SAN FRANCISCO (Map, News) - Disbelief from zoo staff members, limited access to radios and guns, a lean zoo crew and a low moat wall were all factors to blame in the fatal tiger attack at the San Francisco Zoo on Christmas Day, according to the results of an investigation by the Association of Zoos and Aquariums.

The zoo lacks personnel to “effectively train, oversee and enforce existing policies and procedures,” a report released by the agency’s accreditation commission Tuesday concluded. “The zoo is often chasing problems rather than proactively addressing known concerns,” it said.

A month after a 4-year-old Siberian tiger named Tatiana escaped her grotto and fatally mauled a 17-year-old visitor and injured two of his friends, investigators with the AZA interviewed zoo employees and officials as well as city representatives. Tatiana killed 17-year-old Carlos Sousa Jr., of San Jose, after he tried to intervene while the tiger attacked his friend, Paul Dhaliwal. Paul and his older brother, Kulbir, then fled to a zoo cafe and asked for help from the manager, who refused the young men admittance because of their “erratic behavior.”

The manager also violated protocol by not administering first aid, according to the report. But such contract personnel were never included in emergency drills, the report said.

When the attack occurred around 5 p.m., the zoo manager on duty had left for the day, as well as 29 of 31 animal-care personnel and two of three veterinarians assigned to work. Visitors were allowed to roam the park after the 5 p.m. closing time, the report said.

Tatiana appeared to have escaped her enclosure where the moat wall was 12 inches shorter, a result of material being added in 1982 to improve drainage, according to the report.

Additionally, keys to zoo vehicles and the area of the zoo where the guns are held were not readily available for staff responding to the incident, and radios were locked away by zoo staff who had left early, the report noted.

Nonetheless, the report applauded the “exceptional response” by zoo staff to the incident.

Michael Cardoza, the attorney for the Sousa family, addressed the “skeleton crew” working at the zoo that day. “That’s, to me, tantamount to saying, ‘We have 10,000 people rioting, and for the two cops that were there they did a great job,’” he said.

The zoo will keep its accreditation from the association, but it must submit a written report to the AZA by the end of 2008 on security and safety changes it made, then undergo a second inspection from the AZA in early 2009, Manuel Mollinedo, president of the San Francisco Zoo, told The Examiner.

“We’ve really had to re-evaluate everything we’re doing,” Mollinedo said.

dsmith@examiner.com