Eat, Run and Celebrate- Day 7- Last Day and New Orleans

[Poolrat]

NTSB monorailreport

I got this in my daily amusement update. As a bit of a monrail and a safety nerd, I found this fascinating.
This was a horrific accident that in the end, did not need to happen. A series of events that had become common enough, along with a few events that made a late night just that much worse resulted in the accident.


As most of you know, I supervise lifeguards. I train Lifeguards, I orient them to what proper procedure is for most occurances.

Over time, Lifeguards think they know what is going to happen and they way they deal that slowly works into how to get it done versus how to follow procedure. That is when mistakes happen.

I may turn the NTSB report into a training session to show the parallels between what happened, how it happened and the price paid for all those involved and the effect on the guests, staff and company.

Ok < gets off soapbox> The NTSB report is in the article and does a really good job of explaining the events that early morning. I will warn you there is a picture of the two monorails in the station after the crash.
If you are interested please read it. If not, then scroll on by.

 

[mjaure]

Once I got my shot, I had to chase her down.
Caught you.

It sure does look like she caught me too but with my zoom I was pretty far
away. She is sitting by the carrousel and I thik I was back by Tinks treasures.

Hello! I am enjoying all of your pictures! I usually lurk but I had to chime in about this. I believe her costume is of Sailor Neptune from the Sailor Moon anime/cartoon series. I can't wait to read about the 5K! I was there! (in the back...)

--Mary

 

[Poolrat]

Hello! I am enjoying all of your pictures! I usually lurk but I had to chime in about this. I believe her costume is of Sailor Neptune from the Sailor Moon anime/cartoon series. I can't wait to read about the 5K! I was there! (in the back...)

--Mary

Glad you came out of lurkdom.

OOOO Sailor Neptune, that looks about right. I only latched onto the Blue fairy because ... well the blue hair.

Congrats onthe 5K as well. I stared out in the slowest group as well. Did you see Batman?

 

[Captain_Oblivious]

Looks like a lovely evening on the Seven Seas Lagoon. One of these days I'm going to have to stay at the Poly so I can enjoy that relaxed atmosphere and hang out on the beach in the evenings. Love watching the fireworks from there. Got any winning lottery tickets to help me accomplish this?

 

[mjaure]

Glad you came out of lurkdom.

OOOO Sailor Neptune, that looks about right. I only latched onto the Blue fairy because ... well the blue hair.

Congrats onthe 5K as well. I stared out in the slowest group as well. Did you see Batman?

Haha, yes I saw him! He must have been hot in that suit! Did you see Cruella and the dalmatians?

--Mary

 

[momof2TNboys]

Hey Pat! I am way behind. Love the updates. I love the pics of HM, IASW, and the flag ceremony. The anime girl is something else. Great pictures of GF. I am holding off on adding on to my DVC until GF is available. It is my dream resort and I have stayed there twice and it is my "home".
Keep the updates coming!! BTW, NYE will be here before we know it!

 

[MEK]

NTSB monorailreport

Wow! That was REALLY interesting. Thanks for posting that. It really laid out all the events in the accident. It's interesting to me that the monorail manager or coordinator did not have to be on site prior to this accident and that there was no procedure for verifying that the track switch had taken place. It's really a shame that this accident resulted in a death, but it really sounds like a system problem. It's actually surprising that an accident like this did not happen sooner.

No back to the TR - YUM Mai Tai! sounds like I need to try one of those babies, especially if John is making it!

 

[jenseib]

I think Sailor Neptune looks a lot like Carrie Fisher. I love how you snuck around taking pictures of her.

 

[swwake]

I did ask about "my regular bartender" Clinta. John said Clinta was back the next day. It seems they work opposite each other according to John. John was there on a Tuesday. Clinta makes a good drink too.

Also good to know! Sounds like Tambu is the place to be!

So sad about the monorail crash in 09. I can't believe they had NO SOP prior to that. Really? Just so hard to believe. I know they stopped letting people ride in the front after that - do you know if they are now allowing again?

 

[Poolrat]

Looks like a lovely evening on the Seven Seas Lagoon. One of these days I'm going to have to stay at the Poly so I can enjoy that relaxed atmosphere and hang out on the beach in the evenings. Love watching the fireworks from there. Got any winning lottery tickets to help me accomplish this?

I am content with "visiting" to hang out on the beach and watch the parade and fireworks. After hearing everyone's "must do's" I started to think what I always like to do and that is it. Every trip for at least one night I will spend it on the beach at the Poly with a drink in my hand and my toes in the sand.

Maybe we should pool money and get those lottery tickets? Then we can share the winnings?

Haha, yes I saw him! He must have been hot in that suit! Did you see Cruella and the dalmatians?

--Mary

HAHA you must have been near us then. Us meaning punkin413 and myself. I did see Cruella while I was on the backstage road. The only good thing about that part of the run was you could see just about everyone in front of you and in back of you since you switchbacked.

 

[Poolrat]

Hey Pat! I am way behind. Love the updates. I love the pics of HM, IASW, and the flag ceremony. The anime girl is something else. Great pictures of GF. I am holding off on adding on to my DVC until GF is available. It is my dream resort and I have stayed there twice and it is my "home".
Keep the updates coming!! BTW, NYE will be here before we know it!

Glad you are all caught up. I think that anime girl looks more like Sailor Moon than Sailor Neptune< ba da bum> only for the "moon" part.
I would do GF with points, probably the closest I will get to the Poly beach!

Less than 2 months until NYE.

Wow! That was REALLY interesting. Thanks for posting that. It really laid out all the events in the accident. It's interesting to me that the monorail manager or coordinator did not have to be on site prior to this accident and that there was no procedure for verifying that the track switch had taken place. It's really a shame that this accident resulted in a death, but it really sounds like a system problem. It's actually surprising that an accident like this did not happen sooner.

I think with those procedures, some of the things like the monorail manager staying on site and checking to see the spur was moved are in my opinion what I call "duh" procedures. It is implied but not stated. I would think it would be expected that the monorail manager or coordinator who has equipment in the tower to verify a spur change stay in the tower to verify the spur change is a given. Also the camera is there to both verify the train is past the spur point before the change and should verify the change along with the board and the verification from the manager after the spur change. It was not stated but if the driver is backing up to the spur point as stated in the SOP manual, they also would have a visual.
Well I am so sorry that it took this accident for them to tighten up and take a look at what what they have down on paper compared to what was actually happening. It also gave them the opportunity to be really specific and take any guessing out of the procedures.

I think it was very significant that the NTSB actually named blame to those two specific workers. I wonder what if any other legal action will be taken against them ?

No back to the TR - YUM Mai Tai! sounds like I need to try one of those babies, especially if John is making it!

John works Tuesdays - opposite Clinta so if you see Clinta, John is not working but Clinta makes a good drink too.

 

[Poolrat]

I think Sailor Neptune looks a lot like Carrie Fisher. I love how you snuck around taking pictures of her.

It was funny that she kept popping up around me.

Also good to know! Sounds like Tambu is the place to be!

Not too hard to find a seat at the bar. Either that or one of the tables around the area. The food comes pretty fast and the people watching is good too.

So sad about the monorail crash in 09. I can't believe they had NO SOP prior to that. Really? Just so hard to believe. I know they stopped letting people ride in the front after that - do you know if they are now allowing again?

I think the report said there were 6 passangers on purple. That is the only reason they were not up front. I think it has to be 5 or less to ride up front. If that family was up front .... I can't even think about it. It is bad enough a young man had to lose his life.
I don't think they will ever allow anyone to ride up front unless they reinforce the monorail cabs.

The reports states that while in reverse the monorail cannot exceed 15 mph so that much damage was from the pink monorail going less that 15 mph. Compare that to a car bumper that must be made to withstand at least 5mph with no damage?

I think they had some SOP but it was not followed and some pretty basic information that was implied but not listed.

 

[mom3sonstt]

subscribing.....saw your link on Rosie's report. Don't know when I will get back here to catch up.....

 

[KatMark]

Great update, Pat.

Those wings have me drooling.

I do love the Poly and it's beach.

 

[Poolrat]

subscribing.....saw your link on Rosie's report. Don't know when I will get back here to catch up.....

Glad to haveyou here. I am not "speed" updating right now and I am working this weekend so hopefully you should have some time to catch up. I am not through day 1 yet.

Great update, Pat.

Those wings have me drooling.

I do love the Poly and it's beach.

Those wings are good. wings, MaiTais and the poly beach...

 

[MEK]

I think with those procedures, some of the things like the monorail manager staying on site and checking to see the spur was moved are in my opinion what I call "duh" procedures. It is implied but not stated. I would think it would be expected that the monorail manager or coordinator who has equipment in the tower to verify a spur change stay in the tower to verify the spur change is a given. Also the camera is there to both verify the train is past the spur point before the change and should verify the change along with the board and the verification from the manager after the spur change. It was not stated but if the driver is backing up to the spur point as stated in the SOP manual, they also would have a visual.
Well I am so sorry that it took this accident for them to tighten up and take a look at what what they have down on paper compared to what was actually happening. It also gave them the opportunity to be really specific and take any guessing out of the procedures.

I think it was very significant that the NTSB actually named blame to those two specific workers. I wonder what if any other legal action will be taken against them ?

In health care an accident like this would be called a sentinel event and there is an important trend toward moving away from punitive action against individuals and looking at the system which allowed the accident to occur. It seems to me that they addressed and rectified multiple variables that contributed to this accident. They fixed the system. I feel horrible for the operator and the manager because they have to live with this and that must be unbearable. I should go back and read it again because I didn't pick up all the tech talk the first time through. Really, really interesting though!

 

[Poolrat]

In health care an accident like this would be called a sentinel event and there is an important trend toward moving away from punitive action against individuals and looking at the system which allowed the accident to occur. It seems to me that they addressed and rectified multiple variables that contributed to this accident. They fixed the system. I feel horrible for the operator and the manager because they have to live with this and that must be unbearable. I should go back and read it again because I didn't pick up all the tech talk the first time through. Really, really interesting though!

Usually they look to the training documents and hold the company responsible. I was very surprised to see that they they name individual positions and I cannot even imagine being either one of them. Both those positions have redundacies built in and both positions neglected to follow through or even be in position to be effective.
I would read a paragraph and then wonder why this or why that and read on and and go aha. The report was really well done.

I think the "vision" was there for the SOP. Certain aspects seemed to be assumed and during the review those gaps were closed and very specific SOP was formed.

The key change was driving the monorail forwards to the spur point and then backing onto the Express spur. The original SOP called for backing to the spur point and then going forward to the express point and beyond. I heard there was significant downtime in "changing cabs" and the procedure was changed along the way to limit that downtime.

I can only assume that those that wrote the SOP were never there during the end of the shift or ever caught on that someone had changed the procedure and did not consider that every redundant action is built in for a reason.

I am re-writing our staff manual ( at the new place). I have my old one and I actually emailed to the girl who the position I now hold so most of it is mine already but I need to make it site specific and more detailed.

Somehow I will run parallels between the monorail accident and pool safety. It would make a good in-service training.

 

[Poolrat]

I am planning to post an update in the morning. Since I am working the weekend I would lile to get everyone through the first day soon.

 

[MAGICFOR2]

So sad. I remember reading that the switch person might have been to blame. I hope they've figured out how to avoid this in the future. Seems like there should be stopgaps in place a long time ago....

 

[MeMom]

Thanks for the Poly pictures! One day, I will stay there.

Yes, I got a glass for our sand. At first, I thought it was too big, but it seems that it is almost filled with Poly sand now. After a little pinch every trip - it adds up!

Have you thought about a Plan B spot for NYE in case they have the beach blocked off?