Gorilla invest­igator never talked to keeper

San Francisco Zoo officials Wednesday said they would make changes to prevent further accidents like one that killed a young gorilla earlier this month following the release of an investigators report.

The youngest member of the Jones Family Gorilla Preserve, a gorilla named Kabibe, died Nov. 7 while a staff member was carrying out its nightly post-closing routine of moving the animals into their night quarters.

Kabibe darted unexpectedly under a closing hydraulic door and died from her injuries, according to zoo officials. Her death raised questions from the media and the public about the zoo’s staffing policies and relocation procedures.

Zoo administrators hired Dr. Terry Maple, a Florida-based animal psychobiologic, to investigate, officials said. Maple began his work from Florida on Nov. 10, according to a five-page report released Tuesday that he authored, and he arrived at the zoo on Nov. 16.

He was in San Francisco for five days, according to a zoo spokesman, but never once had the opportunity to speak with the on-duty keeper of the gorilla preserve. According to his report, she was the only one working at the time of the accident.

Maple said, based on a statement sent by the employee:

“There were no other witnesses to the accident. … An interview with the keeper on duty could not be arranged during the time I was in San Francisco.”

Maple did manage to arrange interviews with “five of the six” fulltime keepers who work with gorillas at the zoo.

In response to the report’s recommendations zoo officials said they would continue the use of a “buddy system” for keepers implemented on Nov. 8, retrofit the existing 34-year-old doors with new technology, provide headsets for gorilla preserve operators, improve training, and form an expert training advisory committee.

Zoo officials also said they would install a backup generator at the gorilla facility in case of unexpected power loss, enhance maintenance inspections, and share Kabibe’s story and the resulting facility and protocol improvements with other zoos.

Zoo spokesman Danny Latham said neither Maple nor zoo officials would answer any questions about the incident or the keeper’s lack of availability while the investigator was in town.

Maple said, “For one year zoo keepers have worked in pairs,” but did not explain why the keeper was not with a buddy when she was moving the gorillas into their nighttime habitats.

Zoo officials said in a statement the “buddy system” was implemented on Nov. 8, but declined to explain the discrepancy between the report and their own press release.

Officials have said that the policy is in place now, and Maple’s report said:

“… keepers can no longer operate the electric moving doors to transfer animals when they are working alone.”

The five keepers who were interviewed all said mechanical failure was not the cause of the accident, according to Maple’s report. “The motor-driven doors have been operated safely in the gorilla holding building since it opened in 1980,” Maple said in the report.

Zoo officials said in a press release that the doors had operated for “more than 30 years without major incident” until Kabibe died.

The report says only that the keeper operating the door immediately opened it and contacted a veterinary technician. Maple consulted with zoo architect Gary Lee of CLR Design about the construction of the gorilla facility and its gates.

According to the report, Lee said the position of the door control panel is fixed and confines the operator to a distant location from several of the moving doors.

The report reads:

“The operator’s view of the door is partially obstructed by metal poles which makes it difficult to monitor all of the gorillas simultaneously.”

Transfers are often noisy and gorillas are active and unpredictable.” According to Maple’s report, the report was not intended to identify a cause of the accident, but rather to introduce recommendations, which zoo officials said they “wholeheartedly” embrace.