Sewing Needles in Sandwiches!

Posted on August 12, 2012 | in Concession Stand, Defects, Error-Proofing, Lean Wastes, Root Cause Analysis, Small Business | by

sewing needle thread bobbin airline air canada delta plane caterers police sandwiches lean blitz consulting

In an article by the Associated Press, from the “That’s Not What I Ordered” Department”:

Air Canada says a passenger found what appears to be a sewing needle in a catered sandwich on board a flight fromVictoria, British Columbia, to Toronto.

Peter Fitzpatrick, a spokesman for the airline, said late Tuesday that the airline is “working closely with our caterers to ensure heightened security measures have been put in place.”

Well that’s pretty scary. Let’s hope the passenger saw the needle first before taking a bite of the sandwich.

This is apparently not an isolated recent incident. From the same article:

Dutch police said earlier in July they were investigating how needles got into six sandwiches on Delta Air Lines flights from Amsterdam to Minneapolis, Seattle and Atlanta. Passengers discovered four of them.

I’m not sure if Delta and Air Canada use the same catering services or the same supplier for sandwiches, but it certainly appears that there are pretty big questions that must be asked of both airlines.

Easily the biggest question to ask is not “Why were needles in the sandwiches?” but instead “How and where did the needles get introduced to the sandwiches in the first place?” (“Why?” can be answered later.)

This calls for some fact-finding and a little root cause analysis. First, identifying all of the relevant elements of the process by asking some of those fact finding questions.

Do both airlines use the same caterer?
Were the needles found in the same type of sandwich or a bunch of different varieties?
In what part of the sandwich were they found (bread, meat, vegetables)?
How are sandwiches constructed/packaged/delivered? Are packages tamper-proof?
What are the sandwich origins (or component origins)?
At how many points in the construction/packaging/delivering process is the sandwich exposed to potential outside threats? Is there a consistent chain of command?

Asking these questions will help rule out potential variables (for example, if both airlines use the same caterers and have the same point of origin, you only need to focus initial efforts on those caterers and origins).

Now let’s look at all possible opportunities for the needle to be introduced to the sandwich, starting from the end customer. (I’m on the outside looking in – these are all assumptions.) There are lots of root cause analysis tools out there, but each of these elements here would be part of the process flow diagram.

End customer, the patron in the seat: it’s possible for a patron to slip a needle into the sandwich and cry foul (or fowl, if it was a chicken sandwich) to a flight attendant. However, between the Delta flights and the Air Canada flight for so many needles to be found by passengers in a short amount of time makes this scenario highly unlikely (or highly coincidental). But again, it’s possible.

Flight attendant: if containers are sealed and tamper-proof from the point the flight attendant grabs a sandwich to when the sandwich is handed to the customer, there are no methods by which they can insert a needle into the sandwich. However, if packages are not tamper-proof or if there is significant exposure to sandwiches from outside threats then you’d have to look at the flight attendants’ exposure to sewing needles.

Catering transportation/logistics between supplier and plane: see Flight attendant.

Sandwich construction and packaging: Here’s where things might get messy. Why would a food services provider have access to sewing needles? In what part of the sandwich – bun, meat, other toppings – were the needles located? Is it possible that the food supplied by food distributors contained the needles prior to delivery to the food service provider? (This also goes back to Principle #11 from The Toyota Way about challenging your suppliers to improve.) Food service providers are so heavily regulated and held to a different cleanliness and safety standard that it would have to be a really unique situation in which a dangerous foreign object like a sewing needle would find its way into food preparation. That being said, are regulations in place but simply not enforced strictly enough at the food service provider?

Sandwich component supplier: again, referring back to Principle #11. Is it possible that somehow needles were introduced to processed portions of the sandwich components?

In order to properly determine how the needles were introduced, you not only need to break the process down into the exposure points by starting with the end customer and working back upstream, but you must also be thorough in the investigation of each step in the process. That means you must thoroughly evaluate each entity that touches the process.

Hopefully by this point the opportunity for the needle to make its way into the sandwich has been identified. To prevent this action from ever occurring again the process must have solid corrective actions implemented.

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