Safety Report for Zebra Incident at National Zoo

A Smithsonian safety investigator completed her investigation of an incident involving a male Grevy's zebra, Gumu, that seriously injured a zoo keeper Nov. 18. The safety investigator concluded the incident appears to be the result of human error.

Read the Executive Summary of the Safety Report. The report highlights are:

• There were no engineering or mechanical failures with the facility or equipment that house the zebras. (Note: The facility meets Association of Zoos and Aquariums standards.)
• Specific protocols are in place for this routine/these animals.
• The gates and doors from the Grevy's zebra stall to the adjoining yard where the keeper was working were not secured. This is a breach of protocol.

It is the Zoo's standard practice to evaluate and respond to all internal or external evaluations of animal care and safety reports. All of the recommendations in this safety report are under review, and the Zoo is now conducting its own internal audit of management protocols.

Regrettably, a zoo keeper was seriously injured during the incident. The animal management protocol states that humans and dangerous animals, such as a Grevy's zebra, should never be in the same space together. There was no other witness to inform the investigator team as to how the zebra and keeper ended up together. The zebra should have been contained in his primary stall while the keeper was cleaning the adjoining stall.

The Zoo acknowledges the heroic efforts of staff and a volunteer keeper aide who managed to rescue the injured keeper by distracting the zebra and shifting the animal to a different secure location. The Zoo also acknowledges that the injured keeper acted with clarity during the incident, which likely prevented him from receiving further injuries.

The zebra involved was checked immediately by the veterinarian team and has been under close observation for any changes in behavior. He has not shown any evidence of illness, and the keeper team reports that he follows his daily schedule and has not exhibited any unusual behavior, even though he is described as an aggressive animal.

Below is additional context to clarify portions of the analysis:

Safety Investigation Report Executive Summary: Past incidents were not reported to the safety coordinator, providing opportunities for prevention initiatives and/or sharing of lessons learned.

Clarification: The Nov. 18 incident is the only incident at the Cheetah Conservation Station that involved an animal injuring a keeper or staff member. Past incidents include:

• A zebra gaining access to secondary containment, Dec. 29, 2012.
  Animals have multiple areas they transition through from their primary area where they are on view to the public to their internal off-exhibit spaces. These transitional areas serve as a safeguard for Zoo visitors, staff and animals. A zebra gained access to the secondary holding area where it was not supposed to be. This was a performance issue linked to human error, and proper action was taken. Personnel/performance issues are not reported to the NZP Safety Office. Further, when an animal gets out of primary containment, a "Code Green" is issued. A Code Green is an alert that is sent out Zoo-wide when an animal is out of primary or secondary containment. After the incident, a Code Green report was filed as required.
• A keeper put two animals that do not cohabitate into the same enclosure, Dec. 8, 2008.
  The zebra and gazelle were together in the public viewing area, also known as primary containment, and were safely separated. No animal or staff member was injured. As this incident was a personnel/performance matter, no report with the Safety Office was filed.
  
  

Safety Investigation Report Executive Summary: There is no documented training or training plan for this protocol.

Clarification: All animal keepers undergo extensive training by senior keepers and curators for protocols or guidelines that must be followed while caring for the animals they work with. The first element in a keeper's work plan is following proper animal care protocols. The report refers to the fact that no signed training document is on file with the NZP Safety Office for the keeper in question. Departments across the Zoo are moving to a documented training program where after training, both keeper and supervisor sign a document that the training was properly completed. The veteran keeper had completed his training prior to the new documentation process.

Read the Executive Summary of the Safety Report.