A health and safety auditor says Hamilton Zoo curator Samantha Kudeweh's death may have been prevented had Hamilton City Council undertaken a more thorough investigation following another keeper's near miss with a tiger in 2013.
Leigh-Anne Peake has picked more than 25 holes in Council's internal report into the March 2013 incident, which also reveals stark details of where the tiger was able to escape from and approach the keeper along with a hand-drawn, not-to-scale map of the tiger's path.
Kudeweh was killed by a Sumatran tiger last Sunday.
Despite treating the earlier incident as one of serious harm, Hamilton City Council's health and safety manager did not carry out their own investigation of the incident.
Hamilton News has obtained the internal report that detailed how a hand-raised Sumatran tiger escaped from an insecure den and entered the exhibit where the keeper was present.
Following the 2013 incident, Council issued a press release that said a Ministry for Primary Industries (MPI) investigation found the incident was the result of human error.
Council said a key retention padlock system for carnivores and primates at the zoo would be installed.
When asked why the health and safety manager did not conduct their own investigation, Council chief executive Richard Briggs said the incident was elevated to one of 'serious harm' because, at the time, serious harm incidents had to be reported to the senior leadership team.
"It was felt it was appropriate for the senior leadership team to be aware of this incident, hence the 'serious harm' classification," he said.
"The health and safety manager assisted the zoo director [Stephen Standley] to prepare his accident report."
Hamilton News asked independent health and safety consultant and auditor Leigh-Anne Peake to audit that report - she identified more than 20 potential flaws in the report and investigation process.
Peake, the managing director of a specialised compliance consultancy, said she had "looked at the 2013 report and critiqued it from a point of view of what should have occurred in terms of accepted protocol for a quality investigation".
"The whole slant of the investigation is that it was a hand-reared tiger. This is mentioned multiple times. Therefore it seems, no big deal, no drama, and no need to be overly concerned. This is the "feel" throughout the whole document."
She pointed out the report mentions two witnesses but does not include statements from them, nor from the keeper, but which Council says it has on file.
"It is common and necessary practice to have these statements attached to the investigation. These should be produced for all three involved - they form a crucial part of the investigation evidence and supporting knowledge."
Peake said the report shows that three doors were left open and the tiger had to go through all to get to the keeper.
"This is not investigated further. It is all blamed on the keeper. Maintenance was not considered. Sabotage was not considered. Each door should have been investigated separately as it is three near misses.
"Why didn't the doors spring shut? There is no consideration of the elimination of their chosen root cause, that the human made a mistake. Why didn't they assess how to eliminate this mistake?"
Peake also said the hand-drawn map wasn't up to scratch.
"The layout of the enclosures should be formally AutoCAD or other, and should be in all manuals and part of training, including awareness and emergency drills."
Standley's report states the Zoo Hazard Register was to be reviewed to identify possible improvements to it. However, Peake says the Register itself should have formed part of the report.
"The register and all of its controls should have been picked over by all of the investigation team - one of the controls failed badly. They didn't pick which one, they prematurely blamed human error."
Following the 2013 incident, the keeper involved was taken off working with the tigers for 12 months. Briggs said the keeper "was retrained and assigned as competent on June 24, 2014".
Briggs said the organisation's internal process for a serious harm incident was followed.
"This involved the completion of an incident report, which was done by the keeper involved in the incident, and completion of the investigation form a supervisor, who in this case was the zoo director."
He said all forms were sent to Council's health and safety advisor and the zoo director was required to present a report to the senior leadership team.
"The zoo director also carried out a formal investigation, which was required by MAF Biosecurity NZ (now MPI - the Ministry of Primary Industries) as a breach of containment had occurred."
Allan Halse was a Hamilton City Council staff member in 2013 and a PSA (Public Service Association) delegate. Also a former health and safety advisor, Halse said MPI investigated the 2013 incident from "the tiger's perspective, not from the health and safety of the employee's perspective".
He said Council was legally obliged, under the Health and Safety Act, to investigate incidents.
"If you have good systems and processes, then people don't die. This didn't have to happen," said Halse.
"I will be talking to WorkSafe and to the Coroner because I do have information about the previous incident and what I believe is the failure of Hamilton City Council to investigate."
The tiger that attacked Kudeweh, Oz, will not be euthanised.
Samantha's friends have set up a Give a Little page to generate the funds needed to establish a Family Trust to ensure that her and Richard's children have a secure future. All donations will be put towards the children's future education needs and ensuring the children's physical and emotional wellbeing in the coming months and years are cared for. To donate, go to https://givealittle.co.nz/cause/kudewehfamilytrust/