L37 CASE STUDY -- CONSTRUCTED                               Label: No AI
Every person, business and number in this case is invented. It is not
based on any real incident.
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THE SPRING ALLERGEN GUIDE

Fairmead Food Co-op supplies baked goods and ingredients to 41 member
cafes. Every spring it publishes an Allergen Guide: one table listing
each of its 340 products and which of the major allergens each contains
or may contain. Member cafes use the guide to label what they sell.

Here is what happened, in order.

1. THE SUPPLIER CHANGES ITS SHEET (14 February)
   Hollins Bakery, one of Fairmead's suppliers, starts making its seeded
   rye roll on a line that also handles sesame. It updates its product
   specification sheet the same day. The main allergen box still reads
   "Contains: wheat, rye". A new footnote at the bottom of the sheet reads
   "May contain: sesame (shared line from 14 Feb)". Hollins emails a
   change notice to Fairmead's general inbox, as its contract requires.

2. THE INBOX (15 February)
   Dana Price, Fairmead's office administrator, handles the general inbox.
   The written procedure says supplier change notices are saved to that
   supplier's folder on the shared drive. Dana saves the notice and the
   new sheet to the Hollins folder. The procedure does not say to tell
   anyone else, and nobody has ever asked her to.

3. BUILDING THE TABLE (3-7 March)
   Ines Varga, the product data coordinator, builds this year's table.
   In past years this took her three weeks by hand. This year she uses an
   AI assistant approved by Fairmead for internal documents: she gives it
   all 340 current specification sheets from the shared drive and asks it
   to fill the allergen table. It finishes in an afternoon.
   Ines checks 20 rows chosen at random against the source sheets. All 20
   are correct. She records in the process note: "Generated with the
   approved assistant from current sheets on the shared drive; 20-row
   random sample checked, 0 errors." She does not know about the Hollins
   change; the Hollins roll is not in her sample.
   For the Hollins seeded rye roll, the table reads: wheat, rye. The
   assistant used the main allergen box and did not carry over the
   footnote.

4. QUALITY REVIEW (10 March)
   Marcus Lee reviews the table against Fairmead's quality checklist:
   every product present, every allergen column filled, product codes
   match the catalogue, formatting correct. Everything passes. The
   checklist was written years ago for a table typed by hand from the
   sheets, and does not ask the reviewer to compare entries to sources.
   Marcus reads Ines's process note and signs the checklist.

5. SIGN-OFF AND PUBLICATION (12 March)
   Priya Anand, operations manager, receives the table with Marcus's
   signed checklist and Ines's process note. Both look complete. She
   signs the guide for publication. It is emailed as a PDF to all 41 cafes
   and printed copies are posted to them on 13 March.

6. AT THE CAFE (2 April)
   Tom Reyes owns one of the member cafes. He uses the guide, as he has
   every year, to update the allergen cards on his counter. The card for
   the seeded rye sandwich lists wheat and rye. A customer with a sesame
   allergy asks staff about sesame; staff check the card and say there is
   none. The customer has an allergic reaction, is treated, and recovers.
   The customer complains to the cafe; Tom contacts Fairmead.

7. AFTERWARDS (3 April)
   Fairmead finds the footnote on the Hollins sheet within an hour. A
   corrected guide goes out the same day. Fairmead does not know how many
   other cafes have already printed cards from the old guide.
