From Jason Garcia at the O'Sentinel
Hectic moments preceded Disney World fatal monorail crash
At about 2 a.m. July 5, as the last of Walt Disney World’s theme parks was closing after one of the busiest days of the year, there was still much to do inside the resort’s monorail-maintenance shop. An electrician there was juggling multiple tasks as he operated the track switches linking the monorail system’s Magic Kingdom and Epcot loops. Three of Disney’s 12 trains were waiting to transfer between tracks, and a fourth was approaching the bay where it was to be parked for the night.
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, killing that train’s pilot, 21-year-old Austin Wuennenberg of Kissimmee.
Investigators with the U.S. Occupational Safety and Health Administration determined, according to an internal memo summarizing the accident, that the unidentified electrician was “over tasked” that night, though it is unclear whether the agency thought Disney had assigned him too many responsibilities or whether the electrician himself tried to do too much at once.
The internal report is among hundreds of pages of documents compiled by OSHA during a six-month investigation into the accident and reviewed by the Orlando Sentinel after a Freedom of Information Act request. The records provide new details and deeper context to the formal citation OSHA issued in December, when it charged the resort with four workplace-safety violations and proposed a fine totaling $44,000.
An OSHA spokesman characterized the memo as “a draft version” of the final citation. He would not elaborate on the comments within it. “The citations are what OSHA decided to actually cite the company with. … Anything before that is preliminary,” spokesman Mike Wald said.
Among other details from the OSHA’s documents:
– Disney did not provide the electrician with written procedures for operating the computers that controlled the track switches. The electrician was given only oral instructions on the switching procedures sometime in September or October 2008. Disney has since provided written training materials to employees.
– The electrician operating the track switches that night was not the regular person in the job. He was substituting for another employee who has handled switching operations for 21 years — but who was on vacation.
– OSHA investigators considered the guest-service manager who was coordinating the monorail system via radio from an off-property restaurant “negligent” because he was not at a control console where he could have seen that the maintenance worker had not realigned the track. The manager, who was on a dinner break, had allowed the primary coordinator to go home sick and was temporarily handling coordination duties until a replacement worker could reach the central console. The ill employee clocked out at 1:47 a.m. — about 13 minutes before the collision — and his replacement was en route to the central tower at the time of the crash.
– The driver of the train that backed into Wuennenberg’s train had “limited visibility” at the time of the crash. The driver told investigators he could not see with his side-view mirrors because humidity and fog on the windshield “made it nearly impossible to see clearly.” Data from the National Oceanic and Atmospheric Administration showed that, at the time of the accident, the temperature was about 76 degrees, with 90 percent humidity.
– Disney’s own investigation of the accident appears to have placed the blame primarily on the electrician in the maintenance shop. Though OSHA did not provide Disney’s internal report as part of its documents, citing a federal public-records exemption governing trade secrets, a letter to OSHA from one of Disney’s lawyers said the company’s internal probe “demonstrates that the accident was caused when the maintenance panel operator improperly gave the command that the switch had been completed by him when, in fact, it had not been completed.”
A spokeswoman for Disney would not comment on issues raised in OSHA’s documents, saying the resort has agreed not to discuss the accident until the National Transportation Safety Board completes its own investigation. A representative for the International Brotherhood of Electrical Workers, the union that represents the electrician, also would not comment.
A representative for the Transportation Communications International Union, which represents monorail drivers, said the investigation demonstrated that neither Wuennenberg nor the other monorail driver was to blame for the accident.
“It was proven by multiple agencies that none of the Service Trades Council employees were found to be at fault, including either monorail pilot,” said Randall Sluder, a field representative for the union.
OSHA’s investigation ultimately led to a formal citation, issued Dec. 23, charging Disney with one “serious” workplace-safety violation that contributed to the collision.
In that citation, OSHA broadly criticized Disney for failing to provide a safe workplace, noting several policy lapses.
Among them: failing to follow a recommendation from monorail-manufacturer Bombardier that a spotter be used to watch the back end of any train driving in reverse, and failing to require the monorail’s central coordinator to be stationed at the main console whenever a track switch was occurring.
OSHA also cited Disney for three other, unrelated safety violations that it discovered during the monorail probe.
Disney has made a series of policy changes in the accident’s aftermath. The day after the crash, for instance, the resort began requiring that coordinators remain at the central console during track switches and that monorail drivers switch ends and drive from twin controls in the rear cabin of their trains when reversing direction through the Epcot switch.
In September, Disney said it had provided monorail-maintenance-shop workers with written instructions for the panel that controls the track switches. And in December, three days before OSHA publicly issued its citation, Disney began requiring spotters to watch the rear end of any train backing up.
Shortly after the accident, Disney placed the three employees directly involved with the sequence of events leading up to the accident — the electrician in the maintenance shop, the manager who had been filling in as central coordinator, and the driver of the second train in the collision — on administrative leave. The electrician and the manager recently returned to work in different roles with the company, according to a person familiar with their employment status; the driver has been offered a new job within Disney but has so far opted not to return.
Disney spokeswoman Zoraya Suarez would say only that two of the employees are back at work, while the other is “not yet” back.
OSHA ultimately fined Disney $35,200, a 20 percent reduction from the $44,000 in penalties it initially proposed. Disney paid with a check dated Jan. 22.
Jason Garcia can be reached at jrgarcia@orlandosentinel.com or 407-420-5414.
http://thedailydisney.com/blog/2010/02/disney-monorail-crash/
Hectic moments preceded Disney World fatal monorail crash
At about 2 a.m. July 5, as the last of Walt Disney World’s theme parks was closing after one of the busiest days of the year, there was still much to do inside the resort’s monorail-maintenance shop. An electrician there was juggling multiple tasks as he operated the track switches linking the monorail system’s Magic Kingdom and Epcot loops. Three of Disney’s 12 trains were waiting to transfer between tracks, and a fourth was approaching the bay where it was to be parked for the night.
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, killing that train’s pilot, 21-year-old Austin Wuennenberg of Kissimmee.
Investigators with the U.S. Occupational Safety and Health Administration determined, according to an internal memo summarizing the accident, that the unidentified electrician was “over tasked” that night, though it is unclear whether the agency thought Disney had assigned him too many responsibilities or whether the electrician himself tried to do too much at once.
The internal report is among hundreds of pages of documents compiled by OSHA during a six-month investigation into the accident and reviewed by the Orlando Sentinel after a Freedom of Information Act request. The records provide new details and deeper context to the formal citation OSHA issued in December, when it charged the resort with four workplace-safety violations and proposed a fine totaling $44,000.
An OSHA spokesman characterized the memo as “a draft version” of the final citation. He would not elaborate on the comments within it. “The citations are what OSHA decided to actually cite the company with. … Anything before that is preliminary,” spokesman Mike Wald said.
Among other details from the OSHA’s documents:
– Disney did not provide the electrician with written procedures for operating the computers that controlled the track switches. The electrician was given only oral instructions on the switching procedures sometime in September or October 2008. Disney has since provided written training materials to employees.
– The electrician operating the track switches that night was not the regular person in the job. He was substituting for another employee who has handled switching operations for 21 years — but who was on vacation.
– OSHA investigators considered the guest-service manager who was coordinating the monorail system via radio from an off-property restaurant “negligent” because he was not at a control console where he could have seen that the maintenance worker had not realigned the track. The manager, who was on a dinner break, had allowed the primary coordinator to go home sick and was temporarily handling coordination duties until a replacement worker could reach the central console. The ill employee clocked out at 1:47 a.m. — about 13 minutes before the collision — and his replacement was en route to the central tower at the time of the crash.
– The driver of the train that backed into Wuennenberg’s train had “limited visibility” at the time of the crash. The driver told investigators he could not see with his side-view mirrors because humidity and fog on the windshield “made it nearly impossible to see clearly.” Data from the National Oceanic and Atmospheric Administration showed that, at the time of the accident, the temperature was about 76 degrees, with 90 percent humidity.
– Disney’s own investigation of the accident appears to have placed the blame primarily on the electrician in the maintenance shop. Though OSHA did not provide Disney’s internal report as part of its documents, citing a federal public-records exemption governing trade secrets, a letter to OSHA from one of Disney’s lawyers said the company’s internal probe “demonstrates that the accident was caused when the maintenance panel operator improperly gave the command that the switch had been completed by him when, in fact, it had not been completed.”
A spokeswoman for Disney would not comment on issues raised in OSHA’s documents, saying the resort has agreed not to discuss the accident until the National Transportation Safety Board completes its own investigation. A representative for the International Brotherhood of Electrical Workers, the union that represents the electrician, also would not comment.
A representative for the Transportation Communications International Union, which represents monorail drivers, said the investigation demonstrated that neither Wuennenberg nor the other monorail driver was to blame for the accident.
“It was proven by multiple agencies that none of the Service Trades Council employees were found to be at fault, including either monorail pilot,” said Randall Sluder, a field representative for the union.
OSHA’s investigation ultimately led to a formal citation, issued Dec. 23, charging Disney with one “serious” workplace-safety violation that contributed to the collision.
In that citation, OSHA broadly criticized Disney for failing to provide a safe workplace, noting several policy lapses.
Among them: failing to follow a recommendation from monorail-manufacturer Bombardier that a spotter be used to watch the back end of any train driving in reverse, and failing to require the monorail’s central coordinator to be stationed at the main console whenever a track switch was occurring.
OSHA also cited Disney for three other, unrelated safety violations that it discovered during the monorail probe.
Disney has made a series of policy changes in the accident’s aftermath. The day after the crash, for instance, the resort began requiring that coordinators remain at the central console during track switches and that monorail drivers switch ends and drive from twin controls in the rear cabin of their trains when reversing direction through the Epcot switch.
In September, Disney said it had provided monorail-maintenance-shop workers with written instructions for the panel that controls the track switches. And in December, three days before OSHA publicly issued its citation, Disney began requiring spotters to watch the rear end of any train backing up.
Shortly after the accident, Disney placed the three employees directly involved with the sequence of events leading up to the accident — the electrician in the maintenance shop, the manager who had been filling in as central coordinator, and the driver of the second train in the collision — on administrative leave. The electrician and the manager recently returned to work in different roles with the company, according to a person familiar with their employment status; the driver has been offered a new job within Disney but has so far opted not to return.
Disney spokeswoman Zoraya Suarez would say only that two of the employees are back at work, while the other is “not yet” back.
OSHA ultimately fined Disney $35,200, a 20 percent reduction from the $44,000 in penalties it initially proposed. Disney paid with a check dated Jan. 22.
Jason Garcia can be reached at jrgarcia@orlandosentinel.com or 407-420-5414.
http://thedailydisney.com/blog/2010/02/disney-monorail-crash/
