List 1. The Course of this caseMarch 31

April 1

June 20
June 23
June 27

June 28

June 30

July 1

July 2

There a was power outage from 11 am for three hours at theTaiki plant of Snow Brand in Hokkaido. Due to this power outage,
the skim milk was kept heated at 68 to 86°F for four hours during
the cream separation process, which usually took only a few
minutes. Also the return tank used to store excess skim milk
during the condensation process was left without cooling fornine hours. Consequently toxic enterotoxin type A propagatedIt was considered to be safe enough to produce skim milk
powder by sterilizing the material that was retained inside thepipe at the plant (the material needed to be discarded), and a
total of 830 bags of skin milk powder were manufactured. And
450 bags out of 830 tested negative for bacteria including
staphylococcus and escherichia coli and shipped (112 bags outof 450 were used for dairy products while the rest were moved
to storage). As the rest of the 380 bags exceeded the amount ofgeneral bacteria by more than 1% of it’s own standard value(9,900 bacteria per gram), they were reused as material of skim
milk powder (due to the lack of safety control management). At
the Taiki plant, 750 bags of skim milk powder weremanufactured out of the toxic material and shipped on April 10
The Osaka plant received the skim milk powder manufactured in
the Taiki plant.
The Osaka plant manufactured the dairy products that had
caused food poisoning (～ 6/28).
The Osaka City and Snow Brand received the first report that theSnow Brand low-fat milk caused food poisoning. The number ofthe illnesses continued to grow through the following day, June
The Osaka City government investigated affected people andinspected the Osaka plant. They directed Snow Brand to refrainfrom producing, and to recall the products, and make anannouncement of the facts of the incident. The incident waspublicized on June 29 and the order of product recall was madeon June 30. The cause was expanded to nearby cities andThe Health Ministry sent office members to the Osaka City
government and held a joint session with related cities andprefectures
The Health Ministry and the Osaka City jointly investigated theOsaka plant under the administration of Hazard Analysis andCritical Control Point (HACCP).
The Osaka Public Health Dept. detected Staphylococcal
enterotoxin type A in a “low-fat milk” product. The Osaka City
government identified it as food poisoning caused by a toxic
agent and prohibited operation of the Osaka plant. Also Osaka
Prefectural Police began an investigation under Suspicion ofNegligence Causing Injury.

July 5

July 10
July 11
July 25
August 2

August 18

August 19- August 23

The number of affected people reached to more than 10,000
and on July 5th, Takuro Ishikawa, the President of Snow Brand
resigned effective the following day.
The Osaka City government issued an interim finding andannounced it’s discoveries of the investigation of the incident.
The reported number of affected people reached to 14,780.
Snow Brand suspended production of dairy products at 21
plants across the county.
The Health Ministry authorized the reopening of 10 plants
including those in Kyoto and Kobe.
Those plants went back in operation from July 27 and a
declaration of safety was issued to 20 plants.
Regarding the mass food poisoning caused by the product ofOsaka plant, the Osaka City announced that toxin (enterotoxintype A) of Staphylococcus bacteria was detected from the skim
milk powder produced (on April 10) at Taiki plant (Taiki, HokkaidoPrefecture). Sales of Snow Brand dairy products began to beReceived the request of investigation from the Osaka City andthe Health Ministry, Hokkaido Prefecture began to investigate
the site from August 19 and announced their findings of thepower outage occurred on August 23 that affected theproduction of the toxic skim milk powder, violated use of skim
milk powder contained viable cell count that did not meet its
standard, and detection of enterotoxin type A in the stored
sample of skim milk powder produced on April 1 and April 10.
The toxic skim milk powder was used as material of dairy
products manufactured at the Osaka plant.
Hokkaido Prefecture also charged violation of Article 4 of Food
Hygiene Law and ordered a ban on producing dairy products
according to Article 23 as well as to recall the skim milk powder

In a joint session, the Health Ministry and the Osaka City issued
September 20 the interim and announced that the outbreak of food poisoning
attributed to the skim milk powder produced at Taiki plant.
The Health Ministry accepted the improvement plan including
September 23 power outage control measures, which were submitted for theTaiki plant, and lifted the ban order.Operation restarted fromSnow Brand announced the financial outlook for the next fiscal
September 26 year. The ordinary loss fell into the deficit of 53.8 billion yen andSnow Brand announced to close the Osaka plant.
“The joint session of the Health Ministry and Osaka City” held ameeting and issued the final report of the food poisoning
caused by Snow Brand dairy products, and concluded that theDecember 20 cause was attributed to the skim milk produced at Taiki plant(Taiki, Hokkaido Prefecture). Toxin of staphylococcus wasgenerated either from cream separation process or condensed
process during power outage.

Snow Brand publicized the final report that the cause of thefood poisoning was attributed to the skin milk produced at theTaiki plant (Taiki, Hokkaido Prefecture). Due to a power outage
in March, the temperature in the Taiki plant was not kept
properly which caused the creation of the toxin. Although theDecember 22 public health institute of the Osaka City government requested
a product recall and an intra-company announcement, SnowJanuary 31,
Brand disagreed with the request and the executive director
2001
directed them to reconfirm the request on early 29th, whichcaused a delay in making an announcement, the reportcontinued. In the meanwhile, on the 22nd, Snow Brand reported
the Osaka plant closure due to revelation of lack of sanitation,and the plant was actually closed down on January 31, 2001.
HACCP: Hazard Analysis and Critical Control Point (HACCP) administered by
the Health Ministry to the institutions that possess high a sanitary system is ameans to analyze possible risks to secure products.