A second inquiry into the Fonterra botulism scare has made 33 recommendations to improve the dairy giant's food-safety processes.
No one factor or individual was responsible for the events leading to a recall of dairy products by Fonterra customers in August, the inquiry found, but there were several key failures.
There was a lack of senior oversight of crucial decisions, problems tracing affected products and belated escalation of the issues to senior management, it said.
Fonterra chairman John Wilson said the board was committed to implementing the 33 recommendations in the report.
Directors were encouraged that the independent review, led by Sir Ralph Norris, echoed the findings of a management review published last month.
"There are no contradictions between the recommendations," Wilson said.
"Much of the recommended change is already under way."
A key finding was that Fonterra did not routinely use sulphite-reducing clostridia tests on its whey protein concentrate, although it was contractually required to do so by at least one customer.
The review found that the test commissioned for botulism were inadequate, as was its crisis management and external comunications.
"There was some lack of alignment and confidence between Fonterra and the New Zealand Government in the critical fortnight after the contamination concerns were advised to the Government and made public," the report said.
The potential presence of botulism in some dairy products emerged on August 3, when Fonterra said there was a quality problem in three batches of whey protein concentrate made at its Hautapu, Waikato, plant in 2012.
Testing in March this year found the presence of clostridium bacteria in the batches, and testing in July indicated it could be the highly dangerous bolulism strain.
Although it proved to be a false alarm, the scare damaged confidence in New Zealand dairy products and could lead to costly litigation.
French company Danone, whose subsidiary makes infant formula using Fonterra ingredients, is reportedly considering a €200 million claim against Fonterra for lost sales.
Fonterra said this month that it was in a dispute-resolution process with Danone but denied legal liability for Danone's product recall.
Fonterra's operational review published last month found a "Swiss cheese" effect was behind the scare, in which several holes in its safety systems lined up to let the potentially tainted product through to the market.
It identified five factors: the decision to reprocess the whey protein concentrate using a piece of non-standard equipment; a lapse in information sharing; the failure to escalate the issue to the chief executive faster; a computer upgrade just before the event slowed down product tracing; and the product recall was complicated because the product was an ingredient in products made by many customers.
A government inquiry, chaired by Miriam Dean, QC, is also looking into the affair.
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