Page 1 f 10 DOLI 6 Summary f Evidence Hamiltn City Cuncil Re: Fatal Tiger Attack n 20 September 2015 Samantha Lynda KUDEWEH File: 5582962 Intrductin Hamiltn Z Curatr, Samantha Lynda KUDEWEH was killed by male Sumatran tiger Oz, when she entered ne f the z s tiger enclsures while he was still able t access the enclsure. Facts Parties Hamiltn City Cuncil ( HCC ) The emplyer. The HCC is respnsible fr staffing and resurcing at the z and cntrls such things as budgets and recruiting. Hamiltn Z Owned by the Hamiltn City Cuncil, the Hamiltn Z cvers 25 hectares (62 acres), and is situated n Brymer Rad in the Hamiltn suburb f Rtkauri. The z was funded in 1969 as the Hilldale Game Park and has grwn in size and nw huse s a large number f extic animals including White Rhincers and Sumatran tigers. Samantha Lynda KUDEWEH (nee STEPHENS) First emplyed by the HCC in 2005 as Team Leader Mammals, Mrs KUDEWEH came with extensive experience having already wrked at the Auckland Z, Melburne Z and with varius wildlife prjects in Thailand and Suth Africa. Mrs KUDEWEH held a degree in Zlgy and was heavily invlved in the Australasian White Rhincers breeding prgramme. She became Z Curatr in September 2012 and had ver 20 year s zlgical experience. The Event On Sunday the 20 th f September 2015, Mrs KUDEWEH was at her place f emplyment, the Hamiltn Z. As Z Curatr, Mrs KUDEWEH wrked every third weekend as part f the z rster and wuld ften cver the rle f tiger/ carnivre keeper due t her experience. Nt all keepers are qualified t lk after the Sumatran tigers. As part f her duties, Mrs KUDEWEH was required t feed the tigers, cheetahs, wild dgs and a number f ther animals n the carnivre run. While Mrs KUDEWEH was perfrming these feeding duties, a trrential dwnpur and hail strm passed ver the Waikat area. As she was wrking n her wn at the time, the fllwing events are speculative and are based n dcumented prcedures. It appears that Mrs KUDEWEH placed the tiger s meat in the feed flap lcated in the Refer t attached Emplyment Agreement Refer t attached Emplyment Agreement and wrk histry. -9(2)(a) Page 4,5 page 2 Refer t NIWA data n rainfall 20/09/2015 DOLI 6 Summary f Evidence Versin 1.1 1/2006
Page 2 f 10 ff-display enclsure and carried n t the Cheetah enclsure. While there, she spke with Rhincers Keeper by radi and discussed the dwnpur and the affect it was having n the z. A shrt time later, after several attempts t cntact Mrs KUDEWEH, Ms drve t the tiger enclsure and lcated Mrs KUDEWEH deceased inside the main enclsure. Oz, the z s male Sumatran tiger, wh weighs 137 kilgrams, was sitting next t her. Mrs KUDEWEH was fund t have injuries that were cnsistent with a tiger attack. Investigatin Emergency Services were called and Wrksafe New Zealand was ntified by Plice. Inspectr Jasn GIBSON attended the scene and liaised with Plice CIB staff. The scene was visited and details recrded and phtgraphed. As the scene was still cnsidered a crime scene at that pint, limited access was granted t Wrksafe NZ until Plice had established n ful-play had ccurred. It appeared that Mrs KUDEWEH had entered the main enclsure thrugh the keeper gate with the intentin f cutting bamb fr the Red Panda s. This was evident by the presence f a pair f lppers lcated next t a clump f bamb situated several metres inside the enclsure. T cut dwn n feeding csts, the z wuld ften use its wn vegetatin as fdder. The keys t the gate were hanging with the padlck n the inside f the gate which is z plicy; this indicates that a keeper is present. Her unifrm cap and prtable radi were lcated n the grund clse by. It appeared that the impact f the tiger s attack had flung the items away fr 2 3 metres. Drag (heel) marks were bserved leading away t where Mrs KUDEWEH s bdy was lcated; a distance f apprximately 10 metres frm her equipment. Plice prvided Wrksafe NZ a cpy f their Sudden Death file fur days later. Analysis There are a number f factrs t be cnsidered in this case. These are: Keeper experience, Prcedure, Enclsure, Other factrs, i.e. weather, wrklad etc. 1. Keeper Experience: Mrs KUDEWEH was the z s senir tiger keeper and had played a majr rle in the breeding prgramme which resulted in the birth f tw tiger cubs t female Sumatran tiger, Sali. She had trained all f the ther tiger keepers at the z and with twenty years experience, was cnsidered ne f the cuntry s tp keepers, in particular with tigers. In her rles as Team Leader and Curatr, Mrs KUDEWEH had written a number f plicies fr the z. Inexperience therefre des nt appear t be a factr. 5582962/01 Page 2, 3 Refer t Plice Pl 47 Reprt fr Crner frm Refer t Investigatin Lg - GIBSON 5582962/02 Page 20 5582962/03 Refer t Plice Sudden Death File Page 11 Refer t tiger keeper training recrds Tab S Hamiltn Z Dcuments flder 9(2)(a) Page 14
Page 3 f 10 2. Enclsure: The tiger enclsure that is invlved in this incident was riginally built in 2000 / 2001. It is referred t as the ld tiger huse as anther tiger enclsure was built sme years later fr Sali and her cubs. (The new tiger huse). The ld tiger huse remained unchanged until 2012 when mdificatins were made in anticipatin f future breeding prgrammes. In 2013, fllwing a near-miss incident with Sali, the keeper gate was relcated and altered. The riginal single gate system was replaced with a tw gate airlck system where ne gate must be clsed befre the ther is pened. This new gate needed t be big enugh t accmmdate a wheelbarrw and therefre its riginal psitin was nt sufficient fr the area the new gate required. Optins cnsidered were: 1. Realign the fence which was deemed t expensive and the tigers wuld have required t be lcked up fr lng perids. 2. Place the airlck inside the enclsure this is cntrary t animal cntainment standards as a tiger culd jump up n tp f it and use it as a stepping stne t escape ver the fence. 3. Mve the gate t anther lcatin. Subsequently, the keeper gate was mved away frm its riginal placing and the new mdified gate installed adjacent t the ff-display enclsure. In its riginal lcatin, the keepers had t walk alng the cat chute, the walkway that the tigers use t exit and enter the dens and ff-display enclsures and culd check t see whether the sliding cntainment gates were up r dwn, befre entering the enclsure. Fllwing the repsitining f the keeper gate, the keepers were less likely t d this. This was t prve a factr in this incident. As stated, the cat-chute is fitted with a number f sliding steel gates, which are used t either cntain the tigers, r stp them frm entering different areas f the enclsure. Each gate is fitted with a heavy steel cunter-weight which sits n the utside f the cat-chute. These cunter-weights assist in lifting the heavy steel gates which withut the help f the cunter-weights, wuld be t heavy t lift n their wn. The cunter-weights wrk in ppsitin t the sliding gates in that when the gate is dwn, the cunter-weight is up and vice versa. At the time f Mrs KUDEWEH s incident, all f the steel wrk, gates, and cunter-weights were a galvanized grey clur. This made identifying which gate was up r dwn difficult t see, unless a clse-up inspectin was made. The z had explred painting the cunter-weights a distinctive clur which wuld have made identifying whether a gate was up r dwn cnsiderably easier, even at a distance. When this was raised prir t Mrs KUDEWEH s incident, it was determined that the z culd nt affrd t buy the paint. Fllwing this incident hwever, the cunter-weights have been painted. Refer t map f tiger enclsure 9(2)(a) Page 14 Refer t MAF Bisecurity Standard 145.03.04 Cntainment Facilities fr Z Animals page 32 9(2)(a) Page 20, 21 5582962/08 5582962/06 KUDEWEH page 8 9(2)(a) Page 27 Page 32, 33 9(2)(a) Page 15 5582962/07 KUDEWEH page 10,11 5582962/06 & 07 9(2)(a) Page 18 page 20 Page 38 Page 9
Page 4 f 10 3. Prcedure Old tiger huse: The Hamiltn Z currently has 5 Sumatran tigers; 2 females, 2 cubs and ne male, Oz. The mther tiger, Sali and cubs are kept separate in anther tiger enclsure referred t as the new tiger huse. Oz and the ther female, Mencari are free t interact during the day in the utside enclsure, the main enclsure where members f the public wuld nrmally view the animals, but during the night, the tigers are separated in the event that they fight and injure each ther. They have alternate nights ut in the utside enclsure. The tiger that is utside during the night has access t its den and hlding r ff-display area. The ther tiger is secured in its wn den during that time. In the mrning the utside tiger is usually waiting in the ff-display enclsure as it is in the rutine f being fed the same time every mrning. This strict rutine als helps t minimise the develpment f steretypical behaviur in caged big cats whereby they pace back and frth. Smetimes hwever, the tiger will nt be in the ff-display area and needs t be called r caxed int the enclsure s that it can be secured. At feeding time, bth tigers are secured in their individual dens, and the keeper places meat in the feed flap lcated in the fences f the ffdisplay enclsures. The tigers are then let ut int the ff-display enclsures t eat; the keeper then walks arund t the sliding drs n the cat-chute and lcks the tigers in ensuring at least 2 sliding drs are clsed between the cats and the utside enclsure. This leaves the utside enclsure safe t be entered by keepers fr cleaning r whatever is required, as bth tigers are secured. Other factrs: Wrklad / distractins: All z keepers interviewed stated that their wrklads were such, that it was a daily struggle t get their rutines dne. Add t that daily distractins and unfreseen events and ften there were nt enugh hurs in the day t cmplete their wrk. In 2013, Tiger Keeper frgt t lck a den dr which allwed female tiger Sali, t exit her den. The tiger then passed thrugh anther pen internal dr, which was rutinely left pen t allw the washed flr t dry. She then walked utside and thrugh the single keeper gate and entered the enclsure behind Ms Ms calmly left the enclsure and secured Sali wh frtunately, had been hand reared and was used t clse cntact with keepers. When spken t abut the incident, Ms stated the fllwing: It was her first day back after three weeks leave. It was a weekend when there were less keepers wrking. As well as her nrmal carnivre rutine, she had the added wrklad f having t check injured Wild Dgs wh had been fighting and sme f which were injured, hand feed baby Red Panda s and n tp f that had a public tiger shw t set up. 5582962/04 Page 8 Page 11-13 5582962/01 and 5582962/06 9(2)(a) Page 13 Page 13,14 9(2)(a) Page 19 Page 20 9(2)(a) Page 7 - page 3 page 7,8 page 19
Page 5 f 10 The PA system was playing up which added mre distractin / stress t her already busy day. N harm resulted but subsequently, the z mved the single keeper gate t the new lcatin and mdified it int a duble gate system. A key retentin system was als intrduced. Ms was std-dwn frm wrking with the tigers fr ver 12 mnths. The key retentin system made securing Oz mre difficult fllwing the incident. The sliding cntainment gates in the cat-chute were nw required t be lcked pen. When Ms was attempting t secure Oz after luring him away frm Mrs KUDEWEH, she had t lcate the tiger enclsure keys t unlck the gates, as well as try t keep the aggressive tiger at bay s t allw her t d this. The previus methd wuld have simply invlved sliding a blt and drpping the gate. Keepers spken t culd see n benefit t lcking the gates pen. Staffing numbers: Keepers interviewed stated that the z was critically under staffed and under resurced and had been that way fr many years. As previusly stated, keepers struggled t cmplete their daily tasks and rutines and rarely finished wrk n time. Added t that was daily distractins, unfreseen events, animals becming sick r injured r public interactins. On weekends it was exacerbated because there were less staff rstered n. Bth tiger incidents that have ccurred at the Hamiltn Z ccurred n weekends. A number f staff had heard it said, smene is ging t die if changes aren t made. In his statement Mr STANDLEY stated that he had advised the HCC that with the current staffing level, an accident was mre likely. He hwever never believed that a fatality wuld ccur. Due t staffing numbers, keepers f the mst dangerus animals, the Chimpanzees and Tigers, wrked alne. The nly keepers that wrked in pairs were the Savanah keepers and this was due t the large number f animals t care fr and the sheer size f the enclsure. Z Directr Steven STANDLEY prvided ratis f keepers t animals which were taken frm the Internatinal Z Yearbk. It stated that Auckland and Wellingtn Zs had a rati f 1 keeper per 7 animals, Orana Park in Christchurch had a rati f 1 keeper per 14 animals and Hamiltn had a rati f 1 keeper per 21 animals. Gun handler plicy: Zs are required t have trained and licensed gun handlers n site in the event f a dangerus animal escaping. The MAF Bisecurity Standard 145.03.04 Cntainment Facilities fr Z Animals states that during visiting hurs, a handler must be n mre than 5 minutes away and within 30 minutes after visiting hurs. In her statement Miss stated that n mst weekends the z did nt have a gun handler n site. 5582962/09 Page 21 Page 34 KUDEWEH page 8 pages 8-12 Page 19 KUDEWEH page 13 page 31 33,43 Page 17,18,25 Page 13,37,39 STANDLEY Page 11 9(2)(a) Page 10 Page 15 Page 28 STANDLEY Page 7 Refer t MAF Bisecurity Standard 145.03.04 Cntainment Facilities fr Z Animals page 34 8.2.3.6 Page 28 STANDLEY Page 29 On the day f this incident, gun handler 9(2)(a) was phned
Page 6 f 10 and it tk him 25 minutes t arrive frm his hme in Bth he and Mr STANDLEY cnfirmed that the Hamiltn Z s plicy states that a gun handler must be available within 30 minutes. 9(2)(a) believes this is t lng. Althugh this was nt a factr in this incident, it demnstrates the need fr existing plicies t be reviewed. Prtable radis: Anther issue that was highlighted during the investigatin was the z s prtable radis. It was cmmn fr the radis t be inadvertently turned ff, turned dwn r kncked ff the channel. Staff spken t said that this was a regular ccurrence and that yu had t get int the habit f checking cnstantly. The use f r the carrying f cell phnes was discuraged as it was believed that they wuld be a distractin. Althugh nt causative in this incident, the fact that n ne was particularly cncerned at first when Mrs KUDEWEH culd nt be cntacted meant that if in fact she was need f assistance, help was delayed in getting t her. Weather: As mentined elsewhere in this reprt, the z and Waikat area was subjected t a massive thunderstrm. In sme areas, hailstnes were 200mm deep. This had an adverse effect n the z in that pathways were flded and animals required sheltering. Prir t the fatal incident and during the dwnpur, Mrs KUDEWEH had spken t Ms abut hw her area f the z was hlding up. Althugh it can nly be surmised that this was an added distractin, it cannt be discunted as it is t much f a cincidence that it happened arund the same time. Mst likely scenari based n evidence available There were n witnesses t the event, s the fllwing is based n evidence available, including statements, plicy and prcedure. Similarities with the 2013 incident have als been referred t. Mrs KUDEWEH was rstered n t her nce every three weeks weekend n. As a senir handler, ne f seven that can wrk with tigers, she ften wrked the carnivre run. It has been stated that it was several weeks since she last wrked with the tigers. She had hwever wrked the same run the day befre. (, wh was invlved in the 2013 near miss, was away frm the tiger run fr 3 weeks.) Being a Sunday, there were fewer keepers rstered n, and therefre the runs included extra chres. (The 2013 incident als ccurred n a weekend.) A visitr frm anther z arrived but it is unknwn whether Mrs KUDEWEH was expecting them. During her run, a trrential dwnpur ccurred which meant that paths became flded, animals required shelter etc. These were added distractins. (Ms Page 6 Page 23 page 6,12 KUDEWEH page 35 Page 22 Refer t NIWA data n rainfall 20/09/2015 Page 24 Page 4,8,24 Page 16,17 9(2)(a) Page 24 page 27 Page 11 Page 26 page 3 9(2)(a)
Page 7 f 10 was als distracted with extra tasks and respnsibilities.) It appears that Mrs KUDEWEH arrived at the tiger enclsure and had fllwed the prcedure t a pint as meat was still present fllwing the incident. It appears that Oz was nt secured in the ff-display enclsure as dictated in the prcedure. Reasns fr this culd have included: Oz culd nt hear Mrs KUDEWEH call him frm where he was in the utside enclsure because f heavy rain. In cntrast it was stated that tigers wuld seek shelter in that type f weather. Hwever it is unclear if Oz wuld have dne this utside, either amng vegetatin r under a tree. It is assumed that he did nt enter the ff display as the meat was nt eaten and Mrs KUDEWEH wuld have subsequently secured him inside. Mrs KUDEWEH was fund wearing full wet weather gear. She was knwn t rarely wear a raincat unless it was raining hard. It is unknwn whether she departed frm prcess t put this n and simply missed a step in the prcedure. It is als unknwn when during the prcess, she wuld have put n the wet weather gear. A shrt time later, while at the Cheetah enclsure, which is lcated apprximately 100 metres further alng the carnivre run, she radied Ms and the tw discussed hw the dwnpur had affected the rhincers and surrunding enclsures. When Mrs KUDEWEH returned t the tiger enclsure, the prcess was t cut bamb fr the Red Panda s and she wuld have gne t get the lppers. It is nt knwn where Oz was at the time Mrs KUDEWEH returned t the tiger enclsure. It appears hwever that she walked directly t the keeper gate and entered the main enclsure. There was n safety features r warning signs t indicate that the tiger had nt been secured. The prcess relied n individuals fllwing a set prcess and did nt take int accunt lapses in fcus; despite a similar event tw years prir. Mments later, it appears Mrs KUDEWEH was attacked frm behind and dragged away. This is suggested because she had nt had sufficient time t cut any bamb. Her lppers were lcated next t the bamb as was her cap and radi. Injuries sustained indicated an attack frm behind. This is als typical behaviur fr a tiger. It has been suggested that Oz was nt used t seeing keepers dressed in full wet weather gear and mistk Mrs KUDEWEH wh was dressed in dark shiny (wet) clthing as a mussel buy, which was his favurite ty. Mr hwever stated that it wuld nt have mattered what Mrs KUDEWEH was wearing, Oz wuld have acted the same. Receptin attempted t cntact Mrs KUDEWEH t advise that her visitr had arrived but there was n reply t radi r cell phne. It was then that Ms went t see where she was. Initially there was n cncern as ften keeper s radi s gt turned ff, r turned dwn and they did nt answer. Page 25,26 Page 13 5582962/02 Refer t Plice Pl 47 Reprt fr Crner frm Refer t Pst Mrtem Reprt KUDEWEH page 2 Page 2 9(2)(a) Page 28, 29
Page 8 f 10 Significant hazard Invlved Keeper cntact with large aggressive carnivre. Current State f Knwledge In 2007, the Ministry f Agriculture and Frestry released Standard 154.03.04 Cntainment Facilities fr Z Animals. This dcument describes the structural and peratinal requirements fr enclsures used t huse varius z animals and is available n the Ministry fr Primary Industries website. It discusses each animal type chapter by chapter, the animals physical abilities, behaviurs etc and the best types f enclsures fr each. It als cvers the subject f Keeper Safety. Chapter 8 which fcuses n Carnivres C1: Felids and Ursidae (Cats and Bears) excluding Cheetah, prescribes the types f fencing, gates and facilities required. Husbandry Manuals and Standard Operating Prcedures were acquired frm Wellingtn and Auckland Zs, bth f wh have Sumatran Tigers amng their menagerie. Bth f these zs use a tw keeper system fr tigers. The United Kingdm s Health and Safety Executive als published a dcument - Managing health and safety in zs. This t prescribes cntainment and prcesses t be adpted and states: Risk assessment cvering greater risk species shuld specify what cntrl measures are required prir t a keeper entering an enclsure, eg. The use f an effective system t check that the animals have been islated prir t a keeper entering the enclsure. Practicable Steps that culd have been taken 1. The HCC culd have emplyed sufficient staff t ensure a 2 keeper system with the dangerus animals, particularly tigers. This in in line with bth Wellingtn and Auckland Zs. This was suggested by Wrksafe NZ n the day f the incident and has since been adpted by the z. Pst-incident, fur new keepers have been emplyed by the HCC. 2. The HCC culd have had fitted mechanical interlck devices t the gates at the tiger enclsure which wuld prevent the keeper gate being pened if the sliding gates in the cat chute were all pen. This technlgy is used in many wrkplaces and is readily available. Pst-incident, this ptin is being explred by the HCC. 3. The keeper gate culd have been left at its riginal lcatin. This prvided a secnd chance fr a keeper t duble check that bth tigers had been cntained befre entering the enclsure. This has been highlighted as a majr cmpnent t this tragedy by a number f experienced z keepers. Pst-incident, the keeper gate is being mved back t its riginal psitin, albeit with a mdified design. 4. Staff wrking with tigers that have been away frm the prcess fr mre than tw weeks due t leave etc, shuld be placed n less Refer t the Ministry f Agriculture and Frestry - Standard 154.03.04 Cntainment Facilities fr Z Animals. Refer t Auckland Zlgical Park - Carnivre Sectin, Husbandry Prcedures Manual Refer t Wellingtn Z- Standard Operating Prcedures fr Serving Tigers. Refer t The United Kingdm s Health and Safety Executive- Managing health and safety in zs. Page 22 STANDLEY Page 22 Page 14 Page 21 KUDEWEH page 8 Refer t Z Actin Plan D-1969518
Page 9 f 10 dangerus runs and supervised, regardless f experience, fr the first few days back at wrk. This was put in place fllwing the 2013 incident but appears t have been discntinued. 5. CCTV inside the dens t allw the keepers t cnfirm that bth tigers were secured r present. 6. The cunter-weights n the cat-chute sliding gates culd have been painted bright clurs s that at a glance, the keepers culd tell if the gates were up r dwn befre entering the enclsure. Pst-incident, these have been painted. 7. Signage culd have been placed n the keeper gates reminding keepers t duble check that bth tigers were secured. Fllwing the incident, these have been put in place. Cnclusins The Hamiltn Z has been running n a very tight budget fr a number f years. This ultimately led t a shrtage f staff which in turn led t staff having t wrk n their wn with dangerus animals (tigers and chimpanzees). Staff interviewed all stated that wrklads were barely manageable. The cheapest alternatives were ften chsen in regards t enclsure mdificatin as demnstrated by the mving f the keeper gate. Despite insisting that the 2013 incident was in n way related t this matter, it was the mdificatins made as a result f the 2013 incident that played a majr rle. Indeed, similarities between the tw incidents include: Bth happened n a weekend when rstered staff have a greater wrklad, Bth keepers were wrking alne, Bth keepers had added distractins, Bth had been away frm the prcess fr several weeks. During the interview with Z Directr Stephen STANDLEY, an Actin Plan was ffered up in which it lists a number f changes which have and are t be made. Further, a full health and safety review f the z s prcesses is planned and at a significant cst. These steps, it is suggested, culd have been carried ut prir t this incident and is likely that in ding s, this matter may have been prevented. When interviewed under cautin, HCC representative Lance VERVOORT, General Manager Business Cmmunity stated: Refer t exhibit WAI/5582962/06 VERVOORT He was nt aware f staff shrtages and believed staffing
Page 10 f 10 numbers were adequate. He stated that if the z had cncerns with its staffing numbers it shuld have brught this t the attentin f senir management. He felt that the z s 30 minute respnse time fr gun handlers was adequate. He cnfirmed that Mrs KUDEWEH was an emplyee f the Hamiltn City Cuncil. He cnfirmed that she was at wrk as Z Curatr at the time f her death. He stated that ptentially the mving f the keeper gate in 2013 was a causative factr in this incident. Recmmendatin It is apparent that the Hamiltn City Cuncil has breached Sectin 6 f the Health and Safety in Emplyment Act 1992 in that being an emplyer, it failed t take all practicable steps t ensure the safety f its emplyee, namely Samantha Lynda KUDEWEH. Given that this incident invlved a death and with the amunt f public interest in this case, it is therefre recmmended that the HCC be prsecuted.