Volume 5: Animal Health, 1989-96
4b. Implementation, enforcement and monitoring of the animal SBO ban: discussion
Why was the animal SBO ban not effective?
(i) Potentially infective material not covered by the ban
(ii) Failure cleanly to remove SBO from matter which went into the animal feed chain
(iii) Tissues designated as SBO were incorporated in animal feed despite the ban

4.605 We have identified a number of reasons why the animal SBO ban failed to keep infectious material out of the animal feed chain:

1. The ban did not cover all potentially infective material.
2. SBO was not cleanly removed from matter which went into the animal feed chain.
3. Tissues designated as SBO were incorporated in animal feed despite the ban.

We shall consider each in turn.

(i) Potentially infective material not covered by the ban

Bovine eyes

4.606 Bovine eyes were recognised as having high potential infectivity - hence the recommendation that the eyeball should not be dissected in schools (see vol. 6: Human Health, 1989-96). They were not included in the list of SBO because industry advised that they were not used in the production of food for human consumption. ¹ The practice of removing the brain from the skull and then sending the skull for rendering as BSE-free material had the result that bovine eyes were included in the material rendered for animal feed. This position persisted until August 1995 when the removal of the eyes was prohibited by the Specified Bovine Offal Order 1995. ²

Obvious nervous and lymphatic tissue

4.607 By Decision 90/200 as amended by Decision 90/261 the European Commission prohibited the UK from exporting boneless beef unless it was certified to be:

Fresh meat from which during the cutting process obvious nervous and lymphatic tissue has been removed. ³

4.608 Ministers agreed that the Decision ought to be implemented administratively by issuing guidelines rather than by legislation, a decision which is discussed in vol. 6: Human Health, 1989-96, Chapter 4. Accordingly, obvious lymphatic and nervous tissue were not included in the definition of SBO.

4.609 There would also be lymphoid tissue not normally removed because it was associated with organs (eg, lungs) not normally used for human consumption.

4.610 Although mouse and calf bioassay has not to date detected infectivity in any lymphoid tissue, it is possible that these tissues were a source of infectivity in MBM.

Thymus and intestine of calves

4.611 Offal from calves under the age of 6 months was initially excluded from the human and animal SBO bans on the basis that it was not likely to be infective. In June 1994 infectivity was detected in the distal ileum (small intestine) of calves subject to the pathogenesis experiment within six months of having been fed BSE-infected material. This led to an extension of both the human and animal SBO bans to include the thymus and intestines of calves aged between 2 and 6 months (see paragraph 4.389 above). It is possible that these tissues may have carried infectivity into animal feed before this extension was made.

Dorsal root ganglia

4.612 This peripheral nervous tissue was liable to be left attached to the spinal column when the spinal cord was removed. Spinal columns went to be rendered to produce MBM for supply to manufacturers of animal feed (see vol. 11: Industry, Processes and Controls). Thus dorsal root ganglia would have been a source of MBM used for animal feed. Results of the pathogenesis experiment have now shown dorsal root ganglia to carry high infectivity (see vol. 2: Science). This, then, was a further potential source of infectivity in MBM that was sold for animal feed.

Tallow and gelatine

4.613 Tallow contained traces of protein. Thus tallow derived from SBO material contained traces of SBO. When derived from cattle it contained traces of ruminant protein. Gelatine, when derived from cattle, contained ruminant protein. Both were incorporated in cattle feed. ⁴

Conclusions on potentially infective material not covered by the ban

4.614 We do not suggest that anyone is to be criticised for failure to appreciate the potential infectivity of thymus and intestines of calves and dorsal root ganglia. This was, of course, primarily of importance in the context of precautions to protect human health and these issues receive consideration in vol. 6: Human Health, 1989-96. The exclusion of obvious nervous and lymphatic tissue from the animal SBO ban appears to have been an oversight. So too was the exclusion of tallow and gelatine. The consequences will have been relatively insignificant compared to those of the incorporation of SBO in animal feed, which we are about to consider, and we have not explored the extent to which any particular individuals are responsible for that oversight.

(ii) Failure cleanly to remove SBO from matter which went into the animal feed chain

Brain

4.615 In a draft submission to the Minister dated 31 March 1995, Mr Howard explained that head-boning plants removed the brain from the skull so that the latter could be disposed of at a cost of £30 per tonne, rather than £60 per tonne payable if the brain was retained and the entire skull had to be disposed of as SBO. He added:

Complete removal of the brain is difficult. To remove the brain the skull has to be opened and sharp edges are formed at the opening. The brain is scooped out by hand but since it is friable and firmly attached, in parts, to the interior of the skull, the brain can break up and is removed in pieces. There is a risk that skulls still containing brain tissue may be rendered into meat and bone meal and subsequently incorporated into animal feedingstuffs. ⁵

4.616 We believe that remnants of brain in skulls sent for rendering as SBO-free material are likely to have made a significant contribution to the contamination of MBM with the BSE agent. The practice of removing the brain was prohibited by the Specified Bovine Offal Order 1995. ⁶

Spinal cord

4.617 In vol. 6: Human Health, 1989-96 we have described the risk to human health consequent upon failure cleanly to remove the whole of the spinal cord from the spinal column, and the additional risk posed by dorsal root ganglia. The presence of these in spinal columns sent for rendering was a further possible source of contamination of MBM produced for animal feed. This risk was particularly marked in those cases where knacker's yards attempted to remove spinal cord, with a view to disposing of the spinal column to renderers at the lower rate payable in respect of SBO-free material (see paragraph 4.61). This practice was prohibited by the Specified Bovine Offal Order 1995. ⁷

Conclusions on lack of clean removal of SBO

4.618 The delay in addressing these potential sources of contamination of animal feed was, we believe, a consequence of the failure to appreciate (i) the small amount of infective tissue capable of oral transmission of the disease and (ii) the importance of the SBO ban in helping to prevent the infection of cattle. These are matters dealt with in detail later in this chapter.

(iii) Tissues designated as SBO were incorporated in animal feed despite the ban

4.619 We have seen in this chapter how, from the introduction of the animal SBO ban, informal reports were received from time to time indicating that SBO was being delivered to and processed by renderers as if it was matter that was fit for incorporation in animal feed. The first hard evidence of the extent to which this was happening was Mr Fleetwood's impromptu telephone survey in July 1994 (see paragraphs 4.346 to 4.350 above). This suggested that SBO was going astray on a large scale. His rough and ready calculations showed a shortfall of over 400 tonnes on the total of some 1,200 tonnes of SBO that he calculated should, on average, be being collected each week for disposal. ⁸ In the following year further evidence supported the conclusion that this was indeed the scale of the shortfall that was taking place.

4.620 In 1995 Unichema, an oleochemical company, was the only processor of tallow derived from SBO. Their purchasing department informed Prosper De Mulder that their calculations indicated that they were seeing less than half the amount of tallow derived from SBO that they would have expected to see. ⁹

4.621 Further indications of SBO entering the animal feed chain were obtained as a result of the national surveillance of slaughterhouses organised by Mr Fleetwood in and after July 1995 (see paragraphs 4.485ff above). Of particular significance was the increase of 100 per cent or more in SBO being presented for rendering that followed this surveillance and the enforcement campaign conducted by the Meat Hygiene Service (MHS) (see paragraph 4.534 above).

4.622 We have concluded that SBO came to be incorporated in MBM that was sold as an ingredient for animal feed both by accident and by design.

Accidental admixture or cross-contamination

4.623 We shall consider shortly whether there was any legal requirement to keep SBO separate from other material, unfit for human consumption, which was going to be rendered. Whether or not they were legally required to do so, slaughterhouses, renderers and, to some extent, knackers, followed a policy of keeping SBO separate from other material. This practice had its origin in the voluntary SBO ban imposed by the United Kingdom Agricultural Supply Trade Association (UKASTA), though at that stage it was by no means universal. In February 1990 Mr Foxcroft stated that about 25 per cent of Prosper De Mulder's customers did not require SBO-free meal. ¹⁰ Once, however, the animal SBO ban had come into force, slaughterhouses were constrained to separate SBO from other material, as their contractual arrangements with renderers required the two to be distinguishable.

4.624 Renderers, for their part, were contractually required to keep SBO separate from material which they were rendering for on-sale to feed compounders on terms that it should be free of SBO (see Chapter 3).

4.625 There was scope for accidental admixture or cross-contamination at all stages: in the slaughterhouse, in transit vehicles, at collection centres and at renderers. The difficulty of distinguishing visually between SBO and other material, once in a container and in the course of decomposition, was demonstrated to us in the course of the Inquiry by Mr Fleetwood, with the aid of a particularly repulsive slide show. He showed us how, after 48 hours, offal that is in a skip or a bin will sink below a 'level of disgusting liquid'. ¹¹ When commingled in the absence of stain it is almost impossible to tell whether it does or does not contain SBO. ¹²

4.626 Staining was not, of itself, a satisfactory means of identifying SBOs, for the stain that had to be used was the same stain that the 1982 Meat (Sterilisation and Staining) Regulations (MSSR) 1982 required to be used for carcass meat and specified offal other than SBO.

4.627 Mr Brian Rogers, Chairman of the United Kingdom Renderers' Association (UKRA) since 1994, told us of his experience of accidental admixture:

In my experience material got mixed both ways. This rather goes against the suggestion of deliberate flaunting of the rules. I certainly saw plenty of examples of SBO being in with clean material, but I also saw clean material in with SBO, which was disastrous from the abattoir's financial point of view, but this occurred on plenty of occasions. ¹³

4.628 Cross-contamination at the renderers was a particularly acute problem. We shall consider the efficacy of the Code of Practice that UKRA introduced in an attempt to meet this problem. At best, however, as Mr Fleetwood told us, it was not an adequate precaution to preclude infectivity that could be carried by a single gram of material. ¹⁴

Passing off

4.629 While some admixture of SBO with clean material will have occurred inadvertently, we are satisfied that some slaughterhouses deliberately passed off SBO as 'clean' material. Equally we think it likely that some renderers will have yielded to the temptation to render as 'clean' material, material that they knew consisted of or contained SBO.

4.630 That temptation was considerable. As Mr Howell remarked in his letter to Mr Scott (see paragraph 4.284 above) there was often a substantial difference in price between the SBO product and the non-SBO product.

4.631 So far as slaughterhouses were concerned, offal which was not SBO was a by-product of their operations which could be sold to renderers. SBO was waste which they had to pay to have removed and processed. The temptation to include a portion of SBO within a container of offal for which they were being paid must have been very considerable. It would be surprising if some did not succumb, particularly as we were told that many were operating on the margin of profitability.

4.632 Renderers, equally, were faced with the contrast between MBM produced from SBO, which had to be disposed of by incineration or landfill, and MBM produced from other offal, which could be sold. Prosper De Mulder expressed concern to MAFF that some renderers would not be scrupulous in identifying SBO, particularly if it arrived unstained (see paragraph 4.350). We suspect that this concern was justified.

4.633 From March 1990 the major feed companies stipulated that MBM should be free from fallen stock. ¹⁵ Thereafter, knackers had to pay to have offal removed by renderers. They had, however, to pay at a higher rate for SBO than for other material, and some, at least, purported to separate the two. Once again, knackers had an incentive to pass off SBO as non-SBO material.

4.634 A number of witnesses gave evidence of their belief that SBO was deliberately passed off as 'clean' material. Mr Rogers, whom we quoted earlier as giving evidence of accidental admixture, added subsequently:

I have said accurately that I have seen examples of clean material being consigned with SBO. By far the majority of incorrect allocation was in the other direction. It does indicate that it was not all deliberate; that there was some sloppiness. ¹⁶

4.635 Mr Peter Carrigan is an animal by-product contractor, whose business involved taking over the gut rooms of slaughterhouses under what he described as 'a turnkey job'. ¹⁷ He had assisted Mr Lawrence with advice and Mr Lawrence had been impressed by his expertise. In his witness statement he spoke of correspondence evidencing:

. . . people cheating. There were not proper audits and MAFF and the Meat Inspectors were barely interested in appropriate controls being applied at the abattoirs. ¹⁸

4.636 In a letter to Mr Lawrence of 12 December 1990 he commented:

I am sorry to have to report that the rules on staining are being grossly flouted and there are areas which require your very urgent attention. ¹⁹

4.637 He explained to us that he was referring to people not staining, and hiding proscribed material with fit material destined for the animal feed chain. ²⁰

4.638 Mr Fleetwood told us of an instance where a slaughterhouse was found to have deliberately concealed bovine intestine in bins of best fat. ²¹

4.639 These instances were but straws in the wind. We would not have expected in this Inquiry to receive a host of examples of incidents of fraudulent practice which was going undetected. We are satisfied, however, to adopt language used in relation to staining by Mr Fleetwood, that there was 'flagrant and widespread' disregard of the requirement to keep SBO separate and identifiable from other matter that was essential if the animal SBO ban was to be effective. ²² The extent to which this involved breaches of the regulatory requirements we shall consider shortly.

Conclusion on incorporation of tissues designated as SBO

4.640 There was a widespread failure to keep SBO separate from other matter. The result was that the object of the ban - to keep SBO out of all animal feed - was not fully achieved. We examine later in this chapter whether any individual should be criticised for this failure.