Rca Report Form - 0

Food Business Root Cause Analysis Report Form
Introduction: For completion by the food business

A root cause analysis (RCA) can be undertaken to determine the initial cause of a food safety
incident. Details of the RCA should be recorded on this form in the event of a food recall
where the Food Standards Agency (FSA) has issued an Allergy or Food Alert.
This report form allows RCA information to be recorded through a choice of two methods –
the ‘5 Whys?’ or the ‘Fishbone / PEM PEM’.
More information on RCA can be found through the root cause analysis course or contact
your competent authority for further advice.
This form should be completed by the investigating officer / representative and submitted to
the Food Standards Agency via the enforcement authority, as indicated in the sections below.
Section A: For completion by the FSA

FSA Reference (if available):
Allergy Alert or Product Recall Information

Notice (PRIN) reference:
Incident (I) reference:

Section B: For completion by the food business
Food business details:
Name:
Address including
Postcode
Food business investigating officer / representative details:
Name
Telephone number
Email
Product name(s):
Description of product(s):
2
Root Cause Analysis – Option 1: ‘5 Why’s?’ method
Step 1 State the specific problem associated with the food incident in the box below
Step 2 Why did the problem happen? Write the answer in the box below
Step 3 If the above answer does not identify the root cause of the problem stated in the
answer to Step 1, ask ‘Why?’ again and write the answer in the box below
Step 4 Loop back to Step 3 and ask ‘Why?’ again; until the team reaches agreement
that the root cause of the problem has been identified. This may require asking ‘Why?’ fewer
or more than 5 times.
Step 5 Loop back to Step 3 and ask ‘Why?’ again; until the team reaches agreement
that the root cause of the problem has been identified. This may require asking ‘Why?’ fewer
or more than 5 times.
Root Cause Analysis Outcome
State the initial issue (the root cause) that

led to the food incident occurring
State the corrective measures identified to

prevent incident reoccurrence
3
Root Cause Analysis – Option 2: Fishbone/PEM PEM method
Source: People
Source(s) & Reason(s) for Select Description Root cause determined & corrective measures
Error(s) identified to prevent incident reoccurrence
Procedures not followed - one-

off operator error or intentional 
(please indicate which)
Training – absent or incomplete 

Understaffing / Sickness 
Other 
Source: Environment
Source(s) & Reason(s) for Select Description Root cause determined & corrective measures
Error(s) identified to prevent incident reoccurrence
Inadequate lighting 
Inadequate space / layout 
Inadequate temperature control 
Other 
Source: Method
Source(s) & Reason(s) for Error(s) Select Description Root cause determined & corrective measures
identified to prevent incident reoccurrence
Cleanliness - absent or inadequate 

Specifications - absent or non-
compliance 
Work instructions - absent or
inadequate 
Other 
Source: Plant
Machinery failure 
Machinery – incorrect use 
Machinery damage 
Routine maintenance – absent or
inadequate (e.g. inspection, testing, 
measurement or adjustment)
Servicing – absent or inadequate 
5
Source: Equipment
Ancillary devices 
Computer/IT issues 
Printer/scanner issues e.g.
barcodes 
Weighing machine – inaccurate
calibration 
Other 
Source: Material
Composition – incorrect
ingredients / substitution 
Contaminated product 
Food storage - inadequate or
inappropriate 
Labelling - absent / incomplete /
incorrect 
Packaging – defective / incorrect 
Other 
6
Section C: For completion by the enforcement authority
Name of
enforcement
authority
Enforcement Officer details:
Name
Job Title
Telephone
Email
Date
Enforcement authorities should submit the completed Food Business Root Cause
Analysis Form to the appropriate Food Standards Agency Incident Team detailed below:
In England [email protected]
In Wales [email protected]
In Northern Ireland [email protected]

Section D: For completion by the FSA
Description of food safety incident
Please tick the appropriate ‘reported’ food safety incident problem(s) and type(s) from the
selection below and provide a description of the food safety incident.
Nature of problem Type Select Brief description

Natural (e.g. Mycotoxins) 
Chemical Residues of Veterinary
contamination Medicines 
Other 
Allergen - Undeclared,
incorrect emphasis or 
language used
Incorrect labelling Durability dates 
Undeclared ingredient 
Other 
Algal toxin 
E. Coli 
Fungal / Mould 
Microbiological Listeria monocytogenes 
hazard Poor or insufficient
controls (e.g. Clostridium 
botulinum)
Salmonella 
Other 
Animal / Insect origin 
Glass 
Physical
Metal 
contamination Plastic 
Rubber 
Wood 
Other 
Packaging (defective/incorrect) 
Unapproved premises 
Unapproved processes 
Other 
8
Root Cause Analysis:
Was the root cause of the food safety incident identified? Yes  No 
State the initial issue (the root cause) that led to the food incident occurring
State the corrective measures identified to prevent incident reoccurrence
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Food Business Root Cause Analysis Report Form

Introduction: For completion by the food business

Section A: For completion by the FSA

Allergy Alert or Product Recall Information

Incident (I) reference:

Food business investigating officer / representative details:

Root Cause Analysis Outcome

State the initial issue (the root cause) that

State the corrective measures identified to

Procedures not followed - one-

Training – absent or incomplete 

Cleanliness - absent or inadequate 

Servicing – absent or inadequate 

Enforcement Officer details:

In Northern Ireland [email protected]

Nature of problem Type Select Brief description

State the corrective measures identified to prevent incident reoccurrence

© Crown copyright 2020

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