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The 2008 Chinese melamine milk scandal resulted in six reported fatalities and affected around 300,000 children, of whom 54,000 were hospitalised. Previous studies have used linear approaches to examine the root causes of the melamine milk scandal.

In the present study, we applied a systems approach to the melamine milk scandal to identify the complex systems-level failures across the supply chain leading to the incident and why food fraud incidents such as this occurred in the dairy sector. Additionally, systemic failures associated with food fraud vulnerability factors were considered (i.e. opportunities, motivation and control measures).

48 contributory factors of influence were identified and grouped across six sociotechnical levels across the Chinese dairy system, from government to equipment and surroundings. Lack of vertical integration (processes and communication) contributed to the failure. When viewed from a broader perspective, the melamine milk scandal can be linked to a series of human errors and organisational issues associated with government bodies, the dairy supply chain, individual organisations and management decisions and individual actions of staff or processes.

This approach is of value to policymakers and the industry as it supports public health investigations of food fraud incidents and proactive food safety management.

To the best of our knowledge, this is the first study to analyse a food safety or fraud incident using the AcciMap approach and the food fraud vulnerability assessment (FFVA) technique. AcciMap analysis is applied to both unintentional and intentional aspects of the incident.