Life and Death at MetroZoo: What caused fatal errors?

David Marshall, 44, senior keeper at Metrozoo, loved routine. Out of bed at 5 a.m. A couple hundred sit-ups first thing. At the zoo before 7. A run at noon, no matter the heat.

But as he parked his Jeep at the zoo on the morning of June 6, his clockwork was a bit out of kilter.

Thirty minutes later he was dead, mauled by a white Bengal tiger named Lucknow, known to everyone as Lucky. Police virtually ruled out murder and suicide. But the homicide investigator discovered the death wasn't an open-and-shut case. It didn't make sense. Marshall, for 21 years a meticulous zoo keeper, had made two deadly errors.

Why?

"This man was a consummate professional, " Metro-Dade detective John King said. "But he could have been preoccupied with something."

That day, Marshall may well have been thinking about other things -- even as he walked into the tiger den.

Four days before, he had suffered a head injury while working with a rhino. Personal problems also bothered him.

Even the first part of his routine that morning -- moving a slow-witted Malaysian tapir called Psycho -- went awry.

Then came the two fatal mistakes: Marshall walked right past a warning sign left up the night before, "Tiger ON Paddock."

He didn't count the tigers. Four -- not five -- were in night cages. One wasn't.

As he opened the second and last gate to the paddock, Lucky attacked him from behind.

Broke his neck above the fourth vertebra. Tossed him down the hill toward the moat. Killed him instantly.

A CLANNISH GROUP

Zoo people are family to one another. Zoo keepers marry zoo keepers. At parties, they invite few outside their own. On days off, they often work. Money isn't their motivation. Animals are. Marshall made $27,000 a year.

He fit the mold -- and then some. Born in Louisville, Ky., he graduated from high school, landed a job in maintenance at the Louisville Zoo, got drafted and went to Vietnam for four years. He loaded supply airplanes. When he returned home in 1975, he went back to the zoo, this time as a keeper.

It was a fortuitous time for those in the business. Zoos were changing. Curators, for instance, placed emphasis on breeding endangered species.

"We were young and idealistic, " said Steve Taylor, now curator of mammals at the Louisville Zoo. "We were driven by the fact that we could make a difference. His drive helped motivate people around him. He just liked working hard."

Marshall liked everyone, even the zoo eccentrics, whistling all day long, never shy with a kind word.

In Louisville, Marshall rose rapidly. Soon, he supervised keepers and tended to the most dangerous carnivores in the place -- jaguars, Siberian tigers named Butch and Sundance, and a vicious polar bear, Skina.

Taylor and Marshall worked in tandem -- the safety policy at the zoo. "I was always comfortable working with him, " Taylor said. "He was extremely knowledgeable."

His life was the zoo, almost totally. He read books about animal behavior. Drank a beer or two with the zoo guys. Coached football with a zoo guy.

He married a zoo woman. They divorced. He married another. They, too, divorced.

"It wasn't that he was a playboy, or anything like that, " said Eric Blow, a close friend, now director of animal control for Jefferson County, Ky. "It just didn't work out."

Still, he felt more at ease with zoo people than anyone else. "For a person like Dave, it would be almost impossible to share his life with someone outside the zoo."

On June 6, 1983 -- exactly 11 years before his death -- he landed a job at Metrozoo. A month later, his girlfriend, Louisville zoo keeper Martha Thaden, joined him. In September, the zoo hired her.

They married. This one didn't last, either. But like the other breakups, Marshall remained friendly with his ex-wife. Their relationship was so sturdy that Marshall was Thaden's direct supervisor. Both were comfortable with the arrangement.

"He was always helping me out, " Thaden said in her laboratory as she washed week-old, spur-thighed tortoises from Africa. "We were better friends than married people."

At Metrozoo, Marshall met his fourth wife, Lisa Cusmano. Another zoo keeper. This marriage, his friends said, seemed just fine. The couple had a girl, Sarah, now 4 1/2. They jogged together almost daily.

"The relationship was very stable, " Blow said. "Lisa was something great for him, as well as his daughter. He finally had a partnership that worked."

But then, a week before the accident, an unsigned letter tested their trust. The letter, sent to David Marshall, alleged that his wife was having an affair with someone else at the zoo. The letter also was sent to the other person's spouse.

"David told me, 'I want you to know I don't believe anything in this, ' " Lisa Marshall said. "The letter was absolutely false." The two couples met, discussed the letter and decided to ignore it.

The Marshalls, who had different days off, decided they needed to take a short vacation, beginning June 7. "We definitely did not get enough time together, " Lisa Marshall said.

RHINO ACCIDENT

June 2, a Thursday: David Marshall and Martha Thaden were for the third straight day attempting to shut a 2-year-old African black rhino into a crate for shipment to the Great Plains Zoo in Sioux City, S.D. The rhino, Tucker, finally walked into the wood box to eat the bait.

Marshall dropped a metal bar behind the animal and closed a wooden door. But the rhino exploded, scooted under the bar and kicked its hind legs into the door. The door hit Marshall in the face.

"He had a contusion the size of a baseball on his face, " Lisa Marshall said. That afternoon, he fell asleep in a zoo office -- either from the accident, or the heat, or both. Zoo employees and his wife tried to persuade him to have a doctor examine the bruise. He refused.

On Friday, he slept through his 5 a.m. alarm. "He never did that before, " Lisa Marshall said. That was the day the Marshalls had figured they would buy a new home. But the closing fell through because of financial complications.

On Saturday, he said his vision was bothering him. Sunday night, he wondered aloud whether his cheekbone was broken, she said. But he still wouldn't see a doctor.

THE FATAL DAY

June 6, Monday, just before 7 a.m.: Thaden, as always, arrived before anyone else on her shift. She drank coffee at the Hay Barn, where zoo keepers meet in the morning. Marshall arrived second, whistling as always. He sat across from her at a picnic table.

"He was his normal self, " Thaden said. "He was in good spirits." He talked about his mother and his only sibling, a sister. About 7:15 -- after making arrangements with Thaden to work with her later -- he drove alone to a dead-end service road where the zoo keeps cages for tigers and tapirs.

Tapirs are stout, hog-like beasts. One at Metrozoo is notorious for shooting a stream of urine 20 feet. Marshall apparently opened the cage door for Psycho, widely regarded as either lazy or stupid, so he could go on exhibit. But the animal apparently wouldn't budge and Marshall went on to his next task -- cleaning up the tigers' paddock.

To get to the paddock, he unlocked a chain-link fence first, walked past the tiger cages, then opened a large wood door that provided only glimpses into the paddock -- and took a step, maybe two, into the tiger's den.

Precisely what happened no one knows. He may have never seen Lucky.

About 7:30, a zoo keeper radioed Marshall several times. When there was no response, keeper Susan Kong wondered if his radio batteries were dead.

Suddenly, she saw the body face down from a sidewalk in front of the paddock.

"Call rescue! Dave needs help!" Kong cried over her hand- held radio.

She ran around the exhibit, up the service road and saw that the outside safety gate had been left open. Tiger paw prints went right up to the gate.

Lucky was a step away from escaping.

Kong slammed close the gate.

Keepers, maintenance people, veterinarians raced to the paddock.

Among the first to arrive: Lisa Marshall and Martha Thaden.

Lisa Marshall: "I screamed to him, 'David, move your foot!' I didn't know if he was dead. If he was alive, I thought he could be playing dead so the tiger wouldn't attack him. But when he didn't move his foot, I knew."

Martha Thaden: "We made sure that the tiger was in the moat. The tiger would feel very safe down there. People were pitching pebbles, and someone threw a tire down there to keep him busy. I got in a truck and drove onto the paddock to get Dave."

Also in the cab were veterinarian Dr. Chris Miller and assistant Metrozoo director Al Fontana. Thaden flung open the driver's door, jumped out, and with Fontana tugged at the inert body. Frantically, Fontana hauled in the body so it rested over his lap. Thaden ran from the truck to the gate. There was no room for her in the truck.

Lisa Marshall: "When Martha grabbed him by the seat of his pants, his head kind of flipped over. And a tooth was sticking out of his face."

A canine tooth. Lucky's. His lower right incisor.

THE AUTOPSY

Monday, 8:30 a.m.: Third wife Thaden drove fourth wife Marshall to the Ryder Trauma Center. That's when Lisa Marshall cried, "Is this all my fault?"

After they reached the hospital -- a drive that took 90 minutes in the confusion and traffic -- Thaden asked what Lisa Marshall was talking about. A third person in the car, zoo keeper Kong, told Thaden about the anonymous letter.

Even before the corpse had reached the Dade County Medical Examiner's Department, detectives heard about the open gates, the rhino bump, the anonymous letter, the troubles with the house closing.

King, the homicide detective, said the closing may have weighed heavily on his mind. "That's several thousand dollars in limbo."

Monday, 2:30 p.m.: the autopsy at the medical examiner's.

"Keep the foot traffic down. I don't want too many people in here, " operations director Norman Kassoff warned the morgue staff.

Dr. Lance Davis, associate medical examiner, worked No. 94-1461. He took measurements and recorded his observations. The body: 5 feet 9 inches, 146 pounds, well-nourished, abdomen flat, hair brown with some gray, eyes hazel, teeth in good repair.

Marshall's body had multiple scrapes and puncture wounds -- behind both ears, left biceps, back of the left arm, left forearm, left thigh. The body had four claw marks on the right hip and thigh. The tip of the tiger tooth protruded from the left cheek.

But the pathologist searched for something else. He tilted the head. It revealed the cause of death -- a deep cut and a severed cervical spine.

He also looked for evidence of injuries from the rhino accident. There was a black eye, yellowing around the eye and a superficial abrasion next to the left eye. Davis also found blood just above and beside the left eye.

He found no evidence of an underlying contusion or concussion. "I didn't see anything that would lead me to believe he would be impaired by (the rhino accident)."

Dr. Robert Davidoff, a neurology professor at the University of Miami School of Medicine, said it's impossible to know the extent of Marshall's injuries without an examination.

"If your behavior changes after a head injury, you should go to a doctor."

Lisa Marshall believes the rhino accident altered his behavior. "He was in a kind of stupor. He was obsessed with the rhino. He was thinking of new ways to get the rhino in the crate. He took it personal."

HUMAN ERROR?

So why?

What of his safety record? Personnel files show two reprimands in two years, both considered relatively minor. In 1992, he left open a gate allowing an Australian wallaby, a small kangaroo, to escape. The wallaby died, possibly of shock. In another incident, he neglected to close a gate, allowing a male monitor lizard to sneak into a female lizard's cage.

Lisa Marshall said her late husband actually took the blame for someone else in the wallaby incident.

"This guy was as good as anybody I worked with, " zoo spokesman Ron Magill said. "He's the last guy in the world you expect something like this to happen to. It was like swallowing a softball to accept that this was human error."

Human error. Distractions. Or as detective King put it: "Experience breeds complacency."

"I've considered all angles, " said King, who scrutinized the tiger cages four times. "Homicide? Not likely. That would place another person in equal jeopardy. Suicide? Not likely. The last safety gate was open, and he wouldn't have put other people in jeopardy. One hypothesis is that he just lost track of the count in between caring for the tigers and the tapirs."

LOOKING AHEAD

At Metrozoo, some still search for answers. Most, though, want to move on. Most harbor horrible images of that day.

Yet no one wants to forget the life of David Marshall. In his final days, he talked excitedly about Disney's new animated film The Lion King. Disney researched the film at Metrozoo.

On Friday, the movie premiered in South Florida. Many zoo keepers talked of going over the weekend. Thaden wept thinking about it.

Sometime "in early July, " according to an internal memo at the zoo, Lisa Marshall intends to return to her job at the zoo. She works at the children's petting zoo. She also is moving into a new apartment with her daughter Sarah.

In time, Sarah will go back to the zoo.

"Once I'm strong enough, I will bring her over to the tigers, " Lisa Marshall said. "Sarah knows that tigers are not cuddly and cute. She knows that if you go in there, you are dead."

This story was originally published April 16, 2016 at 2:19 PM with the headline "Life and Death at MetroZoo: What caused fatal errors?."