Monorail Accident

[PhotoDave219]

.... Amazing how this thread goes from an accident investigation to complaining about Epcot.

I suppose people will use any excuse to advance their own agendas.

 

[Glasgow]

In my experience, any thread longer than about 10 pages is just a complain-fest. It sure would be nice to have a place to read actual information rather than seeing constant moaning about how miserable the world is, how litigation is the cause of all problems and why the descent at SSE is akin to clubbing baby seals.

Anyone have a full animated schematic (gif) of the monorail system?

 

[tnichols]

In my experience, any thread longer than about 10 pages is just a complain-fest.

We are way over 10 pages on this one.

 

[jakeman]

I apologize if this has been buried in the thread, but it appears from the responses on the past few pages that the investigation has determined that budget contraints and lack of training are the cause of the accident.

Is this true?

 

[Brian Noble]

True or not, it certainly fits many pre-conceived notions.

 

[PhotoDave219]

I apologize if this has been buried in the thread, but it appears from the responses on the past few pages that the investigation has determined that budget contraints and lack of training are the cause of the accident.

Is this true?

Actually, that hasn't been broached in this.

The investigation hasn't released much beyond their "Factual Statement" (conveniently available on NTSB.Gov or in a different thread of its own).

No determination of cause or fault has been stated. No one has mentioned anything about budgetary constraints or training having anything to do with it.

What we have been bashing is the procedures and policies that Disney has in place that allowed the accident to happen as well as a management culture that has bred a mindset that frowns on E-Stops and using the Kill packs.

For example, what's the point of having a safety system if trains are allowed to override it, let alone having two trains moving in override at the same time? Thats a dangerous procedure/policy.

 

[jakeman]

So basically, we are trying this in the court of public opinion?

Fair enough, just wanted to make sure I hadn't missed any factual information.

 

[WDW Monorail]

What we have been bashing is the procedures and policies that Disney has in place that allowed the accident to happen as well as a management culture that has bred a mindset that frowns on E-Stops and using the Kill packs.

For example, what's the point of having a safety system if trains are allowed to override it, let alone having two trains moving in override at the same time? Thats a dangerous procedure/policy.

Honestly, I'd frown upon using the kill pack if a guest was sitting on the railing as well, as broad mentioned. It would be much easier and more logical if the guest were asked to move.

 

[PhotoDave219]

So basically, we are trying this in the court of public opinion?

Fair enough, just wanted to make sure I hadn't missed any factual information.

Some are, some aren't. Me, I'm waiting for the NTSB to come out with a Thousands-page tome that dissects the incident in very long form with all sorts of supporting documentation, but thats a year off more than likely.

I understand that there's no mechanical cause to the accident and that the NTSB is looking at procedures, policies and how Disney does things which is leading towards some appalling revelations for a company that touts "Safety, Courtesy, Efficiency and Show."

The general facts are in that NTSB advisory that came out earlier this week. I'm sure that combined with the radio communications and data logs from the monorails should make the actual accident explanation pretty simple.

Its Disney trying to explain the "Why" their policies broke down and resulted in one death that should be entertaining.

 

[LorangeJuice]

- Operation by Pink past a Stop signal (Red MAPO). From what I've read, he was cleared to override to Base, then "normal" to MK. So when he got to what he thought was Base and still had the Red MAPO, why did he keep going when that was beyond the limit he was cleared for override operation?

I have also been scratching my head over this for the past few days, but, again, I was hesitant to post it because I didn't want to get into speculation. But like my last post, I wanted to use logic. The MPS should have been Green for the reverse direciton if he was on Express like he thought he was. Not only was it likely not green, but it was likely Amber turning to Red! So....again I'm going to skip the speculation and try to ask a question based on logic.

Now, there was a pilot on here (I believe) that referred to the clearance by Central as being 'as good as gold.' So, my question is whether or not there has been a case where Central has given an all clear to override MAPO where there has been anything other than a Green MPS that has turned out to be clear afterall? On the flipside, has Central ever given an all clear to override MAPO where a pilot noticed anything other than a Green MPS and corrected Central on their decision?

Now that I wrote this, I have 2 more questions:

1.) Why would Central clear Pink to reverse in MAPO override on what they belived to be the Express beam when Pink should have gotten a Green MPS all the way through? I know the SOP is to MAPO through the switches, but once he was off the switch (I think even when he was on it) MPS should have been Green until the MK station. I think I also read on here that he was cleared in MAPO override until a Green MPS appeared. So, what would make the MPS anything other than Green in the reverse direction (the switch should have no effect on this direction, right?)? In otherwords, why was he cleared to override MAPO once he was off the switch?

2.) I have read reports about the recent changes in allowing trains going offline to reverse on the Express line for a while now, but how long have they been cleared by Central from the spur all the way to MK station? It seems only clearing to Base may have prevented this too. Just wondering if this was another degree of deviating from the original SOP or if this was all at once to speed the process (though once off the spur, the guests on EPCOT line wouldn't have to wait any longer).

 

[EPCOT Explorer]

Disney is going to get slammed for this ... no doubt about that ... it may have been 'human error' but that excuse only goes so far when corners are cut, procedures aren't followed or changed (even due to 'guest complaints' over waiting etc) when people die.

The Mouse really needs to be repetent beyond belief and fundamentally change this constant cutting of anything or anyone of value ... funny how all the old-timers who are ripping the change in procedures are largely not with the company ... but these new guys know best ...

This may have only happened once ... but the reality is it was disaster that was a decade plus in the making.

Yet again, you can't toss out the playbook that made you what you were (we all know safety is NUMBER ONE, right?) and be ignorant enough to think things will stay the same.

So sad, so stupid and so preventable.

It's scary to think of the implications of this. Being the optimistic person I am, I certainly hope that Disney DOES reform their "laws" so to speak and is better for it.


It's possible.:shrug:

 

[Monorail_Orange]

I have also been scratching my head over this for the past few days, but, again, I was hesitant to post it because I didn't want to get into speculation. But like my last post, I wanted to use logic. The MPS should have been Green for the reverse direciton if he was on Express like he thought he was. Not only was it likely not green, but it was likely Amber turning to Red! So....again I'm going to skip the speculation and try to ask a question based on logic.

Now, there was a pilot on here (I believe) that referred to the clearance by Central as being 'as good as gold.' So, my question is whether or not there has been a case where Central has given an all clear to override MAPO where there has been anything other than a Green MPS that has turned out to be clear afterall? On the flipside, has Central ever given an all clear to override MAPO where a pilot noticed anything other than a Green MPS and corrected Central on their decision?

Now that I wrote this, I have 2 more questions:

1.) Why would Central clear Pink to reverse in MAPO override on what they belived to be the Express beam when Pink should have gotten a Green MPS all the way through? I know the SOP is to MAPO through the switches, but once he was off the switch (I think even when he was on it) MPS should have been Green until the MK station. I think I also read on here that he was cleared in MAPO override until a Green MPS appeared. So, what would make the MPS anything other than Green in the reverse direction (the switch should have no effect on this direction, right?)? In otherwords, why was he cleared to override MAPO once he was off the switch?

2.) I have read reports about the recent changes in allowing trains going offline to reverse on the Express line for a while now, but how long have they been cleared by Central from the spur all the way to MK station? It seems only clearing to Base may have prevented this too. Just wondering if this was another degree of deviating from the original SOP or if this was all at once to speed the process (though once off the spur, the guests on EPCOT line wouldn't have to wait any longer).

With all of the fantastic information and insight he has provided, "board" has actually answered all of these questions before within this thread.

Add me to the list of those thanking him for helping us all to understand the rails and what may have happened that terrible night.

 

[LorangeJuice]

With all of the fantastic information and insight he has provided, "board" has actually answered all of these questions before within this thread.

Add me to the list of those thanking him for helping us all to understand the rails and what may have happened that terrible night.

Oh, I know. I thanked him for it too. I guess I couldn't keep track of all of it, lol!

Maybe I was just asking for verification, then. I do remember having it all sorted out by "board", but then "board" and I discussed the possibility of Purple going into reverse (keep in mind this was before it was confirmed by the NTSB) which he then confirmed was possible since the MPS would have been Green in that direction, so that got me thinking about Pink having the same situation since I had only then learned that the MPS is direction specific.

BUT, having said that I will try to go back and look to verify, but it may take me some time, lol.

 

[DougK]

So basically, we are trying this in the court of public opinion?

Fair enough, just wanted to make sure I hadn't missed any factual information.

I don't think we're trying this in the court of public opinion, at least that is not my intention. We are simply discussing it. That is what discussion boards are for.

We do know a monorail train was going backwards, we do not need the final NTSB report for that, it is a known fact. My only point is they should never be allowed to go backwards, that is, the driver should always be in the front facing forward. No matter what else went wrong or right, I think it is fair to say that this particular accident would not have happened had the pink monorail driver been required to be facing forward. He would have seen Austin and monorail purple ahead of him.

Of course we will be able to make even better assessments after the final report is released, but that shouldn't mean we can't discuss this before then.

 

[LorangeJuice]

Ok, I think I got it. I'm going to repost this so it isn't so buried either.

I would like to shed some light on the process for removing trains from the Epcot Beam.

Monorail Pink would be "deadheaded" at Concourse, meaning the Pilot announces that the train is going out of service and must be fully unloaded. The pilot walks through the train to ensure this, then closes the doors and goes back to Cab 1 (normal driving cab for Epcot.) At this point the conversation goes similar to this:

"Central, Monorail Pink is deadheaded at Concourse."
"10-4, Normal Visual to Pylon 30, hold at notify Central"

Pink then continues out in forward to Pylon 30, which places the end of his train (Cab 6) just past the switch point to take trains from Epcot to Express. Once Pink gets to 30 and notifies Central, Central radios shop to move "Switches 8 and 9 to the Spur Line, with power." This is where something went wrong last night. Either Shop didnt comply, Central didn't call, or something malfunctioned. Either way, something went wrong at this point last night.

Central will also call Purple and say

"Monorail Purple you are Normal Visual [if you have a green MAPO and no visual obstructions ahead, go ahead] to Pylon 379, hold and notify."

Pylon 379 is the primary holdpoint for Concourse, meaning if a train is at the station, the train behind will stop at Pylon 379. Pylon 379 is right over the handicapped parking, by the way.

Last night, from what I have been told by people who had radios on them (and switching is really the only interesting thing going on at 2am) that Pink was "Clear to use MAPO Override, in reverse, through 9, through 8, THROUGH BASE, through Poly, through Grand Flo to the Magic Kingdom, switch ends" meaning, had the switches been aligned properly, Pink would have been expecting to reverse COMPLETELY through Base on Express and all the way to the MK. "CLEAR" from Central means you GO. Even if you get an MBS, you MAPO override. Clear is as good as gold, when given from Central.

By this point, Purple has reached 379 and notified so. Central will then say "Purple you are normal visual to pylon 385 [directly above the tram station] then MAPO Override to reach Concourse, hold and notify."

Purple has to MAPO Override because, had the switches been aligned to the spur, there would have been a gap ahead of Purple, which would have given an RED MBS, even though Purple only needed to reach Concourse.

So IN MY OPINION, last night Pink was coming in Reverse in MAPO Override (as required to pass over a switch) but instead of being on the Spur Line, was in fact still on Epcot beam. I do not know why the Pilot did not realize this, but that is not for me to debate. At the same time, Purple was MAPO Overriding from pylon 385. The pilots did not realize their RED MBS was not from a switch being open, but in fact due to the other train. So Pink came through Concourse at 15mph in reverse (as restricted by computers) as Purple was approaching Concourse in forward, in MAPO Override, just past pylon 385 (as indicated by the photos showing it past the tram loading area) and this is where the collision I believe occured.

I have tried to be as factual about the switching process as I can without being too confusing, and the last paragraph was pure speculation, although I feel I have some credence as I took trains to shop nearly every night. Either way, it is a tragedy that a Cast Member was killed, and I can't imagine what the other driver must be feeling, as well as everyone else involved.

So I guess my question now is: why is an all clear by Central as good as gold? I'm not knocking on it. I just really want to know.

I still leave my original questions open though. Though I doubt there have been examples since the all clear from Central was still 'as good as gold.'

 

[mmzplanet]

Ok, I think I got it. I'm going to repost this so it isn't so buried either.



So I guess my question now is: why is an all clear by Central as good as gold? I'm not knocking on it. I just really want to know.

I still leave my original questions open though. Though I doubt there have been examples since the all clear from Central was still 'as good as gold.'

Air Traffic works in this manner also. If a controller says to turn to a heading, altitude and maintain a set speed.... you do it (it's even better than gold for them), especially in IFR conditions. Although airliners always fly IFR anyway even if VFR conditions exist. You have to trust that a controller is feeding you proper information. Although you should still look out for your craft, even ATC has made errors, yet we still rely on them. The only time an Airliner would disregard ATC is if they have visual evidence or TCAS is alerting to a possible collision.

I feel reversing through the switch is ok... but not all the way to MK. reversing to Base then switching would make much more sense. No reason to be reversing through a bulk of the system. Reversing for a switch can be ok if people were actually watching,

 

[sweetpee_1993]

So I guess my question now is: why is an all clear by Central as good as gold? I'm not knocking on it. I just really want to know.

I still leave my original questions open though. Though I doubt there have been examples since the all clear from Central was still 'as good as gold.'

I used to be a law enforcement dispatch supervisor. I don't know exactly how to put words to some things so that people can understand. If anyone else out there has worked, lived, or functioned within this realm you will totally understand the same as me. To answer your question, there are some jobs out there that require an absolute trust in the voice on the radio that tells you stuff. In the job that I used to do the patrol units on the streets listened to me, we had a "relationship" of sorts, they're lives were quite literally in my hands for 12 hours a day, and they trusted me. At times they had more info than I had and they would relay to me or I had more info than them and I would relay to them. Either way, it took trust. I know that's a small word and it's easy to take it for granted but in some positions that little word "trust" means life or death. Of course it's different in this situation, maybe the meaning isn't quite so literally on an ongoing basis but the person in Central who is giving directions is supposed to know what everyone else is doing. That trust is that Central who knows what everyone else is doing at all times and the voice on the radio telling you to do something isn't putting you in harm's way. That's why the voice from Central that tells a pilot to do something is "as good as gold". It has to be. It's the trust that makes a pilot able to hear an instruction then execute without wasting time trying to double-check or eating up air time on a radio asking "Central, are you sure?" when that same air time may be needed by some other pilot who may be in need of assistance. Wasting time in action and/or air time on a radio can create dangerous situations.

I'm quite sure the dispatcher (or whatever title that person holds) did not intentionally give directions knowingly putting these pilots or the public in danger. As a former dispatcher I cannot fathom how horrible this is for the person(s) in Central when this accident occurred. This is that person's worst nightmare, I assure you.

I hope I could shed some light. It's hard to explain some things. :animwink:

 

[LorangeJuice]

Air Traffic works in this manner also. If a controller says to turn to a heading, altitude and maintain a set speed.... you do it (it's even better than gold for them), especially in IFR conditions. Although airliners always fly IFR anyway even if VFR conditions exist. You have to trust that a controller is feeding you proper information. Although you should still look out for your craft, even ATC has made errors, yet we still rely on them. The only time an Airliner would disregard ATC is if they have visual evidence or TCAS is alerting to a possible collision.

I used to be a law enforcement dispatch supervisor. I don't know exactly how to put words to some things so that people can understand. If anyone else out there has worked, lived, or functioned within this realm you will totally understand the same as me. To answer your question, there are some jobs out there that require an absolute trust in the voice on the radio that tells you stuff. In the job that I used to do the patrol units on the streets listened to me, we had a "relationship" of sorts, they're lives were quite literally in my hands for 12 hours a day, and they trusted me. At times they had more info than I had and they would relay to me or I had more info than them and I would relay to them. Either way, it took trust. I know that's a small word and it's easy to take it for granted but in some positions that little word "trust" means life or death. Of course it's different in this situation, maybe the meaning isn't quite so literally on an ongoing basis but the person in Central who is giving directions is supposed to know what everyone else is doing. That trust is that Central who knows what everyone else is doing at all times and the voice on the radio telling you to do something isn't putting you in harm's way. That's why the voice from Central that tells a pilot to do something is "as good as gold". It has to be. It's the trust that makes a pilot able to hear an instruction then execute without wasting time trying to double-check or eating up air time on a radio asking "Central, are you sure?" when that same air time may be needed by some other pilot who may be in need of assistance. Wasting time in action and/or air time on a radio can create dangerous situations.

I'm quite sure the dispatcher (or whatever title that person holds) did not intentionally give directions knowingly putting these pilots or the public in danger. As a former dispatcher I cannot fathom how horrible this is for the person(s) in Central when this accident occurred. This is that person's worst nightmare, I assure you.

I hope I could shed some light. It's hard to explain some things. :animwink:

You sure did! Thank you, guys.

 

[board57796]

You guys got it. Just another point; "Normal Visual" is Central's instructions that you are clear to proceed with normal operations but it is YOUR RESPONSIBILITY to make sure you don't overrun, that you aren't putting yourself in a dangerous situation, etc. "Clear" means that Central has assured that there is NO reason you would need to stop, AT ALL, between the point that they said you were "clear" and whatever point they cleared you to. "Clear" is ALWAYS used when a train is operated in Reverse. You are NEVER "Normal Visual" in reverse, nor through a switch, regardless of which direction you are facing. To go through a switch in forward it would be "Clear in forward to..." not "Normal Visual to...." if that makes sense.

Normal Visual=pilots responsibility
Clear=youre relying on Central that they've ensured you're good to go to wherever they instructed, no matter what.

Now obviously, had Pink noticed he was on the wrong beam, he would have stopped, its not like he would have said "Oh, well I'm clear so..." because he was clear "through 9 and 8", not reverse on Epcot mainline.

 

[freediverdude]

I can't read through all 98 pages or whatever, but what I'm wondering is, why did the pilot of monorail pink not notice that he was going through the wrong side of the TTC monorail station? You would think that he would see, oh, whoops, I'm going back through the Epcot side, the switch must not have worked, and stop the train before it got all the way to crashing into purple outside the station on the other side. Or at least be in the process of stopping the train by then. That just doesn't seem right to me, especially if the pilot had done that before many times.