On 10 January 2025 the Food Safety and Inspection Service (FSIS) of the US Department of Agriculture released its review of a Listeria monocytogenes outbreak traced to ready-to-eat deli meats from a plant in Jarratt, Virginia (Food Safety and Inspection Service [FSIS], 2025). The outbreak sickened 61 people in 19 states (Centers for Disease Control and Prevention [CDC], 2024), killed 10, and was the largest listeriosis outbreak in the United States since 2011 (Schneider, 2025).
The case is far from Indonesia, but its pattern is familiar in many plants: the same findings appear again and again, each one is closed, and nobody asks why they keep coming back.
The lesson is not limited to food. Component, packaging and pharmaceutical plants, and large production kitchens, face the same question: does the quality system only record and close findings, or does it also learn from the pattern behind them?
What Happened
FSIS opened its outbreak investigation on 12 July 2024. The products causing illness were traced to the Jarratt plant, and on 13 September 2024 the company closed the plant indefinitely. Inspection reports from the two years before the outbreak recorded serious and unresolved hygiene noncompliances, including meat build-up and residue on food contact surfaces, mould, live and dead insects, condensation and pooling water, and rusty pipes (Food Safety Magazine Editorial Team, 2025). In one record, inspectors found meat and fat residue from the previous day's production on equipment, including packaging equipment, and condensation dripping onto exposed product (Schneider, 2025).
What the Review Found
The FSIS review examined inspection documents and the plant's sampling data from January 2022 to September 2024, together with in-person observations. It concluded that inadequate sanitation practices were a notable contributing factor in the outbreak, centred on product residue, condensation, and structural and infrastructure problems (FSIS, 2025; Food Safety Magazine Editorial Team, 2025).
FSIS also looked at its own processes. Each recorded noncompliance had been put right, but repeated insanitary conditions gave Listeria opportunities to grow or persist. FSIS therefore committed to giving its inspectors updated training and tools to recognise systemic food safety problems (FSIS, 2025; Schneider, 2025).
A Quality Lens
We read this case through the ISO 9001 requirements on nonconformity and corrective action. The standard separates two steps: reacting to a nonconformity by controlling and correcting it, and evaluating the need for action to eliminate its causes so it does not recur, then reviewing whether that action worked (International Organization for Standardization [ISO], 2015, clause 10.2). The pattern in the reports suggests the plant's system stopped at the first step. Floors were cleaned, residue was removed and findings were closed, but the sources of condensation, the building damage and the weaknesses in sanitation procedures remained.
As our own illustration, condensation dripping above a packaging line can be corrected by wiping the ceiling every morning. Corrective action only happens when the team traces why the condensation forms, for example a temperature difference between rooms or poor ventilation, fixes that cause, and then checks that the dripping has actually stopped.
The Codex general principles of food hygiene support this reading. HACCP principles call for predefined corrective actions and verification that the system works, and the revised principles place management commitment and a positive food safety culture at the base of any hygiene system (Food and Agriculture Organization of the United Nations & World Health Organization [FAO & WHO], 2022). In our view, findings that repeat for more than two years point to a management and culture problem rather than to lapses by cleaning staff.
Some limits should be stated. We read parts of the full FSIS report through its summary and media coverage, and the case sits within the US food inspection system, which differs from Indonesia's. The assessment above is our interpretation of the reported findings.
Lessons for Plants
- Trend audit and inspection findings by area and type every month; the same finding three times is a system problem, not a daily cleaning problem.
- Separate correction from corrective action on the nonconformity form, and require root cause analysis for repeat findings (ISO, 2015).
- Put facility repairs, such as condensation sources and cracked floors, into the maintenance budget, not only into the cleaning schedule.
- Verify sanitation effectiveness with data, such as environmental monitoring for pathogens, not just visual checks.
- Take repeat findings to management review, because food safety culture starts with leadership commitment (FAO & WHO, 2022).
Nusa Safety helps companies test how well their quality systems work through an ISO gap assessment and internal audit and builds integrated ISO management systems that link findings, corrective actions and management review. To trace the root causes of repeat findings, the Nusa Safety team runs incident investigation and root cause analysis training, with internal training certificates.
This article is general information and not legal or professional advice for any specific case.
References
- Centers for Disease Control and Prevention. (2024). Listeria outbreak linked to meats sliced at delis. https://www.cdc.gov/listeria/outbreaks/delimeats-7-24/investigation.html
- Food and Agriculture Organization of the United Nations, & World Health Organization. (2022). General principles of food hygiene (CXC 1-1969). Codex Alimentarius Commission. https://www.fao.org/fao-who-codexalimentarius/codex-texts/list-standards/en/
- Food Safety and Inspection Service. (2025). Review of the Boar's Head Listeria monocytogenes outbreak. U.S. Department of Agriculture. https://www.fsis.usda.gov/news-events/publications/review-boars-head-listeria-monocytogenes-outbreak-january-2025
- Food Safety Magazine Editorial Team. (2025, January 13). USDA considering more changes to Listeria rule, RTE sampling after Boar's Head outbreak review. Food Safety Magazine. https://www.food-safety.com/articles/10053-usda-considering-more-changes-to-listeria-rule-rte-sampling-after-boars-head-outbreak-review
- International Organization for Standardization. (2015). Quality management systems - Requirements (ISO Standard No. 9001:2015). https://www.iso.org/standard/62085.html
- Schneider, C. M. (2025, January 11). USDA report finds Boar's Head listeria outbreak was due to poor sanitation practices. NPR. https://www.npr.org/2025/01/11/nx-s1-5256921/boars-head-listeria-outbreak-usda-investigation
