns were reported by public health authorities in Wales and Scotland.

Whole Genome Sequencing (WGS) confirmed that the outbreak was caused by the STEC O145 serotype, part of a cluster known as “t5.206.” This cluster had been previously investigated in 2023, though the exact source had not been confirmed at that time. Despite the historical uncertainty, the 2024 investigation began with an open mind, focusing on current indicators rather than relying solely on past findings.

The outbreak was geographically widespread, with 275 cases in countries in the UK. Notably, the Northern Ireland cases were believed to have been exposed while in England. Public health teams across the UK collaborated to gather microbiological evidence, perform WGS to confirm genetic links, and gathered epidemiological data, including food exposure data.

Early analysis identified sandwiches as a common food item consumed among confirmed cases. The FSA, working closely with LAs, examined the supply chains and ingredients of these sandwiches. While mayonnaise was initially considered, it was ruled out due to the diversity of suppliers and lack of a common ingredient. Attention then turned to lettuce, and further investigation revealed that Apollo lettuce, grown in the UK, was the most consistent ingredient across the affected products.

Throughout the investigation, the FSA maintained regular communication with industry stakeholders, including retailers and sandwich manufacturers. This was facilitated through direct engagement and the Food Chain Liaison Group, which supports information sharing between regulators and trade associations. Two independent case-control studies conducted by UKHSA, along with detailed food chain analysis, provided strong evidence linking the outbreak to sandwiches containing lettuce.

In response, food businesses acted on the precautionary principle and initiated product withdrawals and recalls of potentially affected ready-to-eat items, including sandwiches, wraps, and salads. The FSA supported these actions by issuing Product Recall Information Notices (PRINs) and amplified public messaging.

On conclusion of the outbreak, public health authorities confirmed 41% of cases reported attending A&E, 49% were hospitalised, 3%, (7) cases experienced HUS, and UKHSA reported 2 deaths, one of these deaths is expected to be linked to STEC infection. 

The outbreak was genetically related to a cluster of cases from 2023 — and a few from 2022, as such this suggested a persistent contamination issue. This, combined with a separate 2022 outbreak linked to a different STEC serogroup but also linked to salad items, reinforced concerns about UK-grown salad vegetables. In January 2025, the FSA convened a major industry event involving 31 businesses, including salad growers, food manufacturers, and retailers, to identify root causes and develop preventive strategies. The British Leafy Salads Association (BLSA) responded by delivering training for growers and collaborating with LAs to improve understanding of salad production risks, and Chilled Food Association (CFA) also updated guidance for growers to reduce STEC risks.

Looking ahead, the FSA is responding to a broader trend: a rise in foodborne outbreaks caused by non-O157 STEC strains. This increase coincides with improved laboratory capabilities in detecting and analysing these pathogens. To address this, new research projects are planned for 2025–26, jointly funded by the FSA, Food Standards Scotland (FSS), and the Integrated Security Fund. These studies aim to better understand the sources of STEC contamination — whether from livestock, the environment, or food — and how these contribute to human infections. This work builds on the PATH-SAFE programme and aligns with ongoing efforts by the Food Safety Research Network and FSA policy initiatives.

The final UKHSA outbreak report is expected to be released in summer 2025, alongside the FSA report of a prevention event to facilitate industry learning to drive immediate and longer- term risk mitigations which complement broader prevention strategies.

Additional reference material FSA and UKHSA

FSA.FSA-PRIN-30- recall of sandwiches, wraps and salads because of possible contamination with E. coli

FSA. FSA-PRIN-31- recall of sandwiches and wraps because of possible contamination with E. coli

FSA.FSA-PRIN-32- recall of wraps because of possible contamination with E. coli

UKHSA.Emergency department: weekly bulletins for 2024: week 20

UKHSA.Shiga toxin-producing Escherichia coli: questionnaire

UKHSA.Health Protection Report volume 18 issue 2: news

UKHSA.Shiga toxin-producing Escherichia coli: questionnaire

Annex B3: Case study: Peanut contamination in Mustard

The FSA was notified on 14September 2024 by an FBO who was contacted by their supplier, informing them that they had found traces of peanut in mustard powder. The FSA’s effort to coordinate multi-local authority investigations got underway to trace the supply of the mustard powder with a view to identifying the contamination source and root cause of the incident. 

The incident escalated to non-routine status on 19 September 2024 due to the potential severity of impact and impact on food availability for consumers with allergen concerns. The FSA worked closely with LAs, Industry Trade Associations and their members, with other government departments and international countries to determine the supply into the UK. 

The FSA traced the food supply chain and published 3 Allergy alerts with 31 follow up alerts incorporating a total of 59 brands and 307 individual products between 18 September and 20 November 2024.These recalls involved many well-known and widely trusted brands including Iceland, Papa John’s, Waitrose, Dominos, Spar and Harvester. Our advice to consumers at this stage: People who had a peanut allergy to avoid consuming foods that contains or may contain mustard, mustard powder or mustard flour whilst investigations were ongoing. 

Information that was provided on the root cause analysis had shown that the mustard contamination was believed to have taken place at the growing stage. The FSAs assessment however was that this was not correct, and was likely to be the controls by the FBO failing to ensure necessary systems were in place to manage peanut as an allergen. The LA and the FSA received assurances from the UK importer that action had been taken to mitigate the risk of further contamination and additional surveillance and sampling on mustard products had been implemented, to reduce the risk. With this assurance, the FSA issued advice to consumers that the affected product had been removed from the market and mitigations were effective to reduce the risk for consumers with allergens.

On conclusion of the incident, the final updated advice informed consumers who were allergic that they no longer need to avoid consuming foods that contain or may contain mustard, mustard powder or mustard flour because they may have been contaminated with peanuts, both in the home and eating out. This advice remains the same. 

The incident was de-escalated on 22 November 2024 and following the investigation, working with Food Standards Scotland (FSS), Leicester City Council where the FBO was based, and FGS Foods Limited, the FSA was assured that actions taken in response to the initial food safety concerns had been addressed. At the close of the incident, there was no evidence that other mustard products that had not been supplied by FGS were affected.  As a precaution, increased sampling and surveillance of mustard products was implemented to ensure that any further products that may be affected by the cross contamination would not reach the market, enabling consumers to enjoy these foods with confidence. 

Root Cause Analysis

Root Cause Analysis Breakdown 1

 

Root Cause Analysis Breakdown 2

Root Cause Analysis Breakdown 3

Root Cause Analysis Breakdown 4

Root Cause Analysis Breakdown 5

Root Cause Analysis Breakdown 6