The external investigation of the chimpanzee escape is concluded – Identifies lack of routines and systematic security work
Updated on April 14, 2023
The EY investigation of the chimpanzee escape in December is now concluded, and confirms that lack of locking routines lead up to the chimpanzees getting out of their secure area. The investigation also states shortage of the park’s systematic security work. Furuvik has already taken action on several identified points, and plan to go through with all recommendations that the investigation suggests.
Furuvik gave the accounting firm EY the task to investigate the chimpanzee escape of December, to find out how the incident could happen, if there were routines lacking plus identify recommended actions for our continued work. The investigation confirms that lack of locking routines lead to the chimpanzees getting out of their secure area. It also identifies lack of routines in the park’s systematic security work, like the control environment, risk reducing actions, risk assessments plus follow-ups and supervision. A number of the statements in the investigation have already been accomplished or planned for, since those points were already stated through Furuvik’s own investigation and reports to Arbetsmiljöverket and länsstyrelsen (the county board). Furuvik also plans to perform all recommendations suggested by the EY investigation.
-The safety of our colleagues, guests and animals is our first priority, and we have already taken several actions, which was stated by both länsstyrelsen and Arbetsmiljöverket in their reports. We will always try to be better and there are still improvements to be done, which this investigation shows. Some actions will be quickly implemented, but also initiates a long term work increasing our readiness according to the EY recommendations, says Sandra Wilke, CEO of Furuvik.
Control environment EY notes that there is a severe lack of locking routines in the chimpanzee building, and no actual knowledge requirements regarding the chimps and their area for the person to perform the post locking control. The report also states that a structure of document version history is missing in the business, plus no clear hierarchy regarding policies, guidelines and instructions.
Example of measures: A new routine and structure for handling steering documents and policies will be implemented. A new locking routine has already been implemented, and we will oversee all locking routines of the entire park.
Risk assessments and risk reducing actions The investigation states that the physical safety of the facility consists of 1 security layer, meaning the chimpanzees safe area and their gates and locks. After the chimps had gotten out of their enclosed area, they were able to get out through doors and windows of the house. The safety of the rest of the house is not adapted for chimpanzees that are used to people, and able to use both door and window handles as in this case.
Example of measures: Actions have already been taken to increase safety of the chimpanzee building, such as removal of window handles. There are also plans to install window bars plus extra latches on the outside of the doors, to create extra safety layers to the building.
Follow up and supervision According to the safety plan of Furuvik, it states that an annual audit of the security work should be done. However, EY’s investigation notes that the annual audit has not been performed according to plan. This is considered an essential risk.
Examples of measures: A routine for annual follow up and audit of the safety work has already been implemented, and annual crisis drills will be performed.
The conclusion of the EY investigation “What primarily caused this incident is that the locking routine for the chimpanzee building was not being followed by the staff. The coworker had not locked the area after finished work, which was not noticed at the following locking control. The essential shortage of systematical security work at Furuvik that EY has stated during this investigation, has most likely contributed to this incident. Shortage has been noticed in the control environment, risk recuding actions, risk assessments and follow up/supervision”.
EY’s summarized recommendations
- That Furuviksparken establish a clear hierarchy of policies, guidelines and instructions. Plus develop the way of working with steering documents and business routines.
- That Furuviksparken document in writing the actual locking routines of the chimpanzee area, and that the after control is performed independently by a person following a predetermined course of action.
- That Furuviksparken secure that the level of physical safety and other security/ readiness actions are done according to estimated risk level. If that is not the case, consider additional risk reducing/security increasing actions.
- To secure that the Animal department and the facility has enough financing in relation to the evaluation of Furuviksparken’s safety increasing actions.
- That Furuviksparken will map applicable external regulations, incl laws and regulations, that the business is covered by. To secure that for example animal euthanasia.
- That Furuviksparken develop the cooperation within the company group regarding crisis handling, complete crisis plans (with information on who the crisis manager is), and perform crisis drills on a regular bases.
- That Furuviksparken secure follow up of the safety plan regularly.
- That the management of Furuviksparken regularly communicate to the organization regarding safety and crisis preparation, to create awareness of management priorities.
The investigation of the chimpanzee escape at Furuvik by Länsstyrelsen (the County Board) is now completed
Update on April 12, 2023
Today, Länsstyrelsen have shared their conclusions from the investigation of the chimpanzee escape at Furuvik, in December last year. They point out that Furuviksparken was not aware that they should have applied for an exemption for remote euthanasia. Above that, they believe that the park have fulfilled their responsibilities as animal keepers connected to the actual incident, and therefor close the case.
Länsstyrelsen, that investigates questions on animal welfare and animal protection, opened an investigation due to the chimpanzee escape at Furuviksparken in December. The investigation is now concluded and summarized as follows in their control report:
• Länsstyrelsens estimation is that you have fulfilled your action responsibility as animal keepers in this incident. You have also completed improvements of the building where the chimps are being kept, on a level considered enough to avoid something similar to ever happen in the future.
• Länsstyrelsen estimates, from the information provided by you, that knowledge of how to act following the animal protection law for remote euthanasia of chimpanzees was missing at the time. This resulted in you using a euthanasia method that is not approved according by the existing law. Länsstyrelsen states that primates are not included among species that can be put to death remotely using a shooting weapon. In such a case, an exemption must be applied for. However, Länsstyrelsen mean - from the information provided by you - that you have taken enough measures to secure following the law requirements if something similar would ever happen again.
• Länsstyrelsen estimates that you fullfil the demands for holding a permit for public demonstration. The case will be closed.
-We are thankful that Länsstyrelsen have investigated this case so carefully. It feels great that they recognize us fulfilling all requirements, and state that actions we have taken to prevent something similar from ever happening again, are sufficient. We are however self critical and look very seriously on the fact that we did not know about the law missing regulations for remote euthanasia of several high risk animals in zoo parks; chimpanzees among them. This we should of course have noticed, and applied for an exemption earlier, says Sandra Wilke, CEO Furuvik.
Furuviksparken will now apply for exemption from ”Föreskrifter om ändring i Statens jordbruksverks föreskrifter och allmänna råd (SJVFS 2019:8) om slakt och annan avlivning av djur (SIVFS 2020:22, L22)” (”Regulations of changes in the Swedish agricultural works regulations and common advise about animal slaughter and other euthanasia”), to - in an emergency situation - have the choice of remote euthanasia if animals are on the run, not possible to put to sleep or considered a danger to people.
-If there is a crisis situation where people are in danger, human lives and safety comes always in first hand. That being said, we of course hope that this exemption will never need to be used. We have sharpened and improved our locking routine in the chimpanzee building and will also make an extensive overview of all locking routines of the park. Safety will always be the most important thing to us, says Sandra Wilke.
Now, the investigations by Arbetsmiljöverket and Länsstyrelsen are concluded. The police has previously established a notification to Furuvik on crime against the animal welfare law, that investigation is still ongoing. Also the external investigation, that we have given to the accounting firm EY to perform, is still ongoing. We have continously assisted all investigations fully out.
Open grid door behind the chimpanzee escape at Furuvik
Update on February 1st, 2023
A grid door that had been left open enabled the chimps to get out of their enclosed area at Furuviksparken in December, which lead to the fact that four chimpanzees had to be put to death. This is presented in the statement that the park has sent in to länsstyrelsen and Arbetsmiljöverket. Furuvik have now reinforced the routines of the chimpanzee building, and the investigation of this incident continues.
It was a combination of deficient routines and human errors that lead to the escape of the chimpanzees at Furuviksparken on December 14th. At first, a zookeeper forgot to close and lock a door while working in an empty chimp area. Thereafter, two zookeepers missed to doublecheck that same door before the chimps were let back into their area.
In the light of what happened, it is clear that our routine for locking the chimpanzee area has been inadequate. It lead to a very serious situation that could have been dangerous to people, and to us having to put four of our chimpanzees to death, says Sandra Wilke; CEO of Furuviksparken.
Furuviksparken describes the sequence of events in a statement that the park now sent in to länsstyrelsen and Arbetsmiljöverket. The two authorities will now review the escape of the chimpanzees from an animal protection and work environmental perspective.
During 2020 and 2021 two different incidents happened, connected to locking up the chimpanzee area. These incidents have lead to internal reports and Furuvik has taken actions.
With all facts on hand, it is clear that the actions taken have not been sufficient. We have now improved our lock routine in the chimp building, with a checklist and higher demands and knowledge of the area and the animals. Above that, we will do an extensive overview of all lock routines in the zoo. We will do everything we can to prevent that something similar ever happens again, says Sandra Wilke.
Furuviksparken has already given the assignment to accounting firm EY to make an external investigation of the incident. The police have also established a report of crime against the animal welfare law and work environment violations.
We welcome and assist the investigations by the police, länsstyrelsen and Arbetsmiljöverket. We stand humble for the fact that the work by the authorities and EY can come with new facts and insights in how we can improve our work, says Sandra Wilke.
Summary of the sequence of events
• In the morning of Wednesday Dec 14th, Furuvik’s seven chimpanzees is in one of their three enclosed areas, while a zookeeper and a craftsman is working in two of the other areas. After finishing the work, the zookeeper forgets to close and lock one of the grid doors to one of the areas.
• Around twelve that day, two zookeepers check the locks before moving the chimps to two of the other areas. However, both of them miss to check the specific grid door left open.
• When the chimps have been taken back in their areas, one of the zookeepers gets a feeling of missing something. He/She discovers that the grid door is open, that one chimp has gotten out of the area and that another chimp is on it’s way through the open grid door.
• The zookeeper tries to get the chimp back is on it’s way out, but fails. He/She realizes that he/she is not safe, calls for the other coworker to get safe, alarms on the com radio and leaves the chimpanzee building for a safe place.
• Approx five minutes later, the park staff realizes that three chimps have gotten out into the park. Outdoors it’s around minus 15 degrees cold.
• Shooters are called for, and builds different teams together with the parks zookeepers. By cars the teams look for the animals in the park area.
• Around 45 min after the escape, two of the chimps are found by the parks tivoli area. They are found not being on their way back to the chimpanzee building.
• After consulting several veterenaries, where anesthesia is ruled out, the CEO and zoo manager together decide that the two chimps must be put to death.
• During the afternoon, three chimpanzees make several attempts to get out into the park through a window. One of them is hit by a shotgun. The shot is not fatal, so the chimp returns into the building and stays there. The two other chimps that tried to get out of the window is however not scared off by the shooting sound, and continues to go in and out through the windows. The risk of them getting out into the park is considered large. The falling darkness would make it difficult to take a safe shot if needed, and to search for a chimp in a dark park is a huge risk for both the animal – who can freeze to death if not found – and people. Decision is made to put them to death as well. Of security reasons and to minimize the risk to shoot damage the animals, the shots are fired when the chimps are temporarily inside the windows.
• Later during the afternoon and evening, the staff can spot all the lasting chimps within the chimpanzee building, among them the third of the chimps that first escaped. That chimp has returned on it’s own.
• During the Thursday, Friday and Saturday morning, different actions are taken to secure the chimpanzee area without causing danger to people. As soon as possible, heat and food for the chimps and the other animals in the building are provided.
• On Saturday December 17th at 9.06, zookeepers manage to secure the chimps back into their enclosed area. The work with taking care of the lasting three chimps and other animals can continue during safe conditions.
Examples of performed actions so far
• Improvement of locking routine, with an added check list for the lock control. Two zookeepers must each mark on a checklist that they have both controlled each single lock.
• Both zookeepers performing the lock control must have good knowledge about the animals and the construction of the area. One of the zookeepers must, as previously as well, be on the highest competence level within of Furuviksparkens own grading. The other zookeeper must be on at least level 3 of 6.
• Handles on windows are taken away.
Examples of planned actions
• Overview of all lock routines within the zoo.
• New routine of doors connecting staff areas and chimpanzee areas; these must always stay closed.
• Grids on windows in the staff areas of the chimpanzee building will be installed.
Starting points for the decision of putting the chimpanzees to death
• Chimpanzees are classified high risk animals, and can be a huge risk for peoples lives and safety.
• There was staff in several places in the park, and guests at Furuvik Havshotell just outside of the park. There is also a residential community closely connected to the park.
• Anesthesia was not a safe option, which was quickly determined by both zookeepers and vets. It can take a long time, between 10 and 20 minutes, for anesthesia to start working. During that time, the chimp is still a danger to people and can move around. It is also not for certain that anesthesia gives the estimated effect. We also didn’t have the opportunity to place a sleeping chimp in the chimpanzee area, since that area was not secured.
• Several chimps were loose in the park at the same time.
• The chimpanzee building was not secured, meaning there was risk for further escapes.
• The extreme cold and the falling darkness made the situation more difficult in several ways. During the Thursday it was around 15 minus degrees, and the sun set around 2.40 pm.
Update on January 18th, 2023
Accounting firm EY to perform the external investigation of the chimpanzee incident
We have given Ernst & Young the task to perform an external investigation of the chimpanzee escape incident. The investigation will bring light to how the escape could happen, where we failed, if we could have acted differently and how we secure that nothing similar will ever happen again.
This external investigation has now started up, and we will share all results when it’s concluded. We don’t know yet when in time exactly, it is crucial that this investigation is done thoroughly.
Update on January 2nd, 2023
Here is a summary of the situation at Furuvik after the holidays:
The vet visited during the morning to estimate the wellbeing of the chimps. All three chimpanzees Maria-Magdalena, Tobbe and Selma are still improving health wise.
Maria-Magdalena is no longer coughing nor using medicine. Selma is still on meds and eye and arm healing. The vet states that she is starting to open her wounded eye more often.
The chimps dealt well with New Years Eve, despite fireworks and firecrackers. During the evening, zookeepers were present and the chimps were surveilled by cameras constantly. To distract them from the fireworks, the radio was running and lights on during the entire night.
Zookeepers and vet focus on taking care of the animals and monitor their health and wellbeing.
Update on Dec 27nd, 2022
The wellbeing of all three chimps is improving. Zookeepers make sure they are increasing physical activity in their enclosed area. Prior to this weekend, the vets decreased medication from three times per day to two times. Tobbe is more or less back to normal, and no longer on any medication. Maria-Magdalena and Selma are still under treatment.
The zookeepers have offered the chimps environmental enrichment, by hidden nuts in fabric balls. In that way, the chimps search for food while getting in contact with new materials. This is a way to stimulate them.
Zookeepers and vets keep monitoring the animals’ health and wellbeing
Update on Dec 23 rd, 2022
All three chimps are gaining health by the day. The vets have decreased medication from three to two times per day. Zookeepers and vets keep monitoring their health and wellbeing.
It is absolutely crucial that the external party, to whom we assign the investigation of this tragical incident to, is independent from Parks & Resorts. The independence control that was performed, showed no evidence of dependance that could be a possible hinder to KPMGs audit. However, there is a connection to one of our minority partner’s company, where KPMG is the responsible accountant. We have therefor decided to assign the task to another external performer.
It has always been our ambition that this investigation must be performed by an actor with no connections to Parks & Resorts. We will get back on who we will assign this task to instead of KPMG.
Update on Dec 21st, 2022
All three chimpanzees doing well, and we can see that our wounds on one of our females, Selma, are healing well. Eye less swollen and arm more easy to move around.
The other female, Maria-Magdalena, still has a cold but is still on meds to prevent respiratory tract infection. Our male, Tobbe, is more or less back to normal.
We have given the accounting firm KPMG the assignment to perform an external investigation to find out how the chimps could get out, where we have failed and how we can ensure that something like this never happens again. When this investigation is finalized, we will share the conclusions.
Update on Dec 20th, 2022
All three chimpanzees continue to show healthy appetite. Today we have started to go back to their normal diet; meaning pellets, vegetables and lettuce.
We have begun to stimulate the chimps with playful exercises again. They respond well, and show signs of enjoying it.
Our wounded chimp is still on medication, but healing.
The two other chimps are still on antibiotics and other anti-inflammatory medicines, to prevent respiratory tract infection.
Update on Dec 19th, 2022
On December 14th, 2022 a group of chimpanzees at Furuviksparken managed to get out of their enclosed area. Some of them even managed to get out of the building, which lead us to the very difficult decision to shoot them. The safety of people is always our highest priority, and since chimpanzees are classified high risk animals we were left with no choice.
To instead use tranquilizers when a chimp is under stress outside a fenced area, is of high risk since this is in fact a wild and dangerous animal. Tranquilizers require getting close proximity to the animal. Additionally tranquilizers take at least 10 minutes before taking full effect. Unfortunately, shooting is therefor the only solution to a chimp loose in the park.
Five of the chimps remained within the complex, but outside of their normal enclosed area. This includes one chimp who had temporarily left the building, but returned after being wounded outside. The building has been under constant supervision from the outside. Due to the high risk of entering, all of the monitoring and supervising has been done from outside of the building which is a logistical challenge.
On December 16th, 2022 we managed to enter the building to provide the chimps fresh food and drinks. Only then could the two deceased chimps outdoors finally be identified. Three of the five ones indoors have been identified as well, and have been eating from the food they’ve been offered. Two chimps have still not been identified yet, but one of them confirmed deceased.
We understand that this affects many of you, and we are terribly sorry about the situation. We will investigate how this happened and keep communicating with the latest information.
Our thoughts are with our animals, all of you who care for them and our staff. This is all so very sad.
On December 17th, 2022 we managed to get the chimps back in their enclosed safe area, with no risk for them to get out of the building again. Full focus now on taking care of the surviving three chimps, and monitoring their health and wellbeing.
On December 18th, Sandra Wilke (CEO of Furuviksparken) expressed that full focus wlll remain on taking care of the chimps, who are eating and drinking well, moving around, taking antibiotics etc.
It’s an enormously tragic situation where we have clearly failed in keeping our chimpanzees safe in their enclosed area. We understand that many of you are sad, upset and disappointed with us. We also understand that there is criticism on how we have chosen to act and how one preferably would have handled the situation when the chimps were outdoors in the park. We acted according to our safety plan, which is always judged depending on the situation. We considered it a risk for people to get hurt, and therefor people’s safety is first priority.
There are many questions to be answered. Therefor we will make a thorough investigation done by an independent part. This will show how we have failed and if we could have handled things differently.
We will of course share the results of this investigation when it’s done. When in time, can not yet be stated. We will make sure to sort everything out, in order for something like this to never ever happen again.
Our thoughts are with our animals, all of you who care for them and our staff. This is all so very sad.