DOLI 6
Page 1 of 10
Summary of Evidence
Hamilton City Council
Re: Fatal Tiger Attack on
20 September 2015
Samantha Lynda KUDEWEH
File: 5582962
Where Evidence
Recorded & How
Element Proved
Introduction
ACT 1982
Hamilton Zoo Curator, Samantha Lynda KUDEWEH was killed by male
Sumatran tiger ‘Oz’, when she entered one of the zoo’s tiger enclosures
while he was still able to access the enclosure.
Facts
Parties
Hamilton City Council (‘HCC’)
Refer to attached
The employer. The HCC is responsible for staffing and resourcing at the
Employment Agreement
zoo and controls such things as budgets and recruiting.
INFORMATION
Hamilton Zoo
Owned by the Hamilton City Council, the Hamilton Zoo covers 25
hectares (62 acres), and is situated on Brymer Road in the Hamilton
suburb of Rotokauri. The zoo was founded in 1969 as the Hilldale Game
Park and has grown in size and now house’s a large number of exotic
animals including White Rhinoceros and Sumatran tigers.
Samantha Lynda KUDEWEH (nee STEPHENS)
Refer to attached
Employment Agreement
First employed by the HCC in 2005 as Team Leader – Mammals, Mrs
and work history.
KUDEWEH came with extensive experience having already worked at the
Auckland Zoo, Melbourne Zoo and with various wildlife projects in
Thailand and South Africa. Mrs KUDEWEH held a degree in Zoology and
was heavily involved in the Australasian White Rhinoceros breeding
programme. She became Zoo Curator in September 2012 and had over
20 year’s zoological experience.
The Event
On Sunday the 20th of September 2015, Mrs KUDEWEH was at her place
of employment, the Hamilton Zoo. As Zoo Curator, Mrs KUDEWEH
Refer to DOLI9 -9(2)(a)
worked every third weekend as part of the zoo roster and would often
Page 4,5
cover the role of tiger/ carnivore keeper due to her experience. Not all
keepers are qualified to look after the Sumatran tigers.
Refer to DOLI9 –
As part of her duties, Mrs KUDEWEH was required to feed the tigers,
s.9(2)(a)
page 2
cheetahs, wild dogs and a number of other animals on the ‘carnivore run’.
RELEASED UNDER THE OFFICIAL
While Mrs KUDEWEH was performing these feeding duties, a torrential
Refer to NIWA data on
downpour and hail storm passed over the Waikato area.
rainfall – 20/09/2015
As she was working on her own at the time, the following events are
speculative and are based on documented procedures. It appears that
Mrs KUDEWEH placed the tiger’s meat in the ‘feed flap’ located in the
DOLI 6 – Summary of Evidence – Version 1.1 – o1/2006
Element to prove is indicated in
bold type
Page 2 of 10
Where Evidence
Recorded & How
Element Proved
‘off-display enclosure’ and carried on to the Cheetah enclosure. While
there, she spoke with Rhinoceros Keeper
s.9(2)(a)
by radio and
Refer to photograph
discussed the downpour and the affect it was having on the zoo.
5582962/01
A short time later, after several attempts to contact Mrs KUDEWEH, Ms
s.9(2)(a) drove to the tiger enclosure and located Mrs KUDEWEH
deceased inside the main enclosure. Oz, the zoo’s male Sumatran tiger,
1982
who weighs 137 kilograms, was sitting next to her. Mrs KUDEWEH was
Refer to DOLI9 –s.9(2)(a)
found to have injuries that were consistent with a tiger attack.
Page 2, 3
Investigation
ACT
Refer to Police Pol 47
Emergency Services were called and Worksafe New Zealand was notified
Report for Coroner form
by Police. Inspector Jason GIBSON attended the scene and liaised with
Police CIB staff. The scene was visited and details recorded and
photographed. As the scene was still considered a crime scene at that
point, limited access was granted to Worksafe NZ until Police had
established no foul-play had occurred.
Refer to Investigation
Log - GIBSON
It appeared that Mrs KUDEWEH had entered the main enclosure through
the ‘keeper gate’ with the intention of cutting bamboo for the Red
Panda’s. This was evident by the presence of a pair of loppers located
next to a clump of bamboo situated several metres inside the enclosure.
INFORMATION
To cut down on feeding costs, the zoo would often use its own vegetation
Refer to photograph
as fodder. The keys to the gate were hanging with the padlock on the
5582962/02
inside of the gate which is zoo policy; this indicates that a keeper is
Refer to DOLI9 -
9(2)(a)
present.
Page 20
Her uniform cap and portable radio were located on the ground close by.
It appeared that the impact of the tiger’s attack had ‘flung’ the items away
for 2 – 3 metres. Drag (heel) marks were observed leading away to
OFFICIAL
where Mrs KUDEWEH’s body was located; a distance of approximately
Refer to photograph
10 metres from her equipment.
5582962/03
THE
Police provided Worksafe NZ a copy of their Sudden Death file four days
later.
Refer to Police Sudden
Death File
Analysis
There are a number of factors to be considered in this case. These are:
Keeper experience,
UNDER
Procedure,
Enclosure,
Other factors, i.e. weather, workload etc.
1. Keeper Experience:
Mrs KUDEWEH was the zoo’s senior tiger keeper and had played a major
Refer to DOLI9 –
s.9(2)(a)
Page 11
role in the breeding programme which resulted in the birth of two tiger
cubs to female Sumatran tiger, Sali. She had trained all of the other tiger
Refer to tiger keeper
keepers at the zoo and with twenty years’ experience, was considered
training records – Tab ‘S’
RELEASED
one of the country’s top keepers, in particular with tigers.
Hamilton Zoo Documents
folder
In her roles as Team Leader and Curator, Mrs KUDEWEH had written a
Refer to DOLI9-
number of policies for the zoo. Inexperience therefore does not appear to
Page 14
9(2)(a)
be a factor.
DOLI 6 – Summary of Evidence – Version 1 – o9/2004
Element to prove is indicated in
bold type
Page 3 of 10
Where Evidence
Recorded & How
Element Proved
2. Enclosure:
The tiger enclosure that is involved in this incident was originally built in
2000 / 2001. It is referred to as the ‘old tiger house’ as another tiger
Refer to map of tiger
enclosure was built some years later for Sali and her cubs. (The new tiger
enclosure
house). The ‘old tiger house’ remained unchanged until 2012 when
modifications were made in anticipation of future breeding programmes.
Refer to DOLI9-
Page 14
9(2)(a)
1982
In 2013, following a near-miss incident with Sali, the keeper gate was
relocated and altered. The original single gate system was replaced with
a two gate ‘airlock’ system where one gate must be closed before the
other is opened. This new gate needed to be big enough to
Refer to MAF Biosecurity
ACT
Standard 145.03.04
accommodate a wheelbarrow and therefore its original position was not
Containment Facilities
sufficient for the area the new gate required. Options considered were:
for Zoo Animals page 32
1. Realign the fence – which was deemed too expensive and the
tigers would have required to be locked up for long periods.
Refer to DOLI9-
2. Place the ‘airlock’ inside the enclosure – this is contrary to animal
Page 20, 21
9(2)(a)
containment standards as a tiger could jump up on top of it and
Refer to photograph
use it as a stepping stone to escape over the fence.
5582962/08
3. Move the gate to another location.
Subsequently, the keeper gate was moved away from its original placing
and the new modified gate installed adjacent to the off-display enclosure.
Refer to photograph
INFORMATION
5582962/06
In its original location, the keepers had to walk along the ‘cat chute’, the
walkway that the tigers use to exit and enter the dens and off-display
enclosures and could check to see whether the sliding containment gates
Refer to DOLI9 – Richard
were up or down, before entering the enclosure.
KUDEWEH page 8
Following the repositioning of the keeper gate, the keepers were less
Refer to DOLI9-
Page 27
likely to do this. This was to prove a factor in this incident.
9(2)(a)
OFFICIAL
Refer to DOLI9 s.9(2)(a)
As stated, the ‘cat-chute’ is fitted with a number of sliding steel gates,
Page 32, 33
which are used to either contain the tigers, or stop them from entering
different areas of the enclosure. Each gate is fitted with a heavy steel
Refer to DOLI9-
THE
Page 15
9(2)(a)
counter-weight which sits on the outside of the ‘cat-chute’. These
counter-weights assist in lifting the heavy steel gates which without the
Refer to photograph
help of the counter-weights, would be too heavy to lift on their own.
5582962/07
The counter-weights work in opposition to the sliding gates in that when
the gate is down, the counter-weight is up and vice versa.
UNDER
Refer to DOLI9 – Richard
KUDEWEH page 10,11
At the time of Mrs KUDEWEH’s incident, all of the steel work, gates, and
counter-weights were a galvanized grey colour. This made identifying
Refer to photograph
which gate was up or down difficult to see, unless a close-up inspection
5582962/06 & 07
was made.
The zoo had explored painting the counter-weights a distinctive colour
Refer to DOLI9 –
Page 18
which would have made identifying whether a gate was up or down
9(2)(a)
considerably easier, even at a distance. When this was raised prior to Mrs
RELEASED
Refer to DOLI9 s.9(2)(a)
KUDEWEH’s incident, it was determined that the zoo could not afford to
page 20
buy the paint.
Refer to DOLI9 s.9(2)(a)
Page 38
Following this incident however, the counter-weights have been painted.
Refer to DOLI9 -
9(2)(a)
Page 9
DOLI 6 – Summary of Evidence – Version 1 – o9/2004
Element to prove is indicated in
bold type
Page 4 of 10
Where Evidence
Recorded & How
Element Proved
3. Procedure – Old tiger house:
The Hamilton Zoo currently has 5 Sumatran tigers; 2 females, 2 cubs and
one male, Oz. The mother tiger, Sali and cubs are kept separate in
another tiger enclosure referred to as the ‘new tiger house.’
Oz and the other female, Mencari are free to interact during the day in the
outside enclosure, the main enclosure where members of the public
1982
would normally view the animals, but during the night, the tigers are
separated in the event that they fight and injure each other. They have
alternate nights out in the outside enclosure.
Refer to photograph
5582962/04
ACT
The tiger that is outside during the night has access to its den and holding
or ‘off-display’ area. The other tiger is secured in its own den during that
Refer to DOLI9 -
9(2)(a)
time.
Page 8
Refer to DOLI9 s.9(2)(a)
In the morning the ‘outside tiger’ is usually waiting in the off-display
Page 11-13
enclosure as it is in the routine of being fed the same time every morning.
This strict routine also helps to minimise the development of stereotypical
Refer to photograph
behaviour in caged big cats whereby they pace back and forth.
5582962/01 and
Sometimes however, the tiger will not be in the off-display area and needs
5582962/06
to be called or coaxed into the enclosure so that it can be secured.
Refer to DOLI9-
Page 13
9(2)(a)
INFORMATION
At feeding time, both tigers are secured in their individual dens, and the
keeper places meat in the ‘feed flap’ located in the fences of the ‘off-
Refer to DOLI9 s.9(2)(a)
display’ enclosures. The tigers are then let out into the off-display
Page 13,14
enclosures to eat; the keeper then walks around to the sliding doors on
the ‘cat-chute’ and locks the tigers in ensuring at least 2 sliding doors are
Refer to DOLI9-
closed between the cats and the outside enclosure. This leaves the
Page 19
9(2)(a)
outside enclosure safe to be entered by keepers for cleaning or whatever
Refer to DOLI9 s.9(2)(a)
is required, as both tigers are secured. OFFICIAL
Page 20
Other factors:
Refer to DOLI9
Workload / distractions:
Page 7
9(2)(a)
THE
All zoo keepers interviewed stated that their workloads were such, that it
Refer to DOLI9 -
was a daily struggle to get their routines done. Add to that daily
s.9(2)(a)
distractions and unforeseen events and often there were not enough
hours in the day to complete their work.
In 2013, Tiger Keeper
s.9(2)(a)
forgot to lock a den door which
allowed female tiger Sali, to exit her den. The tiger then passed through
UNDER
Refer to DOLI9 s.9(2)(a)
another open internal door, which was routinely left open to allow the
page 3
washed floor to dry. She then walked outside and through the single
keeper gate and entered the enclosure behind Ms s.9(2)(a)
Refer to DOLI9 s.9(2)(a)
Ms s.9(2)(a) calmly left the enclosure and secured Sali who fortunately,
page 7,8
had been hand reared and was used to close contact with keepers.
When spoken to about the incident, Ms s.9(2)(a) stated the following:
o It was her first day back after three weeks leave.
RELEASED
o It was a weekend when there were less keepers working.
Refer to DOLI9 s.9(2)(a)
o As well as her normal carnivore routine, she had the added
page 19
workload of having to check injured Wild Dogs who had been
fighting and some of which were injured, hand feed baby Red
Panda’s and on top of that had a public tiger show to set up.
DOLI 6 – Summary of Evidence – Version 1 – o9/2004
Element to prove is indicated in
bold type
Page 5 of 10
Where Evidence
Recorded & How
Element Proved
o The PA system was playing up which added more distraction /
stress to her already busy day.
Refer to photograph
5582962/09
No harm resulted but subsequently, the zoo moved the single keeper gate
to the new location and modified it into a double gate system. A key
Refer to DOLI9 -
9(2)(a)
retention system was also introduced. Ms s.9(2)(a) was stood-down
Page 21
from working with the tigers for over 12 months.
1982
Refer to DOLI9 s.9(2)(a)
Page 34
The key retention system made securing Oz more difficult following the
incident. The sliding containment gates in the ‘cat-chute’ were now
Refer to DOLI9 – Richard
required to be locked open. When Ms
ACT
s.9(2)(a) was attempting to secure
KUDEWEH page 8
Oz after luring him away from Mrs KUDEWEH, she had to locate the tiger
enclosure keys to unlock the gates, as well as try to keep the aggressive
Refer to DOLI9- s.9(2)(a)
tiger at bay so to allow her to do this.
pages 8 -12
The previous method would have simply involved sliding a bolt and
Refer to DOLI9 -
9(2)(a)
Page 19
dropping the gate. Keepers spoken to could see no benefit to locking the
gates open.
Refer to DOLI9 – Richard
KUDEWEH page 13
Staffing numbers:
Refer to DOLI9 – s.9(2)(a)
Keepers interviewed stated that the zoo was critically under staffed and
page 31 – 33 ,43
under resourced and had been that way for many years. As previously
INFORMATION
stated, keepers struggled to complete their daily tasks and routines and
Refer to DOLI9-
rarely finished work on time. Added to that was daily distractions,
s.9(2)(a)
Page
unforeseen events, animals becoming sick or injured or public
17,18,25
interactions. On weekends it was exacerbated because there were less
Refer to DOLI9 –
staff rostered on. Both tiger incidents that have occurred at the Hamilton
s.9(2)(a)
Page 13,37,39
Zoo occurred on weekends.
Refer to DOLI9-
A number of staff had heard it said, ‘someone is going to die if changes
OFFICIAL
STANDLEY Page 11
aren’t made’. In his statement Mr STANDLEY stated that he had advised
the HCC that with the current staffing level, an accident was more likely.
Refer to DOLI9-
9(2)(a)
He however never believed that a fatality would occur.
Page 10
THE
Refer to DOLI9-
Due to staffing numbers, keepers of the most dangerous animals, the
s.9(2)(a)
Page 15
Chimpanzees and Tigers, worked alone. The only keepers that worked in
pairs were the Savanah keepers and this was due to the large number of
animals to care for and the sheer size of the enclosure.
Refer to DOLI9-
s.9(2)(a)
Page 28
Zoo Director Steven STANDLEY provided ratios of keepers to animals
UNDER
Refer to DOLI9-
which were taken from the International Zoo Yearbook. It stated that
STANDLEY Page 7
Auckland and Wellington Zoos had a ratio of 1 keeper per 7 animals,
Orana Park in Christchurch had a ratio of 1 keeper per 14 animals and
Refer to MAF Biosecurity
Standard 145.03.04
Hamilton had a ratio of 1 keeper per 21 animals.
Containment Facilities
for Zoo Animals page 34
Gun handler policy:
8.2.3.6
Zoos are required to have trained and licensed gun handlers on site in the
event of a dangerous animal escaping. The MAF Biosecurity Standard
Refer to DOLI9-
145.03.04 Containment Facilities for Zoo Animals states that during
RELEASED
s.9(2)(a)
Page 28
visiting hours, a handler must be no more than
5 minutes away and within
30 minutes after visiting hours. In her statement Miss
s.9(2)(a)
stated
Refer to DOLI9-
that on most weekends the zoo did not have a gun handler on site.
STANDLEY Page 29
On the day of this incident, gun handler 9(2)(a)
was phoned
DOLI 6 – Summary of Evidence – Version 1 – o9/2004
Element to prove is indicated in
bold type
Page 6 of 10
Where Evidence
Recorded & How
Element Proved
and it took him 25 minutes to arrive from his home in s.9(2)(a) Both he
and Mr STANDLEY confirmed that the Hamilton Zoo’s policy states that a
Refer to DOLI9
gun handler must be available within 30 minutes.
9(2)(a)
9(2)(a)
believes
Page 6
this is too long.
Although this was not a factor in this incident, it demonstrates the need for
existing policies to be reviewed.
1982
Portable radios:
Another issue that was highlighted during the investigation was the zoo’s
ACT
Refer to DOLI9-
portable radios. It was common for the radios to be inadvertently turned
s.9(2)(a)
Page 23
off, turned down or knocked off the channel. Staff spoken to said that this
was a regular occurrence and that you had to get into the habit of
Refer to DOLI9 s.9(2)(a)
checking constantly. The use of or the carrying of cell phones was
page 6,12
discouraged as it was believed that they would be a distraction.
Refer to DOLI9 – Richard
KUDEWEH page 35
Although not causative in this incident, the fact that no one was
particularly concerned at first when Mrs KUDEWEH could not be
Refer to DOLI9- s.9(2)(a)
contacted meant that if in fact she was need of assistance, help was
Page 22
delayed in getting to her.
Refer to NIWA data on
INFORMATION
Weather:
rainfall – 20/09/2015
As mentioned elsewhere in this report, the zoo and Waikato area was
subjected to a massive thunderstorm. In some areas, hailstones were
200mm deep. This had an adverse effect on the zoo in that pathways
were flooded and animals required sheltering.
Prior to the fatal incident and during the downpour, Mrs KUDEWEH had
spoken to Ms s.9(2)(a) about how her area of the zoo was holding up.
OFFICIAL
Although it can only be surmised that this was an added distraction, it
cannot be discounted as it is too much of a coincidence that it happened
around the same time.
Refer to DOLI9- s.9(2)(a)
THE
Page 24
Most likely scenario based on evidence available
Refer to DOLI9-
There were no witnesses to the event, so the following is based on
s.9(2)(a)
Page 4,8,24
evidence available, including statements, policy and procedure.
Refer to DOLI9 -
9(2)(a)
Similarities with the 2013 incident have also been referred to.
Page 16,17
UNDER
Mrs KUDEWEH was rostered on to her ‘once every three weeks’
weekend on.
Refer to DOLI9
9(2)(a)
Page 24
As a senior handler, one of seven that can work with tigers, she
often worked the ‘carnivore run’.
It has been stated that it was several weeks since she last worked
with the tigers. She had however worked the same run the day
Refer to DOLI9 s.9(2)(a)
page 27
before. (
s.9(2)(a)
, who was involved in the 2013 near
miss, was away from the tiger run for 3 weeks.)
Refer to DOLI9-
Being a Sunday, there were fewer keepers rostered on, and
s.9(2)(a)
Page 11
RELEASED
therefore the runs included extra chores. (
The 2013 incident also
Refer to DOLI9- s.9(2)(a)
occurred on a weekend.)
Page 26
A visitor from another zoo arrived but it is unknown whether Mrs
KUDEWEH was expecting them. During her run, a torrential
Refer to DOLI9 s.9(2)(a)
downpour occurred which meant that paths became flooded,
page 3
animals required shelter etc. These were added distractions. (
Ms
DOLI 6 – Summary of Evidence – Version 1 – o9/2004
Element to prove is indicated in
bold type
Page 7 of 10
Where Evidence
Recorded & How
Element Proved
s.9(2)(a)
was
also
distracted
with
extra
tasks
and
Refer to DOLI9- s.9(2)(a)
responsibilities.)
Page 25,26
It appears that Mrs KUDEWEH arrived at the tiger enclosure and
had followed the procedure to a point as meat was still present
Refer to DOLI9-
following the incident.
s.9(2)(a)
Page 13
It appears that Oz was not secured in the ‘off-display’ enclosure as
dictated in the procedure. Reasons for this could have included:
1982
o Oz could not hear Mrs KUDEWEH call him from where he
was in the outside enclosure because of heavy rain.
o In contrast it was stated that tigers would seek shelter in
ACT
that type of weather. However it is unclear if Oz would
have done this outside, either among vegetation or under a
tree.
Refer to photograph
o It is assumed that he did not enter the off display as the
5582962/02
meat was not eaten and Mrs KUDEWEH would have
subsequently secured him inside.
Mrs KUDEWEH was found wearing full wet weather gear. She
was known to rarely wear a raincoat unless it was raining hard. It
is unknown whether she departed from process to put this on and
simply missed a step in the procedure. It is also unknown when
during the process, she would have put on the wet weather gear.
A short time later, while at the Cheetah enclosure, which is located
INFORMATION
approximately 100 metres further along the carnivore run, she
radioed Ms s.9(2)(a) and the two discussed how the downpour had
affected the rhinoceros and surrounding enclosures.
When Mrs KUDEWEH returned to the tiger enclosure, the process
was to cut bamboo for the Red Panda’s and she would have gone
to get the loppers.
It is not known where Oz was at the time Mrs KUDEWEH returned
to the tiger enclosure. It appears however that she walked directly
OFFICIAL
to the keeper gate and entered the main enclosure.
Refer to Police Pol 47
There was no safety features or warning signs to indicate that the
Report for Coroner form
tiger had not been secured. The process relied on individuals
THE
following a set process and did not take into account lapses in
Refer to Post Mortem
focus; despite a similar event two years prior.
Report
Moments later, it appears Mrs KUDEWEH was attacked from
Refer to DOLI9 – Richard
behind and dragged away. This is suggested because she had not
KUDEWEH page 2
had sufficient time to cut any bamboo. Her loppers were located
next to the bamboo as was her cap and radio. Injuries sustained
UNDER
indicated an attack from behind. This is also typical behaviour for
Refer to DOLI9-
s.9(2)(a)
Page 2
a tiger.
It has been suggested that Oz was not used to seeing keepers
Refer to DOLI9
9(2)(a)
dressed in full wet weather gear and mistook Mrs KUDEWEH who
Page 28, 29
was dressed in dark shiny (wet) clothing as a mussel buoy, which
was his favourite toy. Mr s.9(2)(a) however stated that it would
not have mattered what Mrs KUDEWEH was wearing, Oz would
have acted the same.
Reception attempted to contact Mrs KUDEWEH to advise that her
RELEASED
visitor had arrived but there was no reply to radio or cell phone. It
was then that Ms s.9(2)(a) went to see where she was. Initially
there was no concern as often keeper’s radio’s got turned off, or
turned down and they did not answer.
DOLI 6 – Summary of Evidence – Version 1 – o9/2004
Element to prove is indicated in
bold type
Page 8 of 10
Where Evidence
Recorded & How
Element Proved
Significant hazard Involved
Keeper contact with large aggressive carnivore.
Refer to the Ministry of
Agriculture and Forestry
- Standard 154.03.04
Current State of Knowledge
Containment Facilities
In 2007, the Ministry of Agriculture and Forestry released Standard
for Zoo Animals.
154.03.04 Containment Facilities for Zoo Animals. This document
describes the structural and operational requirements for enclosures used
1982
to house various zoo animals and is available on the Ministry for Primary
Refer to Auckland
Industries website.
Zoological Park -
Carnivore Section,
ACT
It discusses each animal type chapter by chapter, the animals’ physical
Husbandry Procedures
Manual
abilities, behaviours etc and the best types of enclosures for each. It also
covers the subject of Keeper Safety. Chapter 8 which focuses on
Refer to Wellington Zoo-
Carnivores C1: Felids and Ursidae (Cats and Bears) excluding Cheetah,
Standard Operating
prescribes the types of fencing, gates and facilities required.
Procedures for Serving
Tigers.
Husbandry Manuals and Standard Operating Procedures were acquired
from Wellington and Auckland Zoos, both of who have Sumatran Tigers
among their menagerie.
Both of these zoos use a two keeper system for tigers.
Refer to The United
Kingdom’s Health and
INFORMATION
The United Kingdom’s Health and Safety Executive also published a
Safety Executive-
document - Managing health and safety in zoos.
Managing health and
safety in zoos. Page 22
This too prescribes containment and processes to be adopted and states:
Risk assessment covering greater risk species should specify what
control measures are required prior to a keeper entering an enclosure, eg.
The use of an effective system to check that the animals have
been isolated prior to a keeper entering the enclosure.
OFFICIAL
Refer to DOLI9-
STANDLEY Page 22
Practicable Steps that could have been taken
THE
1. The HCC could have employed sufficient staff to ensure a 2
Refer to DOLI9 -
9(2)(a)
keeper system with the dangerous animals, particularly tigers.
Page 14
This in in line with both Wellington and Auckland Zoos. This was
suggested by Worksafe NZ on the day of the incident and has
since been adopted by the zoo.
Post-incident, four new keepers
UNDER
have been employed by the HCC.
2. The HCC could have had fitted mechanical interlock devices to the
gates at the tiger enclosure which would prevent the keeper gate
Refer to DOLI9 -
9(2)(a)
being opened if the sliding gates in the ‘cat chute’ were all open.
Page 21
This technology is used in many workplaces and is readily
available.
Post-incident, this option is being explored by the HCC.
Refer to DOLI9 – Richard
KUDEWEH page 8
3. The keeper gate could have been left at its original location. This
provided a ‘second chance’ for a keeper to double check that both
tigers had been contained before entering the enclosure. This has
Refer to Zoo Action Plan
RELEASED
been highlighted as a major component to this tragedy by a
D-1969518
number of experienced zoo keepers.
Post-incident, the keeper
gate is being moved back to its original position, albeit with a
modified design.
4. Staff working with tigers that have been away from the process for
more than two weeks due to leave etc, should be placed on less
DOLI 6 – Summary of Evidence – Version 1 – o9/2004
Element to prove is indicated in
bold type
Page 9 of 10
Where Evidence
Recorded & How
Element Proved
dangerous runs and supervised, regardless of experience, for the
first few days back at work.
This was put in place following the
2013 incident but appears to have been discontinued.
5. CCTV inside the dens to allow the keepers to confirm that both
tigers were secured or present.
6. The counter-weights on the ‘cat-chute’ sliding gates could have
been painted bright colours so that at a glance, the keepers could
1982
tell if the gates were up or down before entering the enclosure.
Post-incident, these have been painted.
7. Signage could have been placed on the keeper gates reminding
keepers to double check that both tigers were secured
. Following
ACT
the incident, these have been put in place.
Conclusions
The Hamilton Zoo has been running on a very tight budget for a
number of years. This ultimately led to a shortage of staff which in
turn led to staff having to work on their own with dangerous
animals (tigers and chimpanzees).
Staff interviewed all stated that workloads were barely
manageable.
INFORMATION
The cheapest alternatives were often chosen in regards to
enclosure modification as demonstrated by the moving of the
keeper gate.
Despite insisting that the 2013 incident was in no way related to
this matter, it was the modifications made as a result of the 2013
OFFICIAL
incident that played a major role. Indeed, similarities between the
two incidents include:
o Both happened on a weekend when rostered staff have a
THE
greater workload,
o Both keepers were working alone,
o
Both keepers had added distractions,
o Both had been away from the process for several weeks.
During the interview with Zoo Director Stephen STANDLEY, an
UNDER
Refer to exhibit
Action Plan was offered up in which it lists a number of changes
WAI/5582962/06
which have and are to be made.
Further, a full health and safety review of the zoo’s processes is
planned and at a significant cost.
These steps, it is suggested, could have been carried out prior to
this incident and is likely that in doing so, this matter may have
been prevented.
RELEASED
When interviewed under caution, HCC representative Lance
Refer to DOLI9 –
VERVOORT, General Manager Business – Community stated:
VERVOORT
o
He was not aware of staff shortages and believed staffing
DOLI 6 – Summary of Evidence – Version 1 – o9/2004
Element to prove is indicated in
bold type
Page 10 of 10
Where Evidence
Recorded & How
Element Proved
numbers were adequate. He stated that if the zoo had
concerns with its staffing numbers it should have brought
this to the attention of senior management.
o He felt that the zoo’s 30 minute response time for gun
handlers was adequate.
o He confirmed that Mrs KUDEWEH was an employee of the
Hamilton City Council.
1982
o He confirmed that she was ‘at work’ as Zoo Curator at the
time of her death.
o He stated that ‘potentially’ the moving of the keeper gate in
2013 was a causative factor in this incident.
ACT
Recommendation
It is apparent that the Hamilton City Council has breached Section 6 of
the Health and Safety in Employment Act 1992 in that being an employer,
it failed to take all practicable steps to ensure the safety of its employee,
namely Samantha Lynda KUDEWEH.
Given that this incident involved a death and with the amount of public
interest in this case, it is therefore recommended that the HCC be
prosecuted.
INFORMATION
OFFICIAL
THE
UNDER
RELEASED
DOLI 6 – Summary of Evidence – Version 1 – o9/2004
Element to prove is indicated in
bold type
