"It was stated by Lance Vervoort on TV3 that in 2013 the tiger went through one gate. This is incorrect. It went through three gates and then it was in the enclosure with the keeper. And if any one of the gates had been shut it would not have occurred, hence there are three separate events leading up to the event that could have been intercepted and stopped the event from occurring. These gates and how they are opened - and how they are closed - needed to be crucial to the 2013 investigation.
"In 2013, somebody left three gates open, whether it was that keeper or not, who knows. And it should not be the only focus of the investigation. Why was the 2013 incident not a near-miss? A near-miss would have been 'I found a gate open, a tiger could have got out'. It was an actual event which was 'three gates were open and the tiger got into the enclosure with the keeper'. A stroke of luck resulted in no physical injury. It could have been fatal. It could have been instantly fatal if repeated again. The hazard was significant, the risk extreme.
"How do you prevent the person from doing that again? Humans can never design fail-safe systems. But when a human makes a mistake you say 'you found a mistake in the design we didn't know existed, let's fix it'. They didn't do that. I'm not a zoo expert but I know there's a massive mistake if you can leave a gate open between you and a tiger.
"A good investigation will often conclude human error occurred because of a combination of design fault and procedural/system fault. Interestingly, these guys have got both. They've got the design fault ie, they didn't design enough safety into the gate systems and they've got a process system let-down.
"The GM admitted to you it was normal practice to leave two of the three gates open for operational reasons. This shows management condoned the gates to be left open when the procedure requires all gates to be secure. The investigator failed to find these contributors. [Stephen Standley] who did that investigation ticked both design and system as not applicable [in his investigation form].
"This shows to me that two of those three gates were probably left open more often than they were closed. I assume the one that is always required to be closed is into the tiger's den. Of the remaining two allowed to be open: One of those was the gate into the tiger enclosure. The other was into a passage area with a 1.8m high fence, on the other side of that fence was the general zoo area. Here the investigation should have asked 'what if the tiger had decided not to take the path of least resistance and walked out to the enclosure, rather it decided to jump the 1.8m fence, where would it end up?' Given tigers can jump up to 4m, this is a real possibility and again every attempt should have been made to engineer this risk out.
"The 2013 report did offer to increase the height of the fence to 5m,, however, this was later considered necessary. The reason for this turnaround was not included in the 2013 report. Perhaps a promise was made in that investigation to keep the gate closed and this was accepted by MPI as sufficient to prevent a recurrence? Why then has it become accepted practice to leave that gate open again?
"The design was inadequate and they weren't following procedure. Every attempt should have been made to eliminate/engineer out the ability for a person to leave a gate open again. This could have considered (for example, and there will be dozens of other solutions):
- International or best practice protocol in other zoos.
- Whether a time-activated spring could have assisted. It's a cheap fix but a better fix is more fail-safe - a human can override the spring. Now ask, is it a problem the gate is open or isn't closed? In this case, it's a problem the gate isn't closed. Ask 'how do I know I've left it open?'
- A simple fix is have an alarm running on a switch that says 'I'm open, I've been open long enough and I think you've forgotten me' so it closes or sets off an alarm.
- That still has flaws so you could link all gates electronically (programmable logic controller) and if you go to open a tiger gate, it says it's got an open signal somewhere so you can't open the gate until you close the other one.
"The answer is in the gates. It's nothing to do with a human. Humans won't design all errors out because we're human. There's always a mistake waiting to be found but the key is when a human makes a mistake get rid of it for next time."
AUSTRALASIAN ZOO EXPERTS
Hamilton News sought information from the Zoo and Aquarium Association about recommended fence heights and safety measures for big cat enclosures. The association is "the peak body representing the zoo and aquarium community throughout Australasia" and "sets the level of professional standards and practice for its members". A spokesperson confirmed the ZAA was working with Council and wouldn't comment until the investigation had concluded and the findings made public.
EXPERTS FURTHER AFIELD
US-based Association of Zoos and Aquariums(AZA) represents some the best of the world's aquariums and zoos. While a representative was unable to comment before this went to print, media liaison Rob Vernon directed us to their website which says AZA provides members "with the standards and best practices needed to be leaders and innovators in animal care, wildlife conservation and science, conservation education, guest experience and community engagement". Its lion care manual says practice for new exhibits in AZA institutions is at least 4.5m with a turnback/overhang. "Exhibits and service areas should have a secondary door system to maximise safety through keeper error. All doors to lion exhibits should have secondary containment to serve as a safety measure against escape."
