Monorail Accident

So the switch for what ever reason did not change and the monorail then backed up on the same line. There are two switches involved though; one to go from the Epcot line to the spur and a second to go from the spur to the Express line. Did the other switch go? If he completely failed to notice that he did not switch tracks what would have happened if he did get on to the spur but the second switch failed to work. Instead of two destroyed monorail cars and the loss of the purple CM we would be looking at a fully destroyed monorail on the ground and probably the death of the pink CM. It seems like something really has to change to prevent this kind of mistake in the future. I have to wonder if this is the first time a monorail has backed on the same line or is it a repeated occurrence but the first time the monorail was not stopped in time.

PhotoDave219 said:

Ready Creek has its own dispatch and 911 center. (I know, I've called them before)

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Thanks....just when I took the time to look it up too

Then they'd know the acronyms we use as fans. However, the dispatcher is still trying to get info to get to the first responders.

Fievel said:

Thanks....just when I took the time to look it up too

Then they'd know the acronyms we use as fans. However, the dispatcher is still trying to get info to get to the first responders.

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Exactly. That and the EPCOT line is 8 miles long and has two stations. I can understand him trying to clarify exactly where the accident happened and the severity of injuries/damage.

I honestly think that the dispatcher (as well as everyone else involved) never imagined that anything like this would ever happen and trying to find out details for the first responders.

I'm sure that all this information will be in an appendix of the NTSB report. Hell, I'll send someone to the Government Printing Office to buy a hard copy when it eventually comes out.


(.... Now.... What ever happened to that Universal worker that got hit in the head by a train at Dueling Dragons last week?)

deix15x8 said:

So the switch for what ever reason did not change and the monorail then backed up on the same line. There are two switches involved though; one to go from the Epcot line to the spur and a second to go from the spur to the Express line. Did the other switch go? If he completely failed to notice that he did not switch tracks what would have happened if he did get on to the spur but the second switch failed to work. Instead of two destroyed monorail cars and the loss of the purple CM we would be looking at a fully destroyed monorail on the ground and probably the death of the pink CM. It seems like something really has to change to prevent this kind of mistake in the future. I have to wonder if this is the first time a monorail has backed on the same line or is it a repeated occurrence but the first time the monorail was not stopped in time.

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If the switch to get the train off the Epcot beam had worked, but the one to get it on to the Express beam did not, Monorail Pink would have just stopped in its tracks because of the power issue that I just mentioned earlier. Even though it was on MAPO override, it would only be able to go as far as it could draw power. Once it reached the dead zone, the full e-stop would have engaged and the train would not be able to move further. There is battery backup power on board for the PA, the intercom (the phones in the panels at the front and back of each car), and a couple of other systems, but there is not enough to move the train. One day, as I was approaching the Grand Floridian on Resort, I got to experience this as the Cast Member in the station pressed the Zone Kill button on the console, which shut down power to the station and a large part of track on either side. Since I had just made the curve from the Polynesian, I was already in that zone and my train stopped suddenly and its power shut down. In addition to the Red MBS on my screen, there were all sorts of warnings popping up alerting me to the fact that I had no power. Only once shop restored power to the zone could I continue towards the station. (When a kill pack or other button is used to cut power in the station, a Cast Member working that station can, after the reason for pressing the button is resolved, simply turn the key and power the station back up. However, if the Zone Kill button is used, Monorail Shop must be contacted to power up the zone.)

So a couple things to add or talk about I guess. I got an email from a friend of mine that use to work in transportation, and is still a CM. He raised a very good point, people weren't paying attention and thats what caused all this. Not only was the pink driver not aware that they were on the wrong beam which should have been rather obvious when they were passing the wrong station, but more importantly the person at the station that SHOULD have been in front of the control board monitoring the trains in their area obviously wasn't since they would have the power to shut down the trains with the push of a big button.
Now onto the 911 tapes, they were Reedy Creek which has their on dispatch, any time you dial 911 on a phone(Disney landlines) on Disney property it goes to Reedy Creek. The callers were obviously monorail CMs, but as you could easily tell they were calling because they were told to and weren't given information, again back to my points on Disney's lack of disaster training to its frontline employees I wrote about Sunday all over this thread.
This should not have happened, and we can only hope that changes are put in place.
And one last note don't expect any hard details on what really happened to be officially released thats the way it is even with OSHA investigating.

Re: Switch 9 being powered and not Switch 8

I seem to recall an occasion in which a train on the Epcot beam was having serious issues but it was during a heavy exit on Express and Epcot. And in order to keep the system running the train was backed onto the spur line from Epcot and I THINK the express switch was not moved, to not disrupt the Express beams motion. Then once the train was completely on the spur line, the epcot switch was lined back up to the main line and the train sat dead on the spur for a few hours with a very bored pilot. So I think it is possible to go through switch 9 eithout switch 8 (on Express) being in position. In this case the hold point is S10 (for the tenth pylon on the spur line)

I could be wrong about this but I think it happened this way. And if the pilot did not know where S10 was the rear off the train could have gone off the end. Any other pilots confirm/deny this?

deix15x8 said:

So the switch for what ever reason did not change and the monorail then backed up on the same line. There are two switches involved though; one to go from the Epcot line to the spur and a second to go from the spur to the Express line. Did the other switch go? If he completely failed to notice that he did not switch tracks what would have happened if he did get on to the spur but the second switch failed to work. Instead of two destroyed monorail cars and the loss of the purple CM we would be looking at a fully destroyed monorail on the ground and probably the death of the pink CM. It seems like something really has to change to prevent this kind of mistake in the future. I have to wonder if this is the first time a monorail has backed on the same line or is it a repeated occurrence but the first time the monorail was not stopped in time.

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I was wondering this myself.

Has somthing like this - a monorail cleared for MAPO overide and it turns out it is not really clear, but the pilot happens to catch it - ever happend before.

I think that they should be able to tell where each and every train is by communications via the beam system. Each train can easly transmit a unique signal and they can track it by that. No need for GPS that goes wonky in the rain or cloud cover or that has trouble resolving what beam it train is on when the beams are close together. Stick a known gauge of cable on the beam, have the train shoot a pulse, and stick a Time Domain Reflectometer on that sucker and we can tell you to within a foot (or less) where you are on that beam.

-dave

deix15x8 said:

So the switch for what ever reason did not change and the monorail then backed up on the same line. There are two switches involved though; one to go from the Epcot line to the spur and a second to go from the spur to the Express line. Did the other switch go? If he completely failed to notice that he did not switch tracks what would have happened if he did get on to the spur but the second switch failed to work. Instead of two destroyed monorail cars and the loss of the purple CM we would be looking at a fully destroyed monorail on the ground and probably the death of the pink CM. It seems like something really has to change to prevent this kind of mistake in the future. I have to wonder if this is the first time a monorail has backed on the same line or is it a repeated occurrence but the first time the monorail was not stopped in time.

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As someone else mentioned, a switch that is away from the beam and ends in midair has no power. If the train backed onto the spur, it would eventually reach a point where the beam had no power, the train would shut down and emergency brakes would be applied.

And as the train would have to be in MAPO override while doing this, the beam is probably (though don't know the specifics of the design) designed so that a full stop from the override's 15MPH would take less than the distance to the end of the openair beam.

It's also possible that the spur beam only has power if BOTH switches were switched. (That's how I'd design it) I'd probably also connect both beam switches to a single control, as there's no reason (that I can think of) for one switch to be moved and not the other. It'd be either "normal beam allignment" or "connect Express to Epcot" with no possibility of other switch combinations.

But the monorail experts would have to chime in on this point.

EDIT: It looks like they already did. Luckyeye apparently posted almost the same thing as I was starting to type up my reply...


And to touch on the 911 calls for a moment, I haven't listened to them, and may never listen. But are they all from Reedy Creek dispatch? I know that all *landline* phones on-property are sent to Reedy Creek when you dial 911, but what about cell phones? A Guest witnessing the accident who grabs their own phone and dials 911 could get the county dispatch, who will determine the location of the caller, and then route the call to the appropriate dispatch center (i.e. Reedy Creek).

Here in Massachusetts, dialing 911 on your cell phone will get you the State Police. They will determine your location, and route the call accordingly. I don't know the coverage zones for each of the state police barracks to know which one covers which highways, so I say my location and let the dispatcher route me. But I know that if I'm on local roads, I can speed up the process (and thus the response time to the accident) if I immediately ask them for the dispatch for the town that I'm in.

-Rob

lightboy said:

It seems a lot of people are hung up on power and the MAPO system overrides. I feel that that is almost beating a dead horse.

It's obvious that Pink backed down the Epcot track into Concourse instead of backing up through the spur. We KNOW that during this operation, overrides must happen. The correct perfect storm happened, and two monorails collided. Period.

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What I REALLY would like to ask for opinions on...is the following...

(1) After talking with MULTIPLE monorail pilots, they've all answered, "I definitely know when I'm backing through that switch" And the reason is...that you actually FEEL the train shift through a sharp left as you're backing onto the spur. They said it's very hard to not notice.

(2) If you pass ANY switches at night-time, they are lit. You'd be able to see as soon as the cab passes over the switch that you're on the wrong one, and Estop. AND Estop with sufficient room that your back car doesn't even enter the station.

(3) Monorail pilots also tell me...even if its dark, you'd be able to VISUALLY confirm you're on the wrong rail. If you were backing onto the spur, you'd be able to see the Epcot line DIRECTLY to your right (refer to Rob's picture).

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It almost seems to me that if Pink was paying attention like he/she should have been...(and not even a GREAT deal of attention, these are all minor things)...then poor Austin would have went home that night. Lack of attention to the motion and position of his train, I think holds equally accountable as the switches not being in the right position.

You can blame it on the safety overrides all day. But he just wasn't paying a reasonable amount of attention. Now this could also deal with fatigue. But that also falls on the pilot to notify his/her manager that he/she was sleepy or exhausted.

And that I believe where experience comes in. This statement has NOTHING to do with age. Same as a airplane pilot learns the ins and outs of his/her aircraft...from airspeeds, to little changes in performance (they learn to "feel" the aircraft as they fly it)........I honestly believe a monorail pilot with extensive experience, would have noticed he was on the wrong beam. He would have noticed that it didn't "feel right" going through the switch, or perhaps the scenery looked different outside the cab.

And I "am" looking for critiques onto my opinion. If you feel I'm wrong, I have no problem with you telling me!

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This was what I was thinking too after seeing the photo. The bank of the curve would "feel" different than what the pilot was expecting to feel if nothing else.

board57796 said:

Re: Switch 9 being powered and not Switch 8

I seem to recall an occasion in which a train on the Epcot beam was having serious issues but it was during a heavy exit on Express and Epcot. And in order to keep the system running the train was backed onto the spur line from Epcot and I THINK the express switch was not moved, to not disrupt the Express beams motion. Then once the train was completely on the spur line, the epcot switch was lined back up to the main line and the train sat dead on the spur for a few hours with a very bored pilot. So I think it is possible to go through switch 9 eithout switch 8 (on Express) being in position. In this case the hold point is S10 (for the tenth pylon on the spur line)

I could be wrong about this but I think it happened this way. And if the pilot did not know where S10 was the rear off the train could have gone off the end. Any other pilots confirm/deny this?

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I definitely remember my platform trainer discussing this with another Cast Member when I first started in rails. They definitely talked about how a train was held on the Epcot spur for a few hours. However, I was under the impression that if the train went towards the end of the spur line, it would have e-stopped due to lack of power on that end. Of course, pilots are required to know all of the hold points, including the seldom-used S10, but the lack of power for the train would have held it further along the beam, anyway.

My condolences to Austins family and the CMs involved. I piloted MarkIVs back around 82-84. Post #766 by board57796 sounds very plausible to me.

Some questions for those that know:
Are the Epcot spur switches not monitored with sensors? I recall the old switches were monitored at Shop and sometimes had to be moved twice if they did not lock down properly. It would be unfathomable to me that there were no sensors to confirm the beam position. I am assuming the root cause of this was a human communication failure.

Does the Central console display the switch positions? We have all heard the Central was not in the Central console during this switching operation. Could them not being in the console be a contributing factor?

Is there a black box in Shop to record all switch movements? Possibly there was mis-communication between Central and Shop?

Are all switch motion requests done over the radio (and therefore recorded)? I may recall that sometimes Base or Concourse used the phone to talk to shop and get the switches moved. This could lead to Pink and Purple confused about if the switch was actually requested to be moved and the movement confirmed.

The Epcot spur switches are mechanically very different than the old MK switches and are MUCH smoother to drive over. IIRC, that makes it hard to feel if you train is actually switching or not, but once Pinks cab passed the switch they should have seen the switch was in the wrong position, etc and been able to stop safely. There was no way to miss the fact that you were being switched over the old style switches and the speed limit was like 2-3 MPH.

IMHO, based upon the old control system, if you are driving MAPO bypass and see something coming at you, getting the train stopped and put in reverse, would take too long to avoid the collision.

If Purple saw Pinks tail strobe coming at him, he could have keyed the radio and said "Pink STOP", but it is also possible that the radio was busy or Pink could not stop in time. The radio recordings will be invaluable.

IMHO, Central should be required to be in the console during all switching. In my two years, I was cleared MAPO bypass off the ends of open switch beams or into stations where trains were sitting multiple times, so I never totally trusted the leads. The pilots need to know where all the trains around them are.

While not really relevant to this accident, the more I think about it the more sure I am a train can be moved completely onto the Spur line with only one switch open. The Spur line has two holdpoints on it, S10 and S6. The only reason to stop at these hold points is to wait for another switch to be thrown ahead or behind you. I've heard many times "switch 9 ONLY to the spur line with power" with "only" being heavily emphasized, then once shop confirms its moved the train on Epcot is clear in reverse to S10 (with "s10" also heavily emphasized. There are still 6 pylons til the end of the beamway so maybe the train would lose power if it went to far.

Rob562 said:

And to touch on the 911 calls for a moment, I haven't listened to them, and may never listen. But are they all from Reedy Creek dispatch? I know that all *landline* phones on-property are sent to Reedy Creek when you dial 911, but what about cell phones? A Guest witnessing the accident who grabs their own phone and dials 911 could get the county dispatch, who will determine the location of the caller, and then route the call to the appropriate dispatch center (i.e. Reedy Creek).

Here in Massachusetts, dialing 911 on your cell phone will get you the State Police. They will determine your location, and route the call accordingly. I don't know the coverage zones for each of the state police barracks to know which one covers which highways, so I say my location and let the dispatcher route me. But I know that if I'm on local roads, I can speed up the process (and thus the response time to the accident) if I immediately ask them for the dispatch for the town that I'm in.

-Rob

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The audio I listened to included three recordings all released by Reedy Creek. I heard no reason to believe any were not being made by a Cast Member.

MarkIV_railie said:

....

IMHO, Central should be required to be in the console during all switching. In my two years, I was cleared MAPO bypass off the ends of open switch beams or into stations where trains were sitting multiple times, so I never totally trusted the leads. The pilots need to know where all the trains around them are.

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WOW. So this statement basically confirms that this situation has possibly occurred multiple times in the past. This is just the first time it ended in a fatal collision....

P.S. Thanks for the additional insight, MarkIV_railie.

not sure if this has been reported but they are currently not allowing guests to ride in the cab.... probably less of a safety concern, and more of a 'don't want the pilots having to answer 50 million questions about the accident while driving' thing.

I have a bit of new info about the purple monorail, they downloaded the files from the onboard computer, and I don't know the exact timeline, but it would be nice to know. But it seems like purple was trying to go into reverse, the monorail was going forward then stopped, then e-stopped, then put into reverse and that was the last operator action. I'm not really familar with the monorails, so I don't know how long that would take or if it moves immediately or takes a little time to reverse and get up to speed.

Firewolfe51 said:

ok people who has heard the 911 calls made? those calls heard on the Sent. web site only PROVES dispatchers are IDIOTS......now before some decent dispatcher blast me on here you BETTER listen to those calls. Both callers notified the 911 dispatcher therehad been an accident at the TTC and one caller stated they crashed together......neither time was the caller told help was coming. They asked if anyone was injured...blah blah caller said i dont know its just bad.....blah blah. 911 operator says "well go check" THEY ARE IDIOTS.. from those calls you cannot hear any FIRE or EMS units dispatched. it doesnt matter if anyone is hurt or not if two monorails crash there needs to be a fire truck somewhere close and MOST LIKELY a couple of paramedics with a ambulance! just FYI lol i know im about to get it.. for those who like the Disney history WED enterprise developed one of the very 1ST 911 systems in the WORLD! i mean the world not WDW. and i been a paramedic for almost 20 years every SECOND counts :brick:

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Yeah. Right. Let's all blast the dispatchers now.:hammer:Your logical thinking and astute reasoning is just oh, so convincing. 20 years as a medic = BURN OUT. Now that I got that off my chest...

Presuming you are actually a medic for a public service and dispatched by an acredited 911 center, then you should know that there are such things as call-takers and dispatchers. If one is taking the call, another is dispatching it, and thus that portion would not be heard on the call-takers end. You should also know that acredited 911 centers certified by the NAEMD are required to enter all priority calls (E0 and E1 for us) within 60 seconds. Hopefully this makes sense to your small medic brain.

Maybe that's why you are on the boo-boo truck and not in the communications center: you couldn't handle it.

Sorry for being so harsh here, everyone, but let me make one thing perfectly clear: The Dispatchers Are Not To Blame.

mikeymouse said:

I'm not going to blast anyone. I work on both ends of the radio. I personally would not have waited for anyone to check on injuries. I would have dispatched the world. If they're not needed, they can be cancelled. This could have been a mass casualty incident with multiple victims. Agreed, time is critical. They weren't getting a good location though from what I could hear. I heard the one guy say the Epcot monorail station. Units would have been sent to the wrong park. Wouldn't have changed the outcome. Just because you can't hear the units being dispatched doesn't mean someone else isn't doing so.

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Agreed, Mikey! When in doubt, send them out.

MythBuster said:

I have a bit of new info about the purple monorail, they downloaded the files from the onboard computer, and I don't know the exact timeline, but it would be nice to know. But it seems like purple was trying to go into reverse, the monorail was going forward then stopped, then e-stopped, then put into reverse and that was the last operator action. I'm not really familar with the monorails, so I don't know how long that would take or if it moves immediately or takes a little time to reverse and get up to speed.

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if thats true, they you could assume that Austin saw Pink barreling towards him and died while trying to prevent the accident from happening.. The reverse probably didn't 'work' because he was likely not holding the override button down, and it was obviously a situation in which mapo would have shut his train down (the estop).. Just not enough time.. Even 15 MPH is fast compared to dead stopped..


Either way, nothing he could have done beyond what he did..

Remember folks the released 911 tapes are edited so you are not hearing the ENTIRE call taker and RP conversation. From the sounds of it the call taker was eliciting the appropriate information and most likely entering it into the CAD then forwarded to the appropriate PSAP telecommunicator for dispatch. Even while the call taker was online with the RP (reporting person) most likely post the initial caller the dispatch was being done . Why are we armchair quaterbacking this when the fact is we do not have the entire taped PSAP (Public Safety Answering Point or 911 center) call for review. I have listened to some "edited tapes "of fire with entrapment and you would swear no units had been dispatched when in fact they had already hit the street priro to the end of the first caller. Again in listening to these 911 calls on this incident they are edited leaving out information that most likely was provided. You are not going to hear graphic details on publicly released 911 tapes .

Lets remember what happened and leave it at that someone was killed the question now and the only questions to be bantered about is how this happened and how to prevent the next occurrence. Lets not place blame or point fingers. This topic is turning into a bash session of fire and PSAP personnel and ther is no reason for it. Anyone who has ever utilized any 911 system can tell you how it plays out RCFD has its own 911 dispatch located in its main staion they handel thier own incidents and do it well, Remember they handle a multitude of 911 calls a day and no one has ever complained about its service .
I remember post 9/11 everyone placed nbame on the FFs/ management the mayor and thier inability to hear and interact inter agency with each other and how it was this ones fault and that ones fault we lost 343 brothers ans sisters but the fact it it happened and the fact is this tragic event that took a life has happened lets give a break. Lets focus on how and correct it.

I dont see the persons who had been directly involved complaining even the interviews on the media NO ONE COMPLAINED about the actions of emergency service persons.Why are some on hear complaing and surmising. Remember to assume makes and as$ out of u and me.

And to the person who thinks 20 years as a medic is a burnout issue I am doing this 30 and I am not burned out , I manage 20 FF/Paramedics a shift and all preform well including myself and most of them are on the job 10 plus years.

We are all out ther to help you the public each and everyday give us a break . To the poster who complained about the PSAPs not doing a good job yes some do lack in thier dispatching ability but some medics and FF also lack in their areas .


again lets just focus on the loss of the poor mans life and the incident and corrective actions of same.