An AcciMap approach to analyse the Chinese melamine milk scandal

Jan Mei Soon-Sinclair, Rounaq Nayak, Louise Manning
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Abstract

PurposeThe 2008 Chinese melamine milk scandal resulted in six reported fatalities and affected around 300,000 children, of whom 54,000 were hospitalised. Previous studies have used linear approaches to examine the root causes of the melamine milk scandal.Design/methodology/approachIn the present study, we applied a systems approach to the melamine milk scandal to identify the complex systems-level failures across the supply chain leading to the incident and why food fraud incidents such as this occurred in the dairy sector. Additionally, systemic failures associated with food fraud vulnerability factors were considered (i.e. opportunities, motivation and control measures).Findings48 contributory factors of influence were identified and grouped across six sociotechnical levels across the Chinese dairy system, from government to equipment and surroundings. Lack of vertical integration (processes and communication) contributed to the failure. When viewed from a broader perspective, the melamine milk scandal can be linked to a series of human errors and organisational issues associated with government bodies, the dairy supply chain, individual organisations and management decisions and individual actions of staff or processes.Practical implicationsThis approach is of value to policymakers and the industry as it supports public health investigations of food fraud incidents and proactive food safety management.Originality/valueTo the best of our knowledge, this is the first study to analyse a food safety or fraud incident using the AcciMap approach and the food fraud vulnerability assessment (FFVA) technique. AcciMap analysis is applied to both unintentional and intentional aspects of the incident.
用 AcciMap 方法分析中国三聚氰胺牛奶丑闻
目的2008年中国三聚氰胺牛奶丑闻导致6人死亡,约30万儿童受到影响,其中5.4万人住院治疗。在本研究中,我们对三聚氰胺牛奶丑闻采用了系统方法,以确定导致该事件的整个供应链中复杂的系统级故障,以及乳制品行业发生此类食品欺诈事件的原因。此外,我们还考虑了与食品欺诈脆弱性因素(即机会、动机和控制措施)相关的系统性失效。研究结果48个影响因素被识别出来,并在中国乳业系统的六个社会技术层面上进行了分组,从政府到设备和周边环境。缺乏纵向一体化(流程和沟通)是导致失败的原因之一。从更广阔的视角来看,三聚氰胺牛奶丑闻可与一系列人为失误和组织问题联系起来,这些问题涉及政府机构、乳品供应链、单个组织和管理决策以及员工的个人行为或流程。AcciMap 分析适用于事件的无意和有意方面。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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