Failure Knowledge Database / 100 Selected Cases

Mass Food Poisoning Caused by Snow Brand Dairy Products【June 27 ~ beginning of July in 2000, throughout Kansai region】
Masayuki Nakao
Institute of Engineering Innovation, School of Engineering, The University of Tokyo

Food poisoning caused by dairy products such as “low-fat milk” produced at the Osaka
plant of Snow Brand Milk Products Co. (Snow Brand hereinafter) left 14,780 people ill after
it was first reported on June 27, 2000. Original cause was attributed to a toxin generated byincreased bacteria during a power outage that stopped the production line at the Taiki plantin Hokkaido where the raw material was produced. This toxic material was sent to the nextlevel of production line without being discarded and created toxic skim milk powder. Dairy
products that contained the toxic material were produced and shipped from the Osaka plantand caused an outbreak of food poisoning. After the incident, the delay in making
intra-company and public announcements and also in recalling the product accelerated the
spread of the disaster throughout the Kansai region, and this case became an historicoutbreak of food poisoning in Japan.
１．Event
People who consumed Snow Brand dairy products fell ill with food poisoning one after
another and the number of affected people reached a total of 14,780 after this incident was
first reported on June 27, 2000.
On June 28, The Osaka City Government directed Snow Brand to cease making the
products, recall them and also make an announcement of the facts in the case. The incident
was publicized on June 29 and an order to recall the affected products was made on June 30.
The delay in making intra-company and public announcements and also in recalling the
products accelerated the spread of the disaster.
On July 2, the Osaka Prefectural Institute of Public Health (Osaka Public Healthhereafter) detected staphylococcal enterotoxin type A from “low-fat milk”. The Osaka City
identified it as food poisoning caused by a toxic agent and prohibited operation of the Osaka
plant. Snow Brand suspended production of dairy products at 21 plants across the county on
July 11.
On July 25, the Ministry of Health, Labor and Welfare (Health Ministry hereafter)
authorized the reopening of 10 plants and they went back in operation from July 27. A
declaration of safety was issued for 20 plants on August 2, but consumers continued toboycott Snow Brand products throughout the nation.

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Failure Knowledge Database / 100 Selected Cases

Under further investigation, Enterotoxin Type A was found in the skim milk powder(produced on April 10), the material is used for low-fat milk products, which were produced
at the Taiki plant in Hokkaido.
Hokkaido Prefecture began investigating the site from August 19 and announced theirfindings of the effects of the power outage which occurred on August 23, which caused the
production of the toxic skim milk powder, violated use of skim milk powder which contained
viable cell count that did not meet its standards, and detection of enterotoxin type A in thestored sample of skim milk powder produced on April 1 and April 10. Hokkaido Prefecture
also charged them to be in violation of Article 4 of Food Hygiene Law and ordered a ban on
the business according to Article 23 as well as to recall the skim milk powder produced on
April 1 and April 10.
This incident caused Snow Brand to lose consumer confidence and the sales of the largest
dairy product manufacture has since plummeted. The total deficit for the period of this fiscal
year reached to 52.9 billions yen and the company was pushed to close two sites including the
Osaka plant.
２．Course(1) On March 31, there a was power outage from 11 am for three hours at the Taiki 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 for nine hours. Consequently toxic enterotoxin type A
propagated as staphylococcus bacteria grew.
(2) On April 1, it was considered to be safe enough to produce skim milk powder bysterilizing the material that was retained inside the pipe 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 andescherichia coli and shipped (112 bags out of 450 were used for dairy products while therest were moved to storage). As the rest of the 380 bags exceeded the amount of generalbacteria by more than 1% of it’s own standard value (9,900 bacteria per gram), they werereused as material of skim milk powder (due to the lack of safety control management).
At the Taiki plant, 750 bags of skim milk powder were manufactured out of the toxic
material and shipped on April 10 and 278 bags out of 750 were used at the Osaka plant.
(3) On June 20, the Osaka plant received the skim milk powder manufactured in the Taiki
plant.
(4) On June 23, the Osaka plant manufactured the dairy products that had caused foodpoisoning (~6/28).

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Failure Knowledge Database / 100 Selected Cases(5) On June 27, the Osaka City and Snow Brand received the first report that the Snow
Brand low-fat milk caused food poisoning. The number of the illnesses continued to growthrough the following day, June 28.
(6) The Osaka City government investigated affected people and inspected the Osaka plant,
On June 28, they directed Snow Brand to refrain from producing, and to recall the
products, and make an announcement of the facts of the incident. The incident was
publicized on June 29 and the order of product recall was made on June 30. The cause
was expanded to nearby cities and prefectures during the time.
(7) The Health Ministry sent office members to the Osaka City government and held a joint
session with related cities and prefectures on June 30. On July 1, the Health Ministry
and the Osaka City jointly investigated the Osaka plant under the administration ofHazard Analysis and Critical Control Point (HACCP).
(8) On July 2, 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 of Negligence Causing Injury. The number
of affected people reached to more than 10,000 and on July 5th, Takuro Ishikawa, thePresident of Snow Brand resigned effective the following day.
(9) On July 10, the Osaka City government issued an interim finding and announced it’s
discoveries of the investigation of the incident. The reported number of affected people
reached to 14,780.
(10) On July 11, Snow Brand suspended production of dairy products at 21 plants across thecounty.
(11) On July 25, 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 ofsafety was issued to 20 plants on August 2.
(12) On August 18, regarding the mass food poisoning caused by the product of Osaka plant,
the Osaka City announced that toxin (enterotoxin type A) of Staphylococcus bacteria was
detected from the skim milk powder produced (on April 10) at Taiki plant (Taiki,
Hokkaido Prefecture). Sales of Snow Brand dairy products began to be suspended.
(13) Received the request of investigation from the Osaka City and the Health Ministry,
Hokkaido Prefecture began to investigate the site from August 19 and announced theirfindings of the power outage occurred on August 23 that affected the production 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 ofskim milk powder produced on April 1 and April 10. The toxic skim milk powder was usedas material of dairy products manufactured at the Osaka plant.

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Failure Knowledge Database / 100 Selected Cases

Hokkaido Prefecture also charged violation of Article 4 of Food Hygiene Law and ordereda ban on producing dairy products according to Article 23 as well as to recall the skim
milk powder produced on April 1 and April 10.
(14) On September 20, in a joint session, the Health Ministry and the Osaka City issued theinterim and announced that the outbreak of food poisoning attributed to the skim milk
powder produced at Taiki plant.
(15) On September 23, the Health Ministry accepted the improvement plan including power
outage control measures, which were submitted for the Taiki plant, and lifted the banorder. Operation restarted from October 14.
(16) On September 26, Snow Brand announced the financial outlook for the next fiscal year.
The ordinary loss fell into the deficit of 53.8 billion yen and Snow Brand announced toclose the Osaka plant.
(17) On December 20, “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 the cause was attributed to the skim milk produced at Taiki
plant (Taiki, Hokkaido Prefecture). Toxin of staphylococcus was generated either fromcream separation process or condensed process during power outage.
(18) On December 22, Snow Brand publicized the final report that the cause of the foodpoisoning was attributed to the skin milk produced at the Taiki 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 the public health instituteof the Osaka City government requested a product recall and an intra-company
announcement, Snow Brand disagreed with the request and the executive director
directed them to reconfirm the request on early 29th, which caused a delay in making anannouncement, the report continued. 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 a means toanalyze possible risks to secure products.
３．Cause(1) Direct Cause
Enterotoxin type A propagated as staphylococcus bacteria increased due to extended
heating time of collected skim milk material since proper action was not taken when the
product line of Taiki plant stopped due to power outage. The outbreak of food poisoning
was attributed to the dairy products that were produced from the toxic material.
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Failure Knowledge Database / 100 Selected Cases(2) Main Cause (Organizational Cause)① Toxin propagated due to the increase of bacteria since proper action was not taken
when the product line stopped due to power outage. The toxic material was sent to
the next level of production line instead of being discarded.
•

Failed to take necessary sanitary precautions at the site.

•

Lack of awareness of crisis management at the site, no policies in place for power
outages.
There was no policy ascribed as to the prevention of increasing bacteria, restarting
operation, product inspection, or disposal criteria when the production line stopped
due to such incidents as power outages.

② When the number of bacteria in the produced skim milk powder exceeded safety
standard, the material was considered to be safe to be reused if sterilized and the newskim milk powder was produced out of the toxic material and shipped to Osaka plant.
•

The plant manager and his staff not only did not have full knowledge aboutenterotoxin but also lacked the basic knowledge that toxin generated from bacteria
did not lose its toxicity by heating.

•

Lack of basic knowledge of food sanitation.

•

Corporate standards were not strictly kept. Basic manuals were stultified.

(3) Cause of Expansion (Organizational Cause)
After the outbreak of food poisoning occurred, the delay in recollecting products andmaking intra-company and public announcements accelerated the spread of thedisaster.
•

The first mistake was that the initial sign was judged as “a usual complaint or
inquiry”. There was no awareness that it would be food poisoning.

•High brand consciousness verses low awareness of crisis management among top
management. Delay in making decisions against recall and making intra-company
and public announcements. Inattentive involvement of the top management people.
Irresponsible management system. Lack of leadership.

•

Suppression of the facts due to evasion of responsibility. Incompetentcommunicative function.

４．Immediate Action
1) The Osaka City government investigated the affected people and inspected the Osaka
plant. And they directed Snow Brand to desist from making, and to recall the low-fat
milk, and make an announcement of the facts. The recall order was made on June 30.
2) On July 1, the Health Ministry conducted a joint inspection on the premises with the
Osaka City government.

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Failure Knowledge Database / 100 Selected Cases

3) The Osaka City government identified it as food poisoning caused by a disease agent ofstaphylococcal enterotoxin type A and prohibited operation of the Osaka plant on July 2.
4) On July 11, Snow Brand suspended the production of dairy products at 21 plants.
5) On August 18, regarding the mass food poisoning caused by the product of Osaka plant,
the Osaka City announced that toxin (enterotoxin type A) of Staphylococcus bacteria
was detected from the skim milk powder produced (on April 10) at Taiki plant.
6) Hokkaido Prefecture began to investigate the Taiki plant from August 19 andannounced their findings on the power outage which occurred on August 23 that
affected the production 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.
Hokkaido Prefecture also charged violation of Article 4 of Food Hygiene Law andordered a ban on the business as well as to recall the skim milk powder produced on
April 1 and April 10.
7) The Health Ministry considered a mandate on the toxin tests on material for skin milk
power at milk product plants nationwide that are administered by Hazard Analysis andCritical Control Point (HACCP), and also to add enterotoxin in the group of hazardous
causative agent. They also made provision to establish sanitation guideline or to install
HACCP to prevent from occurrence of similar food poisoning incident.
５．Countermeasure(1) Snow Brand established the improvement plan including the power outage control
measure of Taiki plant.
(2) Snow Brand executed radical organizational reformation.
After the incident, Snow Brand drastically reviewed complicated corporate organizationthat was considered as a remote cause. They abolished branch or division system andestablished the product safety management office directly controlled by the president toimprove product quality control.
(3) The Health Ministry has considered a mandatory toxin test on material for skin milk
powder at nationwide milk production plants that are administered by Hazard Analysis
and Critical Control Point (HACCP), and also to add enterotoxin in the group of
hazardous causative agent. They also made provisions to establish sanitation guidelines
or to install HACCP to prevent from occurrence of similar food poisoning incident.
(4) The Japan Dairy Industry Association organized the quality control / crisis management
manual and publicize about the industry best they can.
６．Summary
The Snow Brand food poisoning incident left immense damage to the 75-year old
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Failure Knowledge Database / 100 Selected Cases

time-honored company, which led the top management people to resign. It was initiatedfrom the unexpected cause, power outage, at the Taiki plant, and the outbreak of foodpoisoning was attributed to lack of risk and sanitary management at the production site ofskim milk powder. Moreover, incompetence in communicative functions, lack of risk
management or leadership among top management people delayed making announcements
and collecting products, which resulted in the spread of the disaster.
The production site of the skim milk plant was not the only cause of this incident. The
disaster was exacerbated because proper action for disclosure of the situation was not taken,
and responsiveness of the top management people were called into question.
Snow Brand needs to seriously reflect upon the increase in affected people due to the delay
in disclosure, sloppy sanitary management at the Osaka plant and the Taiki plant, and low
awareness of safety issues as a food production company. Restructuring of the basic safetycontrols is strongly desired.
７．Knowledge(1)

Manual becomes stultified.
Employees cannot follow the manual or deal with unexpected occurrences.
When incidents beyond the scope of the written manuals happened, such as shipping
products that did not meet standard values or a power outage, no action was taken.

(2)

As time passed by, basic knowledge in the organization or office faded away. In this case,the plant manager and employees lacked basic knowledge of food sanitation. The case of
JCO critical accident also told us about lack of or degraded basic knowledge of nuclear
reaction. It is necessary to periodically improve awareness by refreshing theorganization or the office.

(3)

When problems occur, the facts will be suppressed due to evasion of responsibility at the
charged position. Staff come up with some ideas, but do not have the courage to act andthe problem become bigger.

(4)

Inconvenient information that harms operation does not reach to the top management
people. Information is not transmitted (especially in the corporation that tends to be
operated by demerit system).
It is important to create a corporate organization where information is easilytransmitted.
In an ideal organization, a person in charge can frankly tell even the inconvenient
information to top management people.
It is important to establish an organization where information of all the products
including consumer problems can be shared.

(5)

Top management people always need to be aware of the importance of risk management.
When problems occur, they need to take actions to properly disclose information without
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Failure Knowledge Database / 100 Selected Cases

suppressing the facts, to take quick steps to clarify the cause or to recall products (since
only top management people can make decision on these matter.)
８．Background“The dairy industry was the top runner in sanitary management”, the industry
believed until the outbreak of the Snow Brand food poisoning occurred. In January 1998, themajor dairy product companies including Snow Brand were the first industries that met thestandards of Hazard Analysis and Critical Control Point (HACCP) administered by the
Health Ministry.
To obtain HACCP, every dairy product company all together compiled work procedures of
production process in its manual. At last the amount of the manual per factory went over two
files and each file was as thick as 7 to 8 cm in A4 size. The accurate manual has raised amyth that “the company that uses the most perishable material (milk) is the most hygienic.”
In the food industry, the tendency that making manuals to obtain HACCP or ISO waseverything they needed to do was going around, but the manual was nothing but a manual.
It did not mean anything if the manual was not utilized to manage work processes. Putting
too much confidence on manuals prevents from being able to deal with unexpectedoccurrences. Snow Brand was not following its manual for some work procedures such as
cleaning valves. When toxins were found from the skin milk powder at the Taiki plant, noaction was taken and caused the outbreak of food poisoning. In the food industry, to beat costcompetition, more part-timers or temporary employees are hired as substitutes for full-time
employees or operations are put out to subcontractors. It is hard to say that the manual isfully applied even though manufacturers proceed in compiling everything in manuals to keep
certain quality from less experienced part-timers or subcontractors.
Possession of manuals does not guarantee the confidence in a company. The greater
importance is if employees are able to follow the manual or to respond to unexpectedoccurrences. Manuals themselves cannot control safety of company.
<references>[1] Summary of the Second Snow Brand Food Poisoning Countermeasure Meeting (July 14,
2000)
The Sanitation division of the Ministry of Health and Welfare[2] Summary of the First General Sanitary Control & Production Process Assessment
Review Meeting (August 30, 2000)
The Sanitation division of the Ministry of Health and Welfare[3] Background of Staphylococcus Food Poisoning by such as ”Snow Brand Low-fat Milk”(September 4, 2000)
The Sanitation division of the Ministry of Health and Welfare
8Failure Knowledge Database / 100 Selected Cases[4] Background of Staphylococcus Food Poisoning by such as ”Snow Brand Low-fat Milk
(September 21, 2000)
The Sanitation division of the Ministry of Health and Welfare[5] Summary of the Fourth Snow Brand Food Poisoning Countermeasure Meeting(September 29, 2000)
The Sanitation division of the Ministry of Health and Welfare
SequelSnow Brand did not fundamentally reform the cultural organization and closed the casewith conventional remedies, as everyone was worried, in 2002 they raised another scandal of“beef mislabeling incident” (that the Kansai meat center of Snow Brand Food Co., thesubsidiary of Milk Products Co., misused the domestic beef buyback system, a measure tofight BSE, and had industrial group buy the forged beef by misrepresenting imported beef as
domestic beef). Consumer confidence against Snow Brand was diminished due to these
consequent scandals and Snow Brand ended up with not even being able to prolong their
existence as a corporation.

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