An independent report has concluded the largest beef recall in Canada’s history could have been prevented, finding a "weak food safety culture" and "relaxed attitude" to safety protocol at the XL Foods plant where the tainted meat was processed.

The Independent Review of XL Foods Inc. Beef Recall 2012 report into the E. coli contaminated beef produced at the plant in Brooks, Alta., concluded there was "a series of inadequate responses by two key players."

It also found that proper sampling, analysis and response could have detected the contamination earlier and prevented tainted shipments from leaving the plant.

"We found that responsibilities toward food safety programs were not always met — by both plant staff and CFIA officials on site," the report concludes.

Special Report: The XL Foods beef recall

"We found one of the country’s largest beef processors unprepared to handle what turned out to be the largest beef recall in Canadian history."

"As the company had never conducted any mock recalls on a scale that remotely mimicked a real event, XL Foods Inc. found itself overwhelmed with the recall that occurred."

The federal government has accepted all 30 of the recommendations from the independent panel review and has begun taking action, said Agriculture Minister Gerry Ritz at a news conference Wednesday.

"In response to the report, I'm announcing the creation of new Inspection Verification Teams (IVTs). Our government will invest nearly $16 million over the next three years to establish these IVTs," Ritz said.

These 30 inspector positions, which may be staffed by existing employees or new hires, will conduct spot checks at federally inspected plants across the country.

But moving existing inspectors into the IVTs will not solve anything, said the NDP's agriculture critic Malcolm Allen adding that the report "is a damning indictment of his [Ritz's] management of the entire food safety regime."

'Significant problems'

The inspection teams are expected to be up and running later this year.

The report presents a "working hypothesis" of what happened, suggesting the outbreak began after an animal heavily contaminated with E. coli — a super shedder releasing large quantities of the pathogen — entered the plant.

"Perhaps the carcass was inadequately decontaminated or the numbers of bacteria present simply overwhelmed the processing system," the report reads.

As the contaminated carcass moved through the plant, the bacteria became lodged in a piece of equipment, and sanitation of the equipment was "inadequate." The report notes that some of the nozzles on a pasteurizer were clogged.

"It is the panel’s view that equipment maintenance and sanitation were significant problems at the plant."

The report says the recall revealed some strengths in monitoring and surveillance in Canada’s food safety system, but also found XL Foods did not follow all food safety protocols and the Canadian Food Inspection Agency should have been more rigorous in its oversight.

While XL had monitoring measures in place, it was not carrying out adequate trend analysis of the collected data or following "bracketing" procedures by removing containers of beef produced before and after ones found to contain E. coli.

The outbreak led to 18 illnesses and the largest beef recall in Canada’s history.

Similarities with Listeria outbreak

About 4,000 tonnes of beef and beef products were recalled from Canadian, U.S. and other international markets, representing at least 12,000 head of cattle, during the massive recall last fall.

The report lists 30 recommendations to strengthen the food safety system, including:

Greater emphasis on training and continuing education of CFIA inspection staff.

More enforcement of oversight responsibilities.

CFIA and Health Canada should continue to expedite the approval of interventions

The minister of health should assess the effectiveness of the agency’s activities related to its meat programs.

Stronger requirements for data analysis to stop the distribution of contaminated product.

CFIA should ensure a technical expert is available to deal with media and stakeholders.

The report also recalls the Weatherill report on the 2008 Listeria outbreak, noting similar problems of a inadequate food safety culture, a lack of co-ordinated response and resulting public confusion.

Responding to a question in the House of Commons, Agriculture Minister Gerry Ritz said the government is committed to taking action.

"Our government accepts the recommendations that the panel has made. We will continue to work on bolstering our food safety system by improving inspections, strengthening food safety and recalls, and passing things like Bill S-11," he said.

Bill S-11, the Safe Food for Canadians Act, imposes tougher penalties for activities that put health and safety at risk, strengthens control over imports, improves inspection regimes and improves food traceability.

A revised policy that comes into effect July 2, 2013, requires all slaughter and processing establishments handling raw beef to develop a program for trend analysis that takes E. coli results into account.

Last month, Ritz also announced that federally registered meat plans will be required to put new labels on mechanically tenderized beef as part of a broader food safety action plan.

It aims to warn consumers that mechanically tenderized beef must be thoroughly cooked to eliminate the risk of E. coli because the needles used can push E. coli deeper into the meat.