Forensic Impact Report
Clean Slate Representative: Chris Beyer
Name: James Smith
Phone: 123-456-7894
Email: james.smtih@email.com
Report Started: 2025-09-01
Report Completed: 2025-09-02
1. Root Cause Analysis
Method & Findings: The 5 Whys Method
To determine the root cause of the mold contamination, a "5 Whys" analysis was conducted, tracing the issue back to its fundamental origin.
Why was there mold on the Ny Sour Diesel product?
Because the cannabis flower was exposed to a high-moisture environment after it was dried and before it was packaged.
Why was the cannabis exposed to a high-moisture environment?
Because a dehumidifier in the packaging room malfunctioned, allowing humidity levels to rise unchecked.
Why did the dehumidifier malfunction?
Because it was due for a maintenance check and calibration, but this was missed due to a scheduling oversight.
Why was the maintenance check missed?
Because the maintenance log for the packaging equipment was not being consistently updated and cross-referenced with the master maintenance schedule.
Why was the log not being consistently updated?
Because there is no designated person responsible for maintaining and auditing the equipment maintenance log. This responsibility falls into a gray area between the facilities and operations teams.
Findings and Recommendations
The investigation found that the root cause of the mold contamination was a failure in our preventive maintenance scheduling and accountability protocols. The specific failure of the dehumidifier was a symptom of a larger systemic issue related to equipment maintenance. Our findings highlight a critical gap in our operational procedures: the lack of a clear, designated role and system for tracking and ensuring timely maintenance of all facility equipment. This oversight created a high-risk environment where a critical piece of equipment could fail without being detected.
Corrective Actions:
- Implement a Digital Maintenance Management System (CMMS): This system will automate scheduling, send reminders, and create a clear audit trail for all equipment maintenance.
- Assign a Dedicated Maintenance Coordinator: A single point of contact will be responsible for overseeing the CMMS, ensuring all maintenance is performed on schedule, and reporting on the status of all equipment.
- Establish a Bi-Weekly Maintenance Log Audit: The newly appointed coordinator will conduct regular audits to cross-reference the digital system with physical logs, ensuring consistency and accuracy.
- Revise SOPs for Environmental Controls: Update our Standard Operating Procedures (SOPs) to include daily checks of all environmental control systems (e.g., HVAC, dehumidifiers) in production and packaging areas.
2. Risk Assessment
| Risk Factor | Assessment |
|---|---|
| Consumer Impact | Consumer impact risk factors are the potential for a product defect to cause harm to a consumer, ranging from minor inconvenience to severe injury or death. This risk is assessed by considering the severity of the potential harm, the likelihood of it occurring, and the number of people who could be affected. A high consumer impact risk factor often triggers a mandatory, expedited recall to protect the public and mitigate legal and reputational damage. |
| Recall Classification | Class 2 – Temporary adverse health consequence possible. |
| Product Scope | Batch #456789 – 8.26 pounds; Batch #456789 – 625 units |
3. Documentation
- Description: Photo of mold up close, Link: See ZIP File
- Description: Photo of mold on batch in curing bag during packaging, Link: See ZIP File
- Description: Photo of product in quarantine, Link: See ZIP File