Hectic moments preceded Disney World fatal monorail crash

[CR Resort Fan 4 Life]

http://thedailydisney.com/blog/2010/02/disney-monorail-crash/

 

[mrsR123]

LIke so many tragic events, it sounds like a "perfect storm" of things going wrong. If any one of the usual checks and balances had been in place this might not have happened.

It kind of makes you think twice about skipping a seemingly unimportant step in things we do everyday at work, on the roads, at home, etc.

 

[dvcblt93]

Funny how Disney wants to blame an overworked Cast Member!

Bottom line, the train was backing up without a pilot in the back cabin to act as a spotter! Clearly a violation of SOP from the manufacturer of the trains.

Once again, budget cuts cost Disney big time in the "safety" department!

 

[anthony2k7]

how can OSHA find the guest-service manager negligent when he was on his dinner break?

Surely if Disney had denied him his break then they would have then been in trouble for not allowing him his breaks?! so what were they supposed to do?

Overall it seem Disney's cost cutting on staff numbers was to blame to me. It happened at a time when there was so much obvious other cost cutting going on - they just went too far.

 

[CanadianGuy]

how can OSHA find the guest-service manager negligent when he was on his dinner break?

Surely if Disney had denied him his break then they would have then been in trouble for not allowing him his breaks?! so what were they supposed to do?

Overall it seem Disney's cost cutting on staff numbers was to blame to me. It happened at a time when there was so much obvious other cost cutting going on - they just went too far.

It's really quite simple..

He should NOT have been coordinating a track switch from a table in a restaurant. Either he gets up and goes to a console or everyone waits til he's done his dinner break.

I'm not sure how you blame cost cutting when one guy in the shop was on vacation, and in the other area that should have caught the error, the backup to the guy on dinner break went home ill 13 minutes before the accident and the guy on dinner break tried to coordinate a complicated procedure from his dinner table.

I guess you could argue that Disney should have "3" people on at all times who can cover off these track switches but that does seem a bit excessive?

So when the electrician received the radio call instructing him to activate the switch that would allow one of the trains to transfer off the Epcot loop, he logged in to do so. But then, apparently distracted by a call about a door alert from the train approaching the maintenance bay, he did not activate the Epcot switch.

The electrician radioed that he had, though. As a result, the waiting train, driving in reverse to traverse the switch, wound up returning down the Epcot line and crashing into another train,

You might blame cost cutting in that this guy was CLEARLY not trained properly and NEVER should have radioed that he had completed the switch procedure when he had not. That is a huge mistake and if that ONE thing hadn't happened, the entire accident would never have occurred.

The cascade of mess ups that followed led to the tragedy that unfolded.

I'm not sure, beyond the training aspect as noted in the linked article, how cost cutting factors into it.

 

[anthony2k7]

It's really quite simple..

He should NOT have been coordinating a track switch from a table in a restaurant. Either he gets up and goes to a console or everyone waits til he's done his dinner break.

So what should have happened? shut down the whole monorail loop for however long this guys dinner break was?

I'm not sure how you blame cost cutting when one guy in the shop was on vacation, and in the other area that should have caught the error, the backup to the guy on dinner break went home ill 13 minutes before the accident and the guy on dinner break tried to coordinate a complicated procedure from his dinner table.

I guess you could argue that Disney should have "3" people on at all times who can cover off these track switches but that does seem a bit excessive?

Nah, you just have more multiskilled people who you can pull from other jobs when needed to cover things like this. Cost cutting is an issue though because you have to pay for their training and then pay them a higher rate of pay due to them for having the skills - even if they arent using those skills all day long. I assume Disney do this already, but they do appear to need to expand on that.

 

[stitch1094]

So what should have happened? shut down the whole monorail loop for however long this guys dinner break was?

No. He should not have left for dinner until the replacement was on site manning the controls.

 

[manning]

No. He should not have left for dinner until the replacement was on site manning the controls.

Exactly!!

 

[mrsksomeday]

No. He should not have left for dinner until the replacement was on site manning the controls.

I agree with this! Also the electrician never should have radioed that he had switched the tracks if he hadn't.

I also agree with the person that stated it was a "perfect storm", it boggles my mind how all those little things added up to this tragedy .

 

[scot@dvcstore]

A tragedy often has many small "events' which take place and lead to a catastrophe. Very sad for this young man and his family. I will think of him everytime I see the monorail.

 

[peter11435]

No. He should not have left for dinner until the replacement was on site manning the controls.

He didn't. The manager in question was already at dinner when he had to let the coordinator on duty go home sick.

 

[CanadianGuy]

He didn't. The manager in question was already at dinner when he had to let the coordinator on duty go home sick.

At which point one of two things should have happened...

1) No track switching moves (or anything else requiring coordinator oversight) should have taken place til he returned from his break. Yes this would have caused delays in shutting down for the night but the 'empty monorail' could have continued to loop as required or just parked in a station if there were no further guests to move.

or

2) He should accepted that his break was cut short due to illness and returned to his job.

Either of those choices would have been better than trying to execute a track switch blind while enjoying his break.

K

 

[peter11435]

2) He should accepted that his break was cut short due to illness and returned to his job.

K

He did. The manager in question was heading back from his break when the incident took place.

 

[CanadianGuy]

He did. The manager in question was heading back from his break when the incident took place.

Then he really didn't..

Even if what you say is true, he was STILL trying to execute something where he needs to have visual confirmation WITHOUT the visual confirmation...

Of course it's easy for us to armchair quarterback with all the benefits of hindsight and an OSHA report to review. Ahem.

 

[manning]

He did. The manager in question was heading back from his break when the incident took place.

And everything should have come to a stop until he arrived at his post.

 

[peter11435]

Then he really didn't..

Even if what you say is true, he was STILL trying to execute something where he needs to have visual confirmation WITHOUT the visual.

But you have to understand that at that time he did not have to have visual confirmation. Im not defending the procedure but at the time of the incident the manager or coordinator on duty were not required to be in the tower or have visual confirmation.

 

[zulemara]

At which point one of two things should have happened...

1) No track switching moves (or anything else requiring coordinator oversight) should have taken place til he returned from his break. Yes this would have caused delays in shutting down for the night but the 'empty monorail' could have continued to loop as required or just parked in a station if there were no further guests to move.

or

2) He should accepted that his break was cut short due to illness and returned to his job.

Either of those choices would have been better than trying to execute a track switch blind while enjoying his break.

K

yep, that's exactly it. No track switching should have occured unless the replacement was already at the tower or the manager was in a location to properly monitor it.

 

[CanadianGuy]

But you have to understand that at that time he did not have to have visual confirmation. Im not defending the procedure but at the time of the incident the manager or coordinator on duty were not required to be in the tower or have visual confirmation.

I went back and it clearly DOES station that Disney didn't require the operator to be a console or to have visual confirmation. You are correct. I'm guessing that has been corrected.

That said.. I think it was a very foolish decision to proceed in technical compliance with the procedures when visual confirmation would have been MUCH better given the electrician in the shop was not intimately familiar with all the tasks he was assigned.. and the manager/coordinator had to have known that.

OSHA (and Disney's internal report) designated the primary failure as that of the overtasked electrician here.. so I think you and I are just arguing over crumbs.

 

[peter11435]

and the manager/coordinator had to have known that.

Doubtful, they are entirely different departments. Most likely they had no knowledge of the maintenance workers competency or lack thereof.

 

[DisneyFairytale]

That is really unfortunate. I can only imagine how all those involved feel. I wonder if that third guy is going to ever go back to Disney.