OSHA Preliminary Report reveals Chaos before Monorail Crash

OSHA has finished its investigation related to the July 2009 crash of the Walt Disney World Resort monorail that killed one employee and released a preliminary report. Details of the report listed on the Orlando Sentinel reveals how chaos reigned for the moments that preceded the crash.

While Disney’s internal investigation pinned the accident on the engineer who announced he had switched the track when he actually hadn’t, the OSHA investigation looked at the deeper reasons. For instance the company had never issued actual paper procedures to the employ, instead relying on verbal training.

This may be fine when you’re dealing with non guest related positions, but seems inexcusable to me when you’re dealing with any position that requires operating an attraction or system that interacts with guests who might be injured when something goes wrong.

Here is where long-time observers of the Walt Disney parks and resorts can draw a connection back to the string of fatal accidents at Disneyland. After the fatal Columbia accident, where a guest was killed due to a combination of poor maintenance and a cast member who was unfamiliar with the attraction procedures docking the boat, Disney reacted by with-holding their Standard Operation Manuals from day to day cast members, instead relying on on-site verbal training to communicate procedures. The theory being if there was no printed manual to follow, the cast member (and Disney itself) couldn’t be blamed for not following it. I had a feeling at the time that this would come back to bite them eventually, and sadly it has.

This also extends to Disney’s decision to move away from the recommended procedures of the Monorail’s manufacturer as far as not having a supervisor in the both and not having eyes in the back of the train when it was moving in reverse. Disney did have these procedures at one time, but moved away from them slowly in the name of efficiency and changing standard operating procedures that were there more for legal reasons than for safety.

It’s time for everyone at Walt Disney World resort to stand in front of the mirror and think long and hard about their responsibility for safety. If you’re a front line cast member who has never seen the actual procedure manual, safety operations, or evacuation plans for your attraction, stand up and refuse to run the attraction until you’re properly trained. If you’re a mid-level manager, do the research and make sure your manual is properly outfitted with the safety recommendations of its manufacturer and institute a review of all related procedures and training. Upper managers, take some time to reflect if your policies are impacting the safety of your cast members and guests and commit to doing everything you can from the smallest guest interaction to the largest mechanical operation to ensure a perfect safety record. Go back to basics if you have to.

As a resort, you are one major accident away from a string of bad Public Relations moments that will begin to affect guest attitude about your park. And once the shine is off the apple, it takes more than some spit and polish to get it back.