Disney Acknowledges Fault in BTMRR Accident

[raidermatt]

Interesting read.

To me, the bottom line is that there are/were faulty procedures, and that many did not understand the procedures that were in place.

I don't see anything that should not have been caught by a proactive management team.

I'm sure Disney will say the report shows the incident as isolated, but I think there's enough in the report to support a claim that the problem is systemic.

 

[HB2K]

I've got mixed feelings about the report.

I disagree wholeheartedly with Kidds (I know what else is new). While the number of contractors performing maintenance was deemed to be adequate, it's interesting that none of them had a comprension of how to label a ride when it's ready for service and when it needs maintenance attention.

That is glaring.

This would be ugly if it went to court. I don't think it will, but if it did heaven help Disney....

 

[Bob O]

When i ride BTMR next time the last thing i will think about is the accident at DL!!! I will be thinking of how much i enjoy this ride and hope the line is short for my re-rides!!!
As for braving the from seat, no problem!!!! Though i do perfer the back seats in roller ocasters for the airtime!!!!!
I think this will cost the disney company alot of money in settlements to the injured/dead parties and will cost them even more if another accident this serious happens again at DL in the next couple of years. The park at DL will get a black eye, but when you do consider the billions of rides given thru-out their parks, be it in the US/Japan/france the accidents are a mere blip on the screen when you compare number of rides/riders and then the amo8nt of injuries.
Accident shouldnt happen, but the reality is that they will happen and hopefully DL, for the companies sake will improve on their safety standards as wdw doesnt seem to have had the same problems.
And while i generally am not a fan of Vekoma coasters, i wouldnt be afraid to ride any of their coasters.

 

[hopemax]

That could be the result of reduced training I suppose.............but it could also be due to inattentive employees.

Considering that conclusion #4 says

"There was an inadequate instruction in the Operational Guidelines as to what a ride operator is expected to do when an unusual noise is detected."

I consider it a training issue not an attentiveness issue. The ride operators interviewed say they did hear the noise, they just didn't know what to do about it.

 

[DisneyKidds]

I disagree wholeheartedly with Kidds (I know what else is new). While the number of contractors performing maintenance was deemed to be adequate, it's interesting that none of them had a comprension of how to label a ride when it's ready for service and when it needs maintenance attention.

Are you suggesting that if there were two more people that all of the staff would have known how to label a ride? More likely there just would have been more people who didn't know what they were doing.

I bet if we scratch the surface a bit more we can find consensus. Notice I said that I don't think the report would suport a conclusion of systemic maintenance cutbacks leading to the accident. A conclusion that the maintenance staff servicing the attraction was inadequate would certainly support such a conclusion................but that isn't what it says. For you to disagree with me you'd have to take the position that it was maintenance cutbacks that led the maintenance staff to not understand proper procedure. At this point I don't see anything that would lead to that conclusion.

It does seem to me that adequate staffing was provided. Further, it seems that if everyone did their job the way they were supposed to then the accident likely wouldn't have happened. In the event that everyone didn't do their job the way they were suposed to, if supervisors properly reviewed/supervised the work and determined that people weren't doing their jobs correctly the accident likely wouldn't have happened. Yes, the ball was dropped at several different stages, but I just don't see evidence that systemic cutbacks in maintenance can be labelled the prime culprit.

I don't see anything that should not have been caught by a proactive management team.

Care to elaborate Matt? Whom do you mean by "management". Are you suggesting that some suit in the Team Disney buidling should have been aware that a machinist didn't know what to do with a green or yellow tag?

 

[DisneyKidds]

I consider it a training issue not an attentiveness issue.

You may be right on that one Hope. Not sure of the basis of boo's info, but he did indicate that a ride should be stopped when an unusual noise is heard, so some people are aware of what to do. But you are right, inadequate training appears to be a big problem. Not sure if that is something that has been the case since day 1, or if reductions in training are the cause. I still don't see how this report is a sign of systemic maintenance cutbacks leading to this accident. I'd imagine those operational guidelines were written long ago. Other evidence (interviews and such) may show that maintenance cutbacks are suspected by some to be a major cause................but this report doesn't seem to help that argument.

That's my only point here. Disney is at fault. There is no way to defend the company and I'm not trying to do that. I'm just looking at this one piece of evidence and assesing whether it supports a broader conclusion that maintenance cutbacks led to an inadequate level of maintenance.

 

[Mr D]

I think all of Disneyland should be shut down, except of course the churro carts and the gift shops.

There is a wonderful cutting edge amusement park within walking distance that has fully trained staff and maintenance.

 

[HB2K]

Are you suggesting that if there were two more people that all of the staff would have known how to label a ride?

No. I'm just suggesting this...the Disney employees interviewed as a part of the investigation understood the tag system. It's interesting that only the outside contractors, who ostensibly were hired as a part of a cost savings program, did not.

Care to elaborate Matt? Whom do you mean by "management". Are you suggesting that some suit in the Team Disney buidling should have been aware that a machinist didn't know what to do with a green or yellow tag?

I'm not Matt, but I would suggest that someone in the TDA building would have known that the people they hired to guarantee their rides operate in a safe manner had no idea how the tag system worked....

I think all of Disneyland should be shut down, except of course the churro carts and the gift shops

From what I've read they're just about there aren't they?

 

[raidermatt]

I still don't see how this is a sign of systemic maintenance cutbacks leading to this accident. I'd imagine those operational guidelines were written long ago.

What we know is that some procedures were inadequate, and that some procedures in place were not followed.

Whether that was the result of cutbacks cannot be proven or disproven by the report.

This ties into this question....

Care to elaborate Matt? Whom do you mean by "management". Are you suggesting that some suit in the Team Disney buidling should have been aware that a machinist didn't know what to do with a green or yellow tag?

A front line supervisor is responsible for his/her team knowing their procedures, and ensuring they are followed. While management further up the chain is not going to be aware of every procedure and who knows it, they are responsible for putting processes in place that ensure it happens.

These processes have to be able to identify failures in the procedures, as well as identify personnel issues, such as a supervisor not doing their job.

Sometimes this is accomplished through audits, either by an independent entity, or an internal division responsible for such audits. Another method is through contingency planning and testing.

In these types of processes, you find out who knows the process. You sit down and ask people, "What do you do when X happens". You interview staff, review maintenance paperwork, perform spot inspections, monitor employees going about their business, and if practical, actually put folks in a position where they have to follow their procedures and see what they do.

I can't excuse a management team from not having a process in place that at some point asks the machinists how the yellow-tag/green-tag system works, or asks CMs what they do when they hear a "funny" noise. (While I don't think this had anything to do with the accident, it was also noted that trains were not always tested when new cars were added to the train, even though that was procedure).

Now, as to WHY they don't have adequate checks and balances in place, we can only speculate... but unless Disney can come up with a good reason that's beyond their reasonable control, they would have a tough time defending themselves in a court.

 

[hopemax]

Boo works at WDW, this is DL.

And that's part of the issue. The contention is that DL has been veering off the path of long established SOP's since Paul Pressler was named president, further exacerbated by the hiring of T. Irby and allowed to continue during Cynthia's tenure. And as we hear often from Scoop, Al Weiss has fought to keep many of the old ways.

If someone were trying to prove systemic maintence cutbacks was a cause, I'd think they would examine any differences between operational procedures between parks, something that California's DOSH wouldn't concern itself with. It's also unclear whether DOSH examined the SOP's from the past or focused only on the CURRENT operational procedures. If they only focused on the current, than that's hardly a way to prove that the problem isn't cutbacks.

This report isn't the entire story, but at least we don't have to hear any more, "maybe it was a faulty part sent by the manufacturer," excuses. I doubt we've heard the end of this story, and the most interesting thing will be what maintence changes DL makes under the direction of Matt Ouimet and how long T. Irby keeps his job.

{edit} I checked the posts twice while writing this post, and both times Disneykidd's message keep getting longer and longer, it makes it a bit hard to keep up

 

[DisneyKidds]

I checked the posts twice while writing this post, and both times Disneykidd's message keep getting longer and longer, it makes it a bit hard to keep up

Sorry 'bout that Hope . I just want to be sure I communicate clearly on this one and make sure I'm not misunderstood . I'm just trying to discuss this one piece of evidence (the report) and how it fits into some previous speculation. I'm not trying to defend Disney.

Whether that was the result of cutbacks cannot be proven or disproven by the report.

And Matt summarized my feelings very well. This piece of evidence is not the smoking gun for the cutback cause. Not that that may not be the cause, but this piece of evidence doesn't prove it.

I can't excuse a management team from not having a process in place that at some point asks the machinists how the yellow-tag/green-tag system works, or asks CMs what they do when they hear a "funny" noise.

Neither can I. I have no idea what processes were in place, or which ones just broke down..................but it is inexcusable that so many people should be so poorly trained.

It's interesting that only the outside contractors, who ostensibly were hired as a part of a cost savings program, did not.

Maybe that is part of it. I guess we'd have to answer some questions first. Was it only the outside contractors? (I'll read the report again) Do you have any history regarding maintenance staffing at DL attractions? Any idea when Disney started hiring outside machinists? Have they always used them or is that relatively new?

 

[DancingBear]

They both stated that the staffing had been adequate, even though the crew that normally consisted of 7 had consisted of 6 at the time of the accident. In my review of the duties of the outside machinists, I concluded that they were correct in their judgment...

I also concluded that, overall, the procedures for maintenance of the Big Thunder Mountain Railroad, if followed, were generally more than adequate...

There is no evidence that the design of the Big Thunder Mountain Railroad attraction is unsafe..."

 

[raidermatt]

I don't want to assume anything here, so DB, with what exactly are you disputing/agreeing?

 

[crusader]

Thanks to hopemax for posting that link.

I'm not sure if this is public record but am grateful to have read it.

Pages 17 and 18 note the findings pretty conclusively:

The cause of the accident was item 2.

mechanical failure, which occurred as the result of omission during a maintenance procedure of two required actions: The left side upstop/guide wheel on the floating axle of the locomotive #2 was not tightened in accordance with Disneyland Resort specifications for the procedure, and safety wire following tightening of the assembly was not installed

The rest of the problem is the direct result of a complete breakdown in control procedures.........................

Inadequate instruction in the Operation Guidelines as to what a ride operator is expected to do when an unusual noise is detected

Use of Green and Yellow Tags on train #2 not carried out properly as required by the Disneyland Resort procedure

Disneyland resort procedures allowed a car to be added to the attraction without performing a test cycle with the added car

and lastly, "the attraction was never subjected to an applicable audit procedure which is part of the Disneyland Maintenance Operation Guideline "

While I don't see a punitive issue here, I'm not a jury.

I do see a major failure in company procedure.

Whether or not that failure is the result of cutbacks cannot be determined from these findings.

 

[HB2K]

Kidds,

I think we're actually close, although I'm a little farther along the "the outside contractors were brought in by cutbacks" path than you are, but I agree that using ONLY this report it is impossible to determine that. I'm farther down the path I am by combining this report with the articles in the LA Times, the recent history of ride breakdowns and quite frankly some of the banter on this board.

Bear,

While I'm not entirely sure what you're saying, from they way you cobbled together those quotes, I'm assuming you're saying everything was safe and this was a one time occurance since the OSHA report indicates that if proceedures had been followed, this would not have happened.

And that's probably correct. But proceedures were not followed, and the rides are being maintained by a staff that doesn't even know how to properly tag which rides are ready for operation and which need repair.

Makes me warm, fuzzy & safe.

 

[DancingBear]

Sorry, ran out of time when I posted the quotes above. I think they show that the problem was not a design problem, or a short-staffing problem, or a company procedures problem (other than perhaps training).

There was some sort of training problem on the green and yellow ticket issue, although I'd have to go back and read the report, 'cause it wasn't clear to me whether that was a problem directly related to this crash or not.

There was also a signing off on repairs issue, but it's not clear to me whether he's just proposing an enhancement (outside contractors can't sign off on work by outside contractors), or he's saying that problem led to the crash.

There was a training issue on the ride operators having instruction on what to do when they hear a funny noise. Clearly, this is an issue which would have avoided the accident. What's not clear is how the training prior to the enhancement which Disney created, and the CA inspector approved, compares to industry standards on this issue.

For the purposes of this board, I think there are two different issues. One is whether Disney should have done something to avoid this accident, because they are supposed to be the best at this stuff. The other would be whether how what Disney does/did compares with the industry standards, 'cause that's gonna be the standard in looking at possible punitive damages.

 

[DisneyFanGuy]

To me, it just drives another stake into the coffin holding my disney heart. I visit DL every couple of years, and WDW even more frequently. I know people who have come and gone in management. Disney has lost their vision of what their parks should be, and they are risking their brand.

It's one thing for the core Disney fans to discuss whats good and bad, better or worse, etc on a board like this. It's another for people who less frequently purchase their products to lose faith. I think this is going to hurt them badly at DL.

Here is what I believe happened. Disney has cut costs drastically over the past 5-10 years at it's parks. They have reduced training and maintainence activities. Regular visitors have noticed the reduction of service, and cleanliness, but behind the scenes there have been much more severe cuts. This is because Disney has focused on eliminating what people cannot easily see when they visit.

I will not visit DL again until I am convinced that they are truly trying to put safety first. They have lost me as a guest. WDW is still, in my mind, better managed. I will visit there, but if I begin to believe that they are plummeting also, we wont be guests there either.

 

[doubletrouble_vb]

In reading these posts and the report I'm at a loss to see why it wouldn't be negligence on the part of Disney to fail to provide adequate training and procedures on the operation and repair of rollercoasters? Given that the report contained a requirement for re-training of three classes of employees that implies a certain level of negligence on the part of the ride operator (owner)...just in a generic way.

 

[seashoreCM]

Not really unrelated but, I have read stories every now and then about airline mechanics being "told" to sign off on maintenance fixes that were not verified as correct.

All the training in the world won't do any good if your boss tells you to do something his way.

So I think there is a good chance this Big Thunder Mountain issue is largely management's fault.

There needs to be a way for rank and file employees to report problems anonymously, and let management come down and witness the problem and take corrective action.

An accident of this kind may well have happend because some rank and file employee did not want to lose his job or be demoted because of "insubordination".

And we can blame the government too for not having enough laws to protect workers and whistle blowers, including requiring that firing due to "insubordination" be accompanied by a meticulous discourse citing numerous examples in excruciating detail before such employee is denied unemployment benefits and before the firing goes down on the records as "with cause".

Disney hints:
http://members.aol.com/ajaynejr/disney.htm

Big Thunder re-opened late Thanksgiving week at WDW. Rode it twice, waiting time was over 45 minutes much of the day.

Despite what your/my boss says, you should never, and I will not, ever sign a document that you/I do not think is true, correct, and right. You don't want to get caught owing a debt that is not rightfully yours.