Canada's largest-ever beef recall at 4,000 tonnes spread across the country and most U.S. states, after the XL Foods plant in Brooks, Alberta produced beef tainted with E. coli bacteria. It came just four years after an outbreak of listeria bacteria killed 23 Canadians who ate tainted meat produced by Maple Leaf Foods.
"We found a relaxed attitude towards applying mandatory (food safety) procedures," said the report by a retired veterinarian, doctor and food safety expert. Staff employed by the plant and the Canadian Food Inspection Agency (CFIA) were at fault, the review said.
It said XL Foods, privately owned at the time, was overwhelmed, having never practised a mock recall of that scale.
The report, issued on Wednesday, found that the contamination likely occurred after an animal entered the plant and passed the bacteria onto equipment that the review said was not being cleaned adequately.
The government, which was sharply criticized for its handling of the crisis, said it will spend C$16 million ($15.5 million) over three years to establish "inspection verification teams" that conduct unannounced checks of food plants.
That move addresses one of the report's 30 recommendations, which also include better training of CFIA inspection staff.
Ottawa has already increased testing and requirements for documentation to better control E. coli, and said it will address all remaining recommendations.
The largest beef-processing plants in Canada are owned by Cargill Ltd and JBS USA Holdings Inc, which bought the former XL Foods plant after the recall.
