The government inquiry into the Fonterra whey protein scare said the co-operative dairy giant's workplace culture showed an entrenched "silo" mentality that robbed the company of some of the cohesion vital in an organisation of its size.
The report covering the 2013 "WPC80" whey protein incident, which prompted a widespread precautionary product recall when initial tests - which later turned out to be false - showed the product may have contained a botulism-causing bacteria - C. botulinum.
"Both internal and external pressures also contributed to missed opportunities to correct the course of events," the report said.
Communication, both within and between parts of the organisation, was often unclear, it said.
"And there was also a lack of adequate escalation procedures to deal with possible food safety problems," it said.
"The ill-prepared inevitably pay a heavy price in a crisis. Fonterra was not ready for a crisis of this magnitude.
"It lacked an updated, well rehearsed crisis plan to implement, as well as a crisis management team that could spring into action," it said.
The report said the Ministry for Primary Industries also lacked a single, coherent food incident plan to implement straight away.
The inquiry, which was headed by Miriam Dean, QC, said the WPC80 incident had spurred Fonterra into a series of comprehensive changes, from boardroom to factory floor, especially aimed at strengthening food safety and quality and crisis management capability.
It had also prompted changes at the MPI, which had created a regulation and assurance branch devoted more or less solely to food safety.
"The ministry is also preparing a new crisis response model for implementation in 2015," it said.
- Jamie Gray, NZME. News Service business reporter
