'When food kills': a socio-technical systems analysis of the UK Pennington 1996 and 2005 E. coli O157 Outbreak Reports

In 1996 and 2005, two of the largest E. coli O157 outbreaks occurred in the UK. Many people were infected after consuming meat resulting in a number of deaths. In the present study we applied a systems approach to both the outbreak reports to analyse and compare the accidents. Using the Accimap method of systems analysis, this study investigates the human errors and organisational issues involved in the outbreaks and why accidents such as these occur in the food production domain. The systems analysis carried out in this study on the two outbreaks indicates that there are both common as well as unique factors associated with the two outbreaks. The study concludes that it is necessary to address food safety from a systemic point of view and identify and solve the various problems that could arise in the system, in the pre-incubation period before the outbreak actually occurs.