8. Personnel training & supervisory oversight operation
Aseptic gowning & adequacy of process design
Production System & Quality System
?
?
9. Perception is used & appropriate
investigation not done
Considered as anomalous episode that could b
prevented by implementing some minor correction
10. Upon failure, 3 consecutive lots should be
passed but they did not bother
Moving potential without knowledge that non-
sterility problem still exist was actual concern
11. Design flaw in gownng
& human interventions
were the potential
source of
contamination
Lesson