It was a 50th wedding anniversary and the family was counting their blessings that the catering centre had agreed to book them into an already full weekend service – allowing for a family gathering on late Sunday afternoon to celebrate. Little did they know that the sliced turkey being served was going to poison them leading to one of them to die.

It’s a sad story and yet despite all the advances in food preparation technology, all the precautions taken in a professionally managed catering kitchen, events like these do occur. This is a story that is rarely told – not a story of the young server who was fired for her culpability in this incident – not a story of the organization that floods the local news with their ‘safety-first’ messages to reassure the public that this one-off event would and could never happen again – but a story of how disaster stepped into a gap of a well-tuned working kitchen – and this is the story that offers a most interesting perspective on work.

We talk about well-being and human performance as if they are separate entities, separate from the context and situation in which they operate, but when we go through life – in the moment of performing work, we have a weaving together of many factors that is mostly unconscious. Usually outcomes are good – only in hindsight do we draw a seemingly direct and linear path to destruction. Going forward through life is not always obvious what we need to do. Often we are overloaded with information and possibilities and we do not go through choices rationally. We operate heuristically, on automatic most of the time, unconsciously influenced by the past and present, by the landscape, by culture, by the atmosphere, by experience and expertise.

People adapt their actions given the context at hand and this is part of the normal performance variability that takes place as part of normal work - making foresight of the successful path more difficult to discern than we give credit for in hindsight.

To understand why people do what they do, we need to find out why people‘s actions and assessments made sense to them at the time; rather than identifying retrospectively what rule, protocol or process the person violated. I weave through this story the cognitive, affective, social, physical and organisational aspects of working in a catering kitchen to see what we can learn about work.

Kate asked her boss Ben, the Supervisor on shift, to leave the premises in order to arrange for childcare that would be needed on the following day – an added shift for Kate who was assigned to the Salon B team. Normally Salon B, the smaller of the 5 salons was empty on a Sunday afternoon, but this family anniversary event for 15 people was added the Thursday beforehand and so Kate had to scramble to find workable childcare – relying on friends and family to help out. So Saturday afternoon, as per the cook plan, the turkey was removed from the oven, and placed on the counter for cooling before slicing.

To leave a cooked turkey (or roast or chicken for that matter) on the counter is not only a food-safe practice, it usually signalled break time for workers who were freely able to use this time as their own – usually lunch – as the cooldown period passed. Catering event workers were assigned to a single menu and not required to switch over to food prepping for another menu. Since there were 5 salons and a hotel full of guests, the kitchen was always busy but the catering event workers were assigned into teams to prepare and serve to a particular salon. Workers thought it was a bonus – they could work with different people, but once assigned they knew that if they worked hard and gave a good service, they were also entitled to share in any tips provided. So most workers were happy to time their lunch with natural pauses in the cook plan. This time, Kate wanted to leave the premises and thought she better run it past the Supervisor, who agreed.

The Supervisor, Ben, was full time staff with the hotel catering company and worked 5 days a week supervising all of the salon (catering) work. Ben was a hopeful chef and he would receive food plans from the head chef and help pull the team and food together. Having 5 salons to supervise meant he was very busy but he had trained and experienced staff and the teamwork made it easy for him to administer the cook plans for each team and then be a helpful supervisor. Everyone liked him, he was helpful and supportive and Ben knew Kate took on the extra Sunday shift because she needed the money and so he wanted her to be able to work this shift. Besides he figured a two hour cooldown period would provide ample time for Kate to make childcare arrangements as well as have some lunch before returning to complete the turkey slicing. Two hours on the counter was a perfectly acceptable food-safe plan.

So Kate followed the turkey cook plan. Kate was not only a food server working in the catering centre but also single mother who lived nearby with family and friends all from the local area. She was well liked and involved in her child’s school by participating in his soccer coaching and games. Kate was also taking hotel management courses hoping to have a career in the hospitality industry, perhaps becoming supervisor herself one day soon. For now, working her 4 shifts weekly at the catering centre was ideal for her balance of work and home life. The hotel ran their kitchens with all the cook support teams on shifts. That way they could keep a full complement of workers and still provide flexible working hours. There were 3 full time supervisors who worked to supervise all the cooking and ensure a fair distribution of ovens and grill space, counter space and tools as needed. Supervisor would also oversee service to ensure customer satisfaction. Ben, Kate’s supervisor was one of these. There was one head chef who was responsible for receiving requests for banquets and preparing meal plans as well as a sous chef who would procure the food stuffs for the centre and work with the chef to create the meal plans. This was in addition to the hotel restaurant staff who operated under a different management and food plan structure. It was a very busy hotel basement place with 20 people in total, some full time, some on shifts, like Kate.

Kate returned after one and a half hours, becoming late due to traffic unexpectedly being diverted because of water main leak. Ben greeted her as she re-entered the kitchen. She washed her hands and began to finish processing the turkey. She sliced the turkey directly into the chafing dishes which would be used in the catering service the next day. She completed the slicing, perfectly filling 4 chafing dishes and promptly covering them and storing the chafing dishes into one of the refrigerators. And then she completed her shift preparing the stuffing while the rest of her team were completing their vegetable, bread and deserts and prepping the room with tables and set-up. Clean-up and prep for the next day were all completed and everyone enjoyed their evening.

What no one knew was that the turkey, despite being cooked to plan, was actually undercooked. Unbeknownst to the kitchen staff, the bird's internal temperature hadn't reached the necessary threshold to eliminate harmful bacteria. Salmonella was present in the turkey. Five hours (45 minutes at 425F and then 4 hours and 15 minutes at 350F with regular basting) had not managed to fully bring to a safe temperature this large turkey. The chef had prepared a menu to feed a family of 15 people, and this one large frozen turkey was chosen from the freezer. The turkey was removed from the freezer to thaw in the fridge the day before and the menu was designed. Ben the Supervisor on shift created the cook plan the day before (Friday) and oversaw it as it was carried out on Saturday. Kate followed the cook plan.

Interestingly, written cook plans never include a meat thermometer check. It was an occasional thing to check cooked meat with a thermometer. The Supervisor was responsible for calculating size, temperature and time to create the cook plan that would also coordinate all the salon cook plans for the 3 ovens available. The Supervisor would check all outcomes from the oven but it was not verified with a temperature check unless it appeared to be doubtful for some reason. In this case the turkey was deceptively browned and appetizing and in Ben’s 10 years of experience, the turkey looked cooked. Besides, there had never been a food poisoning at the Centre in its 18 year history.

The next day, Sunday at 3 pm, service began for Salon B. Kate brought out the chafing dishes from the fridge onto the heated bases. Although the cook plan did not specify the turkey to be reheated in the oven first, this was a practice that was often followed as meat already sliced would be reheated before being served in the warming dishes – but given the additional service on this day, all ovens were busy. No one on the team, not even Ben the Supervisor found any fault with that - Ben was aware of the turkey cook plan and knew that the full five hours had been dedicated to this turkey. So as a team they tacitly agreed and placed the cold sliced turkey directly into the heating trays for service. The potential disaster was sealed when the undercooked turkey was put out for the eager customers. Service began and it was a lovely meal, the family was very happy and a good sized tip was divvied up amongst the team.

Unfortunately two days later, when Kate was on her regularly scheduled days off the hotel received word that 5 of the family members had gotten ill and one senior person passed away and the hospital deemed it was likely a food poisoning that had been traced back to the Salon B meal. Public health was on their way. After their investigation, Kate, who was assigned to the meat cook plan and service for this family was deemed responsible and was fired. Ben, her supervisor was given a stern warning and a note placed in his personnel file for not supervising closely enough. The incident served as a sobering reminder of the importance of diligence in the culinary world, highlighting that even in the most esteemed kitchens, mistakes can have far-reaching consequences.

Despite automation, people are still often assigned the task of checking and monitoring – as in using a probe to check the temperature of meat. This keeps human behaviour and decision making at the forefront of safe operations – and in the bullseye when things go wrong. Learning offers us operational improvement which is more sustainable than blaming. We can draw many lessons from this story, but these three I leave for you to consider:

1. What are your critical tasks? If you can’t answer that question then you need to analyse the work. Make critical tasks to be task dependent – the food does not move onto the next stage until the meat temperature has been checked, for example. Making critical tasks transparent and auditable also aids in compliant behaviour. For example, post a document next to each oven where the meat temperature, date and time must be recorded;
2. Work-as-done, work-arounds, and human performance are influenced by factors outside the individual. Groups, for example, influence individual behaviour through social norms, belonging, desire for approval, etc. Despite individuals being trained in their responsibilities such as their safety obligations, safety science consistently shows individuals adapt to the work culture and act in alignment with social expectations despite having knowledge of safer alternatives. Organizational factors also influence actions and choices, and in this case a scarcity of resources (not enough ovens to cover a customer commitment) pushed the decision to not re-heat the sliced turkey to a safe temperature past the safety boundary. In this team setting, having a likeable supervisor likely made the decision more difficult to challenge;
3. We tend to place the burden of failure onto the shoulders of the individual who is closest to the work – but the dynamics of delivering a service needs integrated, adaptable processes and communication flows across the working network. Beyond the obvious staffing needs, how are last minute customer requests planned and communicated across the team responsible for menus and service? We often ask for customer feedback, but what types of internal communication flows can close task gaps and help people adapt to social or organisational pressures? The dynamics of delivering a service reliably and safely needs weavers not automatons; a landscape that nourishes learning and improving, not a dry bed of hot heads.

These are just a few learnings drawn from human factors and system safety – they point to knowing the work, understanding why people do what they do, and an organisational landscape that enables people to adapt to match the dynamics of the work situation.