NTSB Releases Final Report on Monorail Crash

[jcb]

WESH is reporting that the National Transportation Safety Board has released its final report on the Monorail Crash.

If you want to read the report (14 pages) here is a direct link to the NTSB Report.

The conclusion:

The National Transportation Safety Board determines that the probable cause of the July 5, 2009, collision between two monorails at Walt Disney World Resort in Lake Buena Vista, Florida, 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.

More interesting statements from the report:

• fatigue was determined not to be a factor
• Toxicological tests of the operator of the striking monorail were negative for alcohol and illegal drugs
• From 2000 until the day of the accident in 2009, OSHA inspectors had been on the Walt Disney World Resort 27 times. . . . None of the visits involved the monorail operations.

 

[OKW Lover]

Interesting reading with some technical details for those of us who are monorail geeks. Very sad situation that could have easily been prevented.

 

[DCTooTall]

I agree... Interesting read.


I also found the Comment regarding oversight interesting. OSHA going on record stating that their responsibility was simply employee safety, and that as a public transit system it was not in their responsible area to overlook guest safety.

It makes me wonder if that means more direct oversight from the NTSB and/or possible official classification change of the Monorails for legal reasons?

(ie. some people refer to them as a Disney Attraction, while others see them as a Public Transit system due to their use.)

 

[Oglet]

I agree... Interesting read.


I also found the Comment regarding oversight interesting. OSHA going on record stating that their responsibility was simply employee safety, and that as a public transit system it was not in their responsible area to overlook guest safety.

It makes me wonder if that means more direct oversight from the NTSB and/or possible official classification change of the Monorails for legal reasons?

(ie. some people refer to them as a Disney Attraction, while others see them as a Public Transit system due to their use.)

Disney have been wanting Monorails classified as an attraction for quite some time. Actually many parts of the Monorail OG have similar phrases and procedures to those of attractions, actually parts of their OG had as of Jan this year references to lap bars (nice job on the copy and paste guys)

I don't believe that it can be called a pure attraction for a number of reasons but its not going to stop Disney from trying. I will say the one good thing that has come out of this is change, there have been many changes some of which are good and some which are just plain crazy and designed to cover them from a legal standpoint only.

Just the name Transportation and Ticket Center in my opinion says it all.