I have thought a lot over the last 20 years about what lessons can be drawn from the tragedy that was the 1993 Jack in the Box E. coli O157:H7 outbreak. Knowing the children—many who are now nearing 30—who still bear the scars of eating a hamburger, and knowing the parents of those who died, makes it difficult for me to see the benefit of those losses. My first reaction is, “why does it always seem to take a tragedy before we seem to be able to act?” Whether it was reinforcing cockpit doors after the horror of 9/11, or now finally having a dialogue about automatic weapons post-Newtown, we have seemed nearly incapable of preventing a tragedy before it has happened multiple times, or with such force that ignoring it any longer is impossible. Frankly, not being able to look ahead to prevent disasters seems so ingrained in human DNA that I am not sure of a ready fix. Human evolution aside, I think there are lessons that can be learned from Jack in the Box that have meaning in the food safety world both in the past and in the future. First, like all food safety failures, and the outbreaks that stem from them, the Jack in the Box outbreak was completely preventable—in other words, Jack in the Box had warnings enough to have prevented the outbreak. And second, after the outbreak there will always be facts—and documents—that prove it. In March of 1992 the Washington State Board of Health mandated that the internal cook temperature for ground beef should be 155 degrees, not the 140 degrees that all other of the 49 states used based on the Federal Food Code. Washington was ahead of the curve because health officials had investigated an earlier outbreak linked to undercooked ground beef. Officials reached out to all restaurants in the State with the new standards. Although Jack in the Box leaders initially claimed that they knew nothing of the changes—and perhaps they did not directly—but the new standards were found in files in corporate headquarters in San Diego. Finding the Washington State Food Code in the bottom drawer of a cabinet was certainly not the best “find” in the litigation. Far from it; a bit of context might be in order. Although the outbreak was announced in mid-January 1993, aggressive litigation and discovery did not really commence until late 1993. It lasted through the end of 1994. During that time, I received nearly 50 boxes of paper from the lawyers representing Jack in the Box and its meat suppliers. From those documents and the dozens of depositions taken, it became clear that Jack in the Box had more than just the new cook temperatures in its desk drawer. Scattered (on purpose) within the boxes were documents that showed that Jack in the Box knew of the new cook-temperature guidelines and simply chose to ignore them. On June 18, 1992—five months before the Jack in the Box E. coli outbreak struck its hometown of San Diego and seven months before it would hit the Pacific Northwest—Wendy Cochinella, the shift leader at the Arlington, Washington Jack in the Box restaurant faxed the below “IN THE SUGGESTION BOX” to Jack in the Box corporate headquarters in San Diego: She wrote,
I think regular patties should cook longer. They don’t get done and we have customer complaints.
If we change this we will be making our burgers done and edible.
After just over a month, Wendy (and most of the Jack in the Box food safety team) received the below response from corporate headquarters. Wendy also received a pen highlighter (I always thought they should have made her at least Vice-President): It read:
We have received your suggestion regarding increasing the cook time for our regular patties.
Your suggestion is currently being researched within the corporate offices. You will again be notified with more detail as soon as a decision has been made regarding this suggestion.
We would like to acknowledge the time and effort you have taken to contribute to the success of JACK IN THE BOX by enclosing this pen/highlighter. Each person submitting suggestions is eligible to receive one gift per quarter with their first suggestion.
But, it did not end there. No, Jack in the Box wanted to see if they could make “[their] burgers done and edible.” What they found in their corporate kitchen was that sometimes they could reach internal temperatures of 155 degrees and above on new grills with the two-minute cook time, but often—too often—internal temperatures of 140 degrees or below were reached on older grills with the two-minute cook time. E. coli O157:H7 bacteria can survive at 140 degrees for two minutes, but not at 155. So, what was the response? Yes, you guessed it, the two-minute cook time was more important than having “burgers done and edible.” Wendy’s next communication from corporate headquarters indicated that a cook time longer than two minutes made burgers “tough.” Wendy and the Jack in the Box food safety team received the following communication from superiors:
We have researched your suggestion and determined that with the variability of our grill temperatures (350° – 400°) the two-minute cook time is appropriate. If the patties are cooked longer than two minutes, they tend to become tough. To ensure that you are meeting quality expectations for regular patties, please ensure that the grill temperature is correct and grill personnel are using proper procedures.
And, as they say, the rest is history—a tragic history. Weeks after the outbreak was announced Jack in the Box changed the cook time from two minutes to two minutes and fifteen seconds – yes, fifteen seconds.