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A Canada Food Inspection Agency employee, left, looks on as beef from the XL Foods cattle processing plant is dumped at a landfill site near Brooks, Alta.JEFF McINTOSH/The Canadian Press

The largest beef recall in Canadian history happened because a massive Alberta producer regularly failed to clean its equipment properly, reacted too slowly once it realized it was shipping contaminated meat, and on-site government inspectors failed to notice key problems at the plant.

"It was all preventable," concludes an independent review of the 2012 XL Foods Inc. beef recall, in which 1,800 products were removed from the Canadian and U.S. markets and 18 consumers became sick.

The XL Foods Inc. plant in Brooks, Alta., accounted for 35 per cent of Canada's beef processing, and the independent panel led by three doctors found long-standing problems with cleanliness and proper inspection practices.

According to the report, the company did not practice what to do in the event of a major recall, and its staff failed to ensure equipment was regularly and properly cleaned. Canadian Food Inspection Agency workers at the plant failed to notice the problems. These and many other issues persisted four years after the government promised sweeping food-safety reforms in response to the 2008 listeria bacteria contamination at Maple Leaf Foods that took the lives of 23 Canadians and led to serious illness in 57 others who ate tainted meat products.

"It was not that long ago," the report notes in reference to the 2008 recall. "Canada's food-safety system – then, as now – is recognized as one of the best in the world. Yet, a mere four years later, Canadians found themselves asking how this could have happened once again."

In a report released on Wednesday, the independent panel said it found "a relaxed attitude toward applying mandatory procedures" at the Brooks plant, where company staff work with government inspectors.

The panel said "it was a series of inadequate responses by two key players in the food-safety continuum that played the most critical part leading to the September, 2012, event at XL Foods Inc. – plant and CFIA staff."

"We found that responsibilities towards food-safety programs were not always met – by both plant staff and CFIA officials on site," the report states.

The panel was chaired by Ronald Lewis and included two other doctors, André Corriveau and Ronald Usborne. They report the root cause of the problem was likely an animal that was heavily contaminated with E. coli-157:H7.

"As the contaminated carcass moved through the plant, the bacteria became lodged in or on a piece of equipment within the establishment," the report states. "It seems likely that sanitation was inadequate."

The report is highly critical of XL Foods Inc. for its poor communication with both the CFIA and the public, particularly for not providing CFIA with information about the contamination quickly after it was discovered. The company was sold earlier this year to JBS South America of Brazil. However, the independent review also found several issues with the performance of the CFIA.

"For its part, CFIA was clearly not monitoring the company's [Food Safety Enhancement Program] and identifying deficiencies as carefully as they should have been," the report states.

The report makes 30 recommendations for reform, including a call for Health Canada to give "prompt consideration" to approving irradiation of Canadian beef products. It also calls on the Minister of Health to assess the effectiveness of the CFIA's activities related to its meat program.

At a news conference, federal Agriculture Minister Gerry Ritz announced a new inspection verification system with a team of 30 inspectors at a cost $16-million over three years, and promised to act on all the recommendations. "Canadian consumers remain our No. 1 priority when it comes to food safety," Mr. Ritz said, promising to act on all of the report's recommendations. "As we all know, no system is perfect."

The report estimates the recall cost Canada's beef industry $16-million to $27-million and further harmed Canadians' confidence in the safety of meat products.

"The images of thousands of pounds of wasted beef being bulldozed into landfill stunned the public," the report states.

NDP agriculture critic Malcolm Allen said Mr. Ritz is failing to take accountability for the problems on his watch.

"It really is a damning indictment of his management of the entire food-safety regime," he said.

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