All the adjustments in policy and procedures have already been made, employees disciplined, OSHA fines levied, and the family’s lawsuit settled. All that we have been waiting for is the final federal investigation’s Accident Report. Today the National Transportation and Safety Board released that report putting a period on the end of a long sentence that I’m sure Disney World would like to put behind them.
That sentence started with a conflagration of errors by operators, management, and poor enforcement of existing policies that ended in the tragic death of a Walt Disney World Monorail Operator early on the morning of July 5th, 2009.
The report itself, issued this afternoon (releasing something on a holiday is almost like intentionally burying it, I wonder if that was coordinated in any way?), is written a very factual manner and in a plainly stated way. The facts outlined clearly put majority of the blame on inadequate procedures and failure to enforce the exact safety procedures that would have prevented the accident. To its credit Disney has made a lot of changes to correct what went wrong, but even if Disney had just enforced one of the common sense errors, this tragedy could have been averted.
The report states that the probable cause was “the shop panel operator’s failure to properly position switch-beam 9 and the failure of the monorail manager acting as the central coordinator to verify the position of switch-beam 9 before authorizing the reverse movement of the Pink monorail. Contributing to the accident was Walt Disney World Resort’s lack of standard operating procedures leading to an unsafe practice when reversing trains on its monorail system.”
Narrowing in on the shop panel operator, the report indicates that distraction related to multitasking calls from multiple monorails diverted the shop panel operator from his duties that would ensure the track had been switched properly. There was also no requirement for visual confirmation of the switch having been completed despite a video unit immediately in the vicinity.
As has been reported previously, allowing the coordination of dispatch by an off-site manager, let alone someone not in the control tower, was not against Disney’s policies, but has been identified as direct contributor to the environment that allowed the accident to occur. The point here is that a need for actual eyeballs on the track, and the monorails as they’re in motion, is key. The control tower is configured for just that purpose, having adequate staffing so that when one cast member is sick you have a backup on site to man the tower, should have been standard procedure.
Even with both of these deviations in effect, if the monorail pilot had been instructed to switch cabins, as was actually in the monorail operating manual, and drive forward across the switch rather than in reverse, this whole tragedy could have been avoided. Disney used to enforce this procedure, but it fell out of use in favor of efficiency.
This kills me as a Disney fan. The four keys (Safety, Courtesy, Show, and Efficiency) were established at Disneyland circa 1966 by the excellent trainer Van Arsdale France. Efficiency is deliberately put at the end, but moves like no longer requiring a pilot cabin switch were made in the name of ‘courtesy’ saying that a more efficient monorail system was a courtesy to guests since they wouldn’t have to wait as long between new trains arriving at the station. Not only did they forget the first key, safety, they were taking the cheap route to courtesy. Pretending efficiency is really courtesy usually results in what I consider bad show, but in this extreme case is caused the death of a cast member.
Despite technically not following written procedures, the pilot of Monorail Pink was essentially cleared of any wrong doing. Conditions were not optimal for the pilot, but were within normal perimeters of operation. Disney could tighten up certain procedures to prevent operation with foggy windows or in low light situations. They have already mandated the most important change, that the monorail pilot now switches cabins before reversing through the gates and a second spotter sits in the other cabin. One thing that was not covered in the report was why Pink did not stop in the station after completing what he considered a beam switch. Instead, he continued at near 15 mph out of the station and to the point of collision outside the station.
Another revelation was that 15 mph was the maximum speed at the time of collision. Purple was stopped and in reverse, but not in motion and Pink was in MAPO Override, which auto-shuts down the monorail if it goes over 15 mph. If there had been any real thought to passenger safety in the construction of the monorail cab, this could have been merely a scare for both pilots. Instead, the fiberglass body and plexiglass dome just crumbled in the low-speed collision and the pilot of Monorail Purple had no chance. If Purple had been in forward motion, the damage would have been multiplied, potentially injuring the family of guests seated in the car directly behind the impact. If any guests had been in the cab, they would have received injures just as serious as the pilot. If there is anything good to be said about that night, it’s that no guests were injured.
Finally, Walt Disney World has submitted a long list of changes made to its operating procedures:
- Operating procedures require that monorail drivers be in the forward facing cab when switching from one beam to another (unless a switching procedure must be terminated before completion due to a safety concern, in which case, a driver is permitted to back out of the switch so long as an observer monitors the rearward motion of the monorail).
- When monorails travel in reverse from the driver’s perspective, a dedicated spotter/observer is assigned to monitor such movement. These spotters/observers are in radio contact with the monorail driver or the monorail central coordinator, can be located in the non-operating cab of the train intended to travel in reverse, within a station, on the ground or in a separate monorail or monorail work tractor on a parallel beam.
- Monorail drivers are required to visually confirm the correct position of switch-beams prior to switching from one beam to another.
- A monorail central coordinator may only direct a monorail to operate in MAPO override when it is transferring from one beam to another during switching operations. All other movement in MAPO override requires monorail manager approval.
- When monorail movement is under the direction of a monorail central coordinator, that coordinator must remain inside the designated control tower. Further, when a monorail central coordinator is directing switching operations, that coordinator must visually verify via an electronic Power Distribution and Monitoring System (“PDMS”) display and video camera monitor that the beams are in the proper switching position and that power has been applied appropriately.
- In addition to verifying switch beam position and power status via the PDMS display as was required on and prior to July 5, 2009, monorail shop panel operators are required to confirm the position of the switch beams via video camera monitors prior to directing monorail movement across those switch beams.
- A second monorail shop panel operator must visually verify the switching process is properly performed by the primary monorail shop panel operator.
- Monorail operations employees have received additional training on measures to address condensation on monorail windshields, including rinsing the windshields and the use of the defogger on the climate control system. In addition, a glass treatment is periodically applied to the windshields to enhance visibility.
- The monorail manager on duty is required to remain on the premises of the Walt Disney World Resort when monorails are under their supervision. This requirement, which is already in effect, will be confirmed in the next operating guide release.
- The E-Stop button in the driver cabs have been reconfigured to remain active when the console is inactive, allowing a rear observer located in the non-operating cab to E-stop a monorail.
- The set point for the cab climate control system was adjusted to reduce internal condensation on windshields. This change is intended to remain in effect until additional climate control upgrades which are currently underway are completed.
- A monorail tracking board that identifies the beams on which monorails are operating was installed for used by shop panel operators during switching procedures.
- The web-based video camera feed from switch-beam 9 has been changed to a direct video camera feed to both the concourse tower and monorail shop.
- Direct feed video cameras were installed to monitor switch-beams 1, 2 and 8. The images are displayed at both the concourse tower and monorail shop. Currently switch-beam 8 and 9 position is verified by both the shop panel operator and monorail central coordinator via PDMS and video feed. Switch-beam 1 and 2 position is verified by the shop panel operator and a maintenance employee station at the switch-beams. The next operating guide will conform the switch-beam 1 and 2 verification procedure to the 8 and 9 procedure, (e.g., verification by the shop panel operator and the monorail central coordinator).
- Monorail operations has designated a new radio signal which, when called, will direct all monorails to stop immediately.
- The PDMS software has been upgraded to capture additional data related to switch-beam operation.
- A design to reconfigure the monorail brake system that will mitigate the loss of signal pipe pressure is being validated.
That list appears to address nearly all the concerns raised by OSHA and the NTSB reports which, like I said, shows that Disney is taking this seriously. The question remains as to Disney’s commitment to apply the funds required to staff and maintain the Walt Disney World Transportation system safely and adequately to meet the needs of the resort and continue to put safety far ahead of efficiency. If that requires a complete rebuild of its existing system, it should be done to prevent just one more guest or cast member death or serious injury.
Are you satisfied with the conclusion of this tragic period in Walt Disney World’s history? Has Disney done enough to prevent further accidents in the future?