Case Study: Ammonia poisoning

The majority of foodborne illnesses arise from avoidable errors—often an accumulation of many errors. In a 2002 case, school children and teachers at an Illinois public school consumed chicken contaminated with ammonia – a poisoning that resulted from the acts and omissions of three separate entities.

In 2001, the State of Illinois contracted with Tyson, a major food company, for processed chicken for school lunches. The chicken was processed at a plant in Pennsylvania. Lanter Refrigeration stored it. But Tyson’s delivery greatly exceeded Lanter’s shipping and storage capacity, so Lanter contracted with Gateway Cold Storage to house the overflow chicken products at its facility in Missouri. The chicken was stored along with large amounts of other food intended for consumption at Illinois schools.

In November, 2001, there was a large ammonia leak at the Missouri storage facility, and massive amounts of food destined for the school lunch program, including the chicken, were exposed to ammonia. Neither gateway nor Lanter notified health authorities or the Illinois State Board of Education. Even more remarkably, Gateway and Lanter continued shipping food from the facility, shipping some 800,000 pounds of product after the leak without any notice to customers. Originally, it was a shipment of potato wedges to Illinois schools that first alerted authorities. Schools began complaining of potatoes that smelled of ammonia, prompting an inquiry, and the companies admitted that a leak had occurred. The state instructed Lanter to place all food connected with the school lunches on hold, pending further evaluation.

The FDA at this time “determined to place all product stored at Gateway at time of ammonia leak on hold until procedures are established for clean up and treatment of products to dissipate ammonia odor.” But the companies decided that, rather than destroy the food and take the loss, they would re-box, re-label, and “re-condition” the boxes, and then send them on to the schools. Apparently the chicken was reconditioned to remove the smell, but nothing was done to actually remove any ammonia. Eventually, the chicken was served to students at the Illinois elementary school. Within minutes, 157 students, roughly half the school, fell ill. The scene verged on total chaos. Students and teachers were running into the halls vomiting, with their throats and noses burning. Students panicked. School administrators called in ambulances, and children were taken to five local hospitals.

Who was at fault? Virtually every entity involved – and, there were criminal charges.