Investigator: S.F. Zoo enclosure where gorilla died is unsafe

A visitor strolls past a memorial arranged for the 16-month-old gorilla Kabibe at the San Francisco Zoo on Nov. 13, 2014, after the gorilla died in an accident Nov. 7. A visitor strolls past a memorial arranged for the 16-month-old gorilla Kabibe at the San Francisco Zoo on Nov. 13, 2014, after the gorilla died in an accident Nov. 7. Photo: Paul Chinn / The Chronicle Photo: Paul Chinn / The Chronicle Image 1 of / 15 Caption Close Investigator: S.F. Zoo enclosure where gorilla died is unsafe 1 / 15 Back to Gallery

The San Francisco Zoo enclosure where a 16-month-old endangered gorilla was fatally crushed under an electric door is outdated and unsafe and should be replaced, the lead investigator into the death said Thursday, raising further questions about conditions at the zoo.

The western lowland gorilla, named Kabibe, darted back under the downward-closing door Nov. 7 after being moved into her night quarters. One focus of the investigation is whether the zookeeper, after activating the door, followed protocol and kept her hand on an emergency stop button designed to prevent accidents.

But Dr. Terry Maple, a gorilla expert hired by the zoo to look into the death and help fix any problems it exposed, said a person using the control panel with the emergency button would not have a clear, unimpeded view of all of the doors — or of the enclosures behind them. And the doors aren’t designed to stop when they hit something, like garage or elevator doors.

“When you look at (the location of the control panel), you can see it’s not perfect,” said Maple, an environmental psychologist and biologist who once chaired the Association of Zoos and Aquariums, which accredits facilities including the San Francisco Zoo. “It can be a lot better. We think it’s time to build a new holding facility.”

'Not easy to do’

Maple said watching each of the doors from the control panel is “possible to do, but it is not easy to do.” He said he will recommend that the zoo scrap the 30-year-old gorilla enclosure and install a state-of-the-art system that would be safer for the apes and could include a portable system for operating the doors, allowing workers to look directly into the cages.

“Sometimes traumatic events lead to big changes,” Maple said in an interview with The Chronicle. “What we are going to do is look at the modern technology, and examine these options. I’m presenting these to the zoo, and will let them decide how to move forward.”

He said the zoo needs a “cutting-edge solution that everyone in the zoo world would look at as the next wave.”

Zoo officials would not respond to questions Thursday about the gorilla exhibit. But the exhibit’s night quarters have a history of mechanical failures and safety issues, including an incident two years ago when a gorilla was injured by an electric door, according to zoo records obtained by The Chronicle.

On July 16, 2012, an adult gorilla named Monifa had her right hand pinched under a door, cutting the base of all four of her fingers, according to a zoo report. She was treated by veterinarians, and mechanics adjusted the door — which was not the same one that killed Kabibe.

On March 4, 2013, the same door that injured Monifa jammed and had to be pried open with a crowbar, records show. The same door then unexpectedly collapsed earlier this year. “Electric door 5 crashed down in AM while securing gorillas,” stated a Feb. 22 report. “No one injured just upset by noise.”

Maple said he was aware of the reports, and that they reinforced his conviction that the enclosure needs to be overhauled.

“There are always maintenance problems with these old doors,” he said. “I think that incident (in February) demonstrates what can happen when you have to constantly care for this equipment. Fortunately that particular incident didn’t result in any injuries, but it certainly could have.”

The zookeeper in last week’s accident, whose name hasn’t been released, said in a handwritten statement to zoo officials that it occurred after Kabibe s grandmother, Bawang — who acted as her surrogate mother — carried her tightly on her arm into their nighttime enclosure from the exhibit area visible to the public.

'Kabibe was caught’

“I began to close electric door 4 and when I looked at the door again, it was closed and Kabibe was caught in the door across her chest and I immediately opened the door,” the zookeeper said.

The day after Kabibe’s death, zoo Director Tanya Peterson sent an e-mail to Recreation and Park Department General Manager Phil Ginsburg. The zoo has a semiprivate leasing agreement with the park department, and several times a year is required to submit reports to the city as part of the agreement.

The e-mail included a picture of a sign next to the gorilla enclosure’s control panel that reads, “To prevent injuries to the gorillas during operation of the electric doors: Move only one door at a time. Keep your hand on the stop button at all times. Do not leave the electric panel until operation of the door is complete.”

“As you can see, the keeper is to maintain a hand on the “STOP” button at all times and not leave until the door operation is complete,” Peterson wrote. “Unfortunately, in this case, it appears the keeper did not follow the protocol.”

Some zoos do not have automatic electric doors in gorilla quarters. At the San Diego Zoo and the San Diego Zoo Safari Park in Escondido, zookeepers open and close doors by hand — doors that were built in the 1970s and 1980s. Neither facility has ever had an incident in which a gorilla was killed by a door, said spokeswoman Christina Simmons.

Other incidents recalled

The safety questions raised after Kabibe’s death are only the latest at the San Francisco Zoo, which over the years has seen injuries to animals, staffers and visitors.

In 2007, a Siberian tiger escaped from her exhibit on Christmas Day, mauling a teenager to death and injuring two of his friends before police shot and killed it. Three years earlier, two elephants died, prompting the city’s Board of Supervisors to step in and force the zoo to move its two remaining elephants to a sanctuary, where one of them soon died.

The U.S. Department of Agriculture, which is responsible for enforcing the Animal Welfare Act at zoos and other facilities, is also looking into Kabibe’s death.

If the agency suspects the zoo was out of compliance in the accident, it can send in an inspector, unannounced, an agency spokeswoman said. That inspector can request an investigation. Ultimately, the agency can issue a fine or a warning, and can also send the case to an administrative law judge, who has the power to suspend or revoke the zoo’s license.

Kabibe, whose name means “little lady” in Swahili, was one of about only 750 Western lowland gorillas living in captivity. There are roughly 100,000 of the endangered species living in the wild in Central Africa.

Evan Sernoffsky is a San Francisco Chronicle staff writer. E-mail: esernoffsky@sfchronicle.com Twitter: @EvanSernoffsky