Sentinel: Monorail crash: Disney did not follow manual

[jakeman]

I think these new procedures will do more harm than good but will probably put Disney in a better legal situation should another accident ever happen which is ultimately why they have implemented this.

I disagree.

It's an additional safety measure. One that the manufacturer recommended.

It's like claiming seat belts cause people to drive more reckless.

There was a process breakdown and a glaring hole in Disney's SOP in that the TTC console was not required to be manned. That more than anything else was the biggest error identified so far. All of the individual errors that took place by inattentive cast members could have been nullified by having some one at the board at the TTC.

That is an SOP problem.

It ultimately depends on what the reports say and how Disney revises policies in reaction to it.

Right now there was a procedure breakdown exacerbated by a flaw in Disney's policies. While the VP is ultimately responsible because of their title, in my opinion, based on the information that we have, the SOP development process as a whole should be looked at.

While having a scapegoat is great, I would rather the processes be looked at for improvement. Blame should be a distant second to ensuring that policies are in place to prevent this from happening again.

 

[PhotoDave219]

While having a scapegoat is great, I would rather the processes be looked at for improvement. Blame should be a distant second to ensuring that policies are in place to prevent this from happening again.

Well yeah, thats spot on but there's plenty of blame to aim at upper management. You know, those who wrote and oversaw the processes that failed?

 

[s8film40]

I disagree.

It's an additional safety measure. One that the manufacturer recommended.

It's like claiming seat belts cause people to drive more reckless.

While I agree some off the measures have added an additional layer of safety they do not address the core problem. Their simply putting more people into the operation to reduce the chances of a problem, It's equivalent to an airline after an accident saying there going to add extra pilots to each flight to help double check everything. They need to hire the right people for the job and create a more extensive training process, but that would cost money. Disney should have known this was coming I know many people in monorails who have talked about problems for years.

 

[Bulldog1653]

Hello all,

Interesting topic for debate. I have a few points I'd like to make here.
MontyMon has it right; polices and regulations in any kind of transportation are almost ALWAYS written in blood because of some incident ocurring and people either getting hurt or killed.
TOTGuy is also correct about the policy makers. Most, if not all of them haven't worked in the field enough to impose the right rules and regs. This is true in any kind of field.
I honestly think that a lot of these supervisors should be required to have field experience before they EVER set rules.
Now about the spotter issue. The idea of having a spotter for a monorail having to reverse is a sound one. A camera on the opposite end of the train is a great idea but it will NEVER replace a person. When track switching takes place, I personally think that there should be a spotter in the cab on the opposite end. This would help considerably.

 

[PhotoDave219]

.... basically the camera can see but the guy watching can scream his _______ head off.

 

[xtina72]

I have to admit that after this incident I was a little Leary about sitting in the first car after the driver on the monorail.....when we were there at the beginning of the month I kept steering my kids to the middle cars and the cast member would say "you can come up here there is room" and I would just smile and say "no thanks we will stand in the middle."

 

[jakeman]

Well yeah, thats spot on but there's plenty of blame to aim at upper management. You know, those who wrote and oversaw the processes that failed?

I would be interested to see the review process for their SOPs. They should be reviewed on a regular basis and have documentation on any improvements or even reasons why they weren't improved.

Either way, there is someone above the GSM level who is probably going to be looked at very closely.

While I agree some off the measures have added an additional layer of safety they do not address the core problem. Their simply putting more people into the operation to reduce the chances of a problem, It's equivalent to an airline after an accident saying there going to add extra pilots to each flight to help double check everything. They need to hire the right people for the job and create a more extensive training process, but that would cost money. Disney should have known this was coming I know many people in monorails who have talked about problems for years.

You're right, the core problem, as identified so far, is an inadequate operating procedure.

No offense to monorail pilots, but they are not the same as airline pilots, in either training or scope of resposibility. I think a more accurate example would be adding more ground crew, but I digress.

If your monorail friends have documented escalation of safety issues with the transportation systems that were ignored by management then that should be made available to OSHA and the NTSB.

If your monorail friends simply talked about the issues while splitting a beer at the Ale House, then how are the people ultimately responsible supposed to know?

Saying, "Disney should know." is a hollow, nebulous statement. Things happen at my job occasionally that I "should know" about that never reaches me. At that point I simply point to a breakdown in communication further down the chain from me that prevented the necessary information from reaching me. Then I work with the appropriate people to make sure it doesn't happen again.

Disney is made of people and people make mistakes. Sometimes groups of people make many mistakes that culminate in a tragic occurance, such as this.

We should hope that Disney does not have the same desire for blame that internet message boards do and fix the issue on every level instead of scapegoating someone in upper management to appease the public.

 

[Mr.EPCOT]

I would be interested to see the review process for their SOPs. They should be reviewed on a regular basis and have documentation on any improvements or even reasons why they weren't improved.

Either way, there is someone above the GSM level who is probably going to be looked at very closely.

You're right, the core problem, as identified so far, is an inadequate operating procedure.

No offense to monorail pilots, but they are not the same as airline pilots, in either training or scope of resposibility. I think a more accurate example would be adding more ground crew, but I digress.

If your monorail friends have documented escalation of safety issues with the transportation systems that were ignored by management then that should be made available to OSHA and the NTSB.

If your monorail friends simply talked about the issues while splitting a beer at the Ale House, then how are the people ultimately responsible supposed to know?

Saying, "Disney should know." is a hollow, nebulous statement. Things happen at my job occasionally that I "should know" about that never reaches me. At that point I simply point to a breakdown in communication further down the chain from me that prevented the necessary information from reaching me. Then I work with the appropriate people to make sure it doesn't happen again.

Disney is made of people and people make mistakes. Sometimes groups of people make many mistakes that culminate in a tragic occurance, such as this.

We should hope that Disney does not have the same desire for blame that internet message boards do and fix the issue on every level instead of scapegoating someone in upper management to appease the public.

From first-hand experience, I'm telling you that the core problem is personnel, not SOP. Beefing up the SOP is just putting a band-aid on a stab wound. It's just trying to make up for the lack of competency with some of the people they're hiring.

 

[s8film40]

Saying, "Disney should know." is a hollow, nebulous statement.

After what I originally posted I decided it might not be appropriate to say here since it involved the specific actions of a few individuals, so I edited it and that statement didn't quite make as much sense, sorry. To sum it up though Disney had a very clear indication of the problems present.

 

[fosse76]

IThis was an accident caused by a series of mistakes that aligned. Could this have been prevented? Absolutely. Does the monorail system need an overhaul? Sure. Are the CMs entirely to blame? NO! You have no idea what it is like to be in that kind of situation, and until you do, do not judge us. Everyone is so quick to blame the cast member, when in fact a lot of these policies are made by people who don't even participate in operations.

I find this argument slightly flawed. While Disney's operating policies did lead to the accident, the accident itself was entirely the fault of the CMs. It was a CM who told the pilot that the beam had been switched, when it had not. It was a CM who wasn't attentive enough to know he was on the wrong beam. Yes, Disney should never have instituted an operating procedure that actually overrides the safety system designed to prevent such accidents, but that is not what caused the accident.

 

[jakeman]

From first-hand experience, I'm telling you that the core problem is personnel, not SOP. Beefing up the SOP is just putting a band-aid on a stab wound. It's just trying to make up for the lack of competency with some of the people they're hiring.

Really? Because it seems to me having someone at the board in the TTC or a spotter like the manufacture recommended 20 years ago would have prevented this accident.

I'm not saying it's not a training or hiring issue, but with the information we have so far it is apparent that SOPs play some role in this. That is what I'm focusing on. The SOP needs to be fixed.

In my opinon, I would be surprised if there wasn't a comment and/or recommendation regarding the training of cast members at all levels of monorail operation.

There are probably training and compliances issues here, we just don't know about them and I'm not going to speculate about them.

Having only 1 fatality in 38 years of operation says to me that several things that go wrong independent of each other went wrong at exactly the same time that night. It will take time to identify each issue and implement a solution. I think we are only seeing the tip of the iceburg.

I should probably make it clear that I in no way thing that one simple SOP was the cause of the accident. Rather this is only one facet of a complex problem.

 

[s8film40]

Really? Because it seems to me having someone at the board in the TTC

I agree with this particular change, but what most people don't realize is that is a very small issue. That position is entirely radio communication, the "board" they look at has very little information and ultimately that person relies on radioed information from the shop. Yes someone being there would have prevented this particular accident, the same is true if someone had been monitoring the console in between resort and express or the console out at Epcot. Again this comes back to complacency they trusted the information being provided by the shop they trusted that the person at the shop had thorough training and knew how to do his job.

or a spotter like the manufacture recommended 20 years ago would have prevented this accident.

If you used a spotter every time you backed up your care you would undoubtably be safer, sometimes practicality outweighs the risk. There are other methods to determine the track is clear.

 

[PhotoDave219]

If you used a spotter every time you backed up your care you would undoubtably be safer, sometimes practicality outweighs the risk. There are other methods to determine the track is clear.

I'm sorry but anyone who works in the railroad business knows that any time you go backwards, you have someone on the back of the train, watching where you're going.

OSHA seems to agree with me.

 

[EpcotServo]

It's just trying to make up for the lack of competency with some of the people they're hiring.

^This. I used to be shocked at some of the Cast Members, until I actually applied and saw how far the standards of the Casting process has sunk too. Need to stop relying on college kids that come and go and focus on Cast Members that they will be relying on for a much longer time. Making sure they are in the right place, doing the right things, and doing it the Disney way.

*I still haven't even got a call yet. Unacceptable from how they used to do things.

 

[EPCOT Explorer]

It began Sunday Dec 20th. What did you see?

I only rode a Monorail on the 18th, but I saw CM's motioning to the Pilot (In the car in front of us) in a manner as described here. Maybe it was nothing...but I'd never seen them communicate that way.:shrug:

 

[s8film40]

I'm sorry but anyone who works in the railroad business knows that any time you go backwards, you have someone on the back of the train, watching where you're going.

OSHA seems to agree with me.

Monorails don't really compare to the traditional railroad business, Many monorails are operated all over the world and do not have spotters. I wouldn't be surprised at all if WDW is now the first and only monorail system with spotters. OSHA just found something in a book and decided to use that as the excuse for the fine that we all knew was coming, and the fine it self was considerably low compared to other fines imposed after accidents. I guess if your not familiar with monorails you can see things the way you do but I can assure you this all comes down to the wrong type of people being put in the wrong jobs with little training so that the management can save some money. The monorail pilots for the past several years have referred to the training program as the "no driver left behind" program. These things just aren't as tangible as clearly written documents.

 

[s8film40]

I only rode a Monorail on the 18th, but I saw CM's motioning to the Pilot (In the car in front of us) in a manner as described here. Maybe it was nothing...but I'd never seen them communicate that way.:shrug:

Instructions for the new procedures were given out on the 17th but were not in effect until sunday. However the new procedures from what I understand require radio communication not hand signals.

 

[EPCOT Explorer]

Instructions for the new procedures were given out on the 17th but were not in effect until sunday. However the new procedures from what I understand require radio communication not hand signals.

So what the heck did I see? :lol:


The CM had a radio, in his hand, but he was not using it...

 

[fosse76]

Monorails don't really compare to the traditional railroad business, Many monorails are operated all over the world and do not have spotters. I wouldn't be surprised at all if WDW is now the first and only monorail system with spotters.

I'd be willing to bet that most non-Disney monorails don't operate in such a reckless matter such as moving backwards on an operating beam while overriding the safety system to remove the trains. And say what you will, that Disney policy, and OSHA agrees with me, was absolutely reckless. Just because there hadn't been an accident until now doesn't mean it wasn't dangerous.

OSHA just found something in a book and decided to use that as the excuse for the fine that we all knew was coming, and the fine it self was considerably low compared to other fines imposed after accidents. I guess if your not familiar with monorails you can see things the way you do but I can assure you this all comes down to the wrong type of people being put in the wrong jobs with little training so that the management can save some money. The monorail pilots for the past several years have referred to the training program as the "no driver left behind" program. These things just aren't as tangible as clearly written documents.

While this was definitely the fault of the CMs involved, it was Disney's reckless policy that ultimately led to this. If you develop a policy that needlessly overrides a safety feature designed to prevent accidents, then the policy is wrong.

 

[Duckberg]

THE findings

HELLO get me LEGAL!!! Duckberg :brick: