Investigate the Ringwood cool room failure

What is going on

On Wednesday 9 September the opening worker at Ringwood found cool room 3 at 7.8 degrees with the door ajar and a worn seal. It is the second excursion in a month. The temperature log shows the reading, the Incident and Hazard Register holds an open hazard entry, and the closing worker from Tuesday says the door was shut. The cool room held sympathy stock for two funeral orders and a week of everyday stock. The General Manager wants a proper investigation: what happened, whether stock must be written off under the freshness policy, whether procedures failed, and what corrective actions will prevent a third event. The refrigeration contractor can attend on Friday. The report is due Friday with both registers updated.

Your brief

Investigate the failure using the records and interviews, assess the stock and record any wastage, determine root causes across equipment, procedure and behaviour, recommend corrective actions in hierarchy order, and update both registers so that the actions have owners and dates.

Work through it

You do not need to do it all. Doing a few of these will show you what the work is like. Your ticks and notes stay on this device.

• Read the Cool Room and Temperature Monitoring Procedure and the Stock Quality and Freshness Policy, and list the requirements that applied on Tuesday night and Wednesday morning.
• Review the Stock Intake and Cool Room Log entries for Ringwood for the past month and chart the readings to identify any pattern before the two excursions.
• Review the open hazard entry in the Incident and Hazard Register and the earlier excursion, and prepare interview questions for the opening and closing workers.
• Record the interview findings in plain words, without blame, distinguishing what was observed from what is assumed.
• Assess the stock that was in cool room 3: grade each line, decide what must be written off under the policy, and record the wastage in the Stock Intake and Cool Room Log.
• Determine root causes across equipment (seal, door closer, alarm), procedure (closing checklist, door check) and behaviour (training, workload), using the hierarchy of controls to rank corrective actions.
• Update the Incident and Hazard Register entry with findings, corrective actions, owners and dates, and set the status to Actions in progress.
• Write a one page report for the General Manager with findings, stock loss value, corrective actions and any procedure changes you recommend.

What someone in this role would produce

• A one page investigation report for the General Manager
• Wastage entries in the Stock Intake and Cool Room Log
• The updated Incident and Hazard Register entry with actions, owners and dates
• Recommended changes to the Cool Room and Temperature Monitoring Procedure