South Florida Museum staff noticed panel was loose but repairs weren't made.

BRADENTON — A series of communications failures cost Manatee County its beloved mascot, Snooty the Manatee, South Florida Museum leaders acknowledged Thursday.

South Florida Museum's CEO, Brynne Anne Besio, said aquarium staff knew that a panel leading to the "cave" where Snooty drowned was askew or missing screws, but because of failures in record keeping, reporting, communications and follow-through, no action was taken and no repairs were made.

"Unfortunately, these same breakdowns in reporting and communications caused us to share inaccurate information immediately following the accident, and I am sorry," Besio said during a press conference, during which she apologized for Snooty's death.

Museum spokeswoman Jessica Schubick confirmed that Snooty's primary caretaker, Marilyn Margold, director of living collections, no longer works at the South Florida Museum, but she could not comment on whether her departure was related to Snooty's death.

The panel leading into the cave opened sometime after Snooty, the world's oldest-known manatee, celebrated his 69th birthday on July 22.

He swam into the enclosed area, where he became stuck and drowned. Manatees of his girth — about 80 inches wide and 1,300 pounds — have not been known to be able to swim backward.

After his death, the Herald-Tribune published photos showing that the panel was loose days earlier.

South Florida Museum officials had said that the panel became dislodged sometime between the evening of his birthday party, July 22, and the following Sunday morning, July 23.

But the Herald-Tribune images called into question the museum officials' contention that divers inspected the 60,000-gallon tank before the celebration and found no problems. The images show noticeable gaps around the door, suggesting it already was loose before dropping open.

The newspaper's photographs were included as part of the museum's investigation into the death.

A month after Snooty's death, the museum hired James Gesualdi, a New York-based attorney and animal welfare advocate, to conduct a review.

Before Gasualdi's hiring, the museum had said it would consult with its partners with the Manatee Rescue & Rehabilitation Partnership, but Schubick said the Board of Trustees selected Gesualdi because members felt confident he would provide answers and "advocate on Snooty's behalf."

According to Gesualdi's report, he reviewed the site of the aquarium, interviewed museum staff — manatee care team members, key facility and executive staff, Snooty's veterinarian Dr. David Murphy — and also reviewed museum records, documents, photos and security camera footage.

Gesualdi found there were deficiencies in record keeping and reporting; a breakdown in departmental and interdepartmental communications; a lack of proactive follow through; and a need for improved staff training.

Gesualdi stated in his report that newer staff were aware of the risks that the cave area posed to humans, but were unaware it could be potentially dangerous to manatees.

Some staff did not realize problems requiring repairs should be noted in dive logs.

The report said the panel had not been removed since 2010, when the aquarium was last drained. The cave was declared "off limits," and cleaning operations inside the space were discontinued until just before Snooty's death.

Maintenance problems with the panel occasionally arose, Gesualdi's report states, such as loose, rusted or worn-out screws.

Staff stated that they all had experienced at least one problem with the panel during their employment.

Two situations involving the panel occurred during the week before Snooty's death, the report states, but doucmentation of these incidents were "verbal and informal" and never included in dive logs, according to the report.

Daily dives the week before Snooty's death were incomplete three times and skipped once.

The panel appeared to be in place in video footage before nightfall July 22 — one day before Snooty's death. Darkness made it impossible to see inside the tank after dark.

On the day Snooty died, the manatees' pool, also occupied by rehab manatees Randall, Baca, and Gale, was murky with stirred-up, brownish water, Gesualdi found. When staff checked the tank they found the younger rehab manatees, but there was no sign of Snooty.

Caretaker Jack Balkan, the chief facility officer, called 911 to report a problem in the manatee tank. He told dispatchers there might be a problem with Snooty.

The Bradenton Fire Department sent a diver into the tank and located Snooty inside the cave area.

Snooty's body was recovered and the fire department resecured the panel with new screws.

Balkan went back into the tank a day later and reinforced the structure behind the panel with high-density PVC supports, and added a middle support in case the panel were to become dislodged in order to prevent manatees from entering the compartment. He secured the panel with 10 stainless-steel screws.

Besio said the museum is restructuring the manatee care staff and working with national animal care experts to help review Gesualdi's findings. The report is being used to create a new program focused around the manatee rehabilitation program.

Museum officials declined to comment about the cost of Gesualdi's report.

"We are working through this situation with the U.S. Department of Agriculture and the U.S. Fish and Wildlife Service," Besio said.

The museum has also asked the Manatee Rescue & Rehabilitation Partnership to review its operational procedures.

"I think that we as a staff are going to embrace a culture of going beyond compliance," Besio said. "That is in the aquarium as well as the entire staff. That is our commitment going forward."

'Love of my life'

One former employee, Sally Senger, who was Snooty's caretaker from 1998 to about 2013, said they always cleaned the cave when she worked there. This included removing the panel, laying it aside and cleaning the dark compartment.

Senger said she was demoted to "voluntary status," and later the museum staff told her that her voluntary services would no longer be needed. She learned about Snooty's death while she was out of town.

"It was a privilege to work with Snooty, but those young kids (newer staff) didn’t think it was privilege," Senger said. "They’d walk by him and didn’t say 'Hi, Snoots.' It was just a job with them. He’s a famous manatee and he was so lovable. He could be swimming around in the pool and I’d say 'Hey, Snoots,' and he’d come over. He was the love of my life."

Senger has a bumper sticker on her car now that says "Snooty lives in my heart."

She last saw Snooty a week before his death.

Now, after the death, the museum will "move forward with a focus on its manatee rehabilitation program, its planetarium and natural history of Florida," Besio said.

"Snooty was a draw — people loved him — but manatees are a draw, our planetarium is a draw, and our natural history museum," Besio said. "Snooty was an ambassador to manatees all over the area. He helped us tell that story. We will continue to tell that story with our rehabilitation program."