New NTSB Documents of Monorail Accident

[Tom]

That sounds about right just skimming over the list of the amount of documents involved. There are lots of pages that are just empty fillers. From the amount of documents it looks like if anyone from the street can read through everything and make a decision.

Well, I'm not from the street, but I was able to read through everything and come to a conclusion. :lookaroun

 

[MarkIV_railie]

I hope I don't get flamed for this, and I am not being mean-spirited here, but it is somewhat surprising (to me) to read a number of cast members statements that seem to be in clear violation of everyone elses perspective. I know guests are always confused about the monorails with no obvious head or tail, so I don't expect guests to be able to say/know which way a train "should" move on each beam. But I would expect a transportation CM to know "normal" direction of train travel. I guess this is just a perfect example of how multiple eyewitnesses can give such conflicting statements about anything that happens unexpectedly in the blink of an eye.

Has anybody deciphered the train logs or found a clear statement to indicate if Purple (RIP Austin) actually managed to get motion in reverse? Many years ago, I made many 40 PSI stops, but I never immediately tried to go in reverse. And the "new" trains are such a totally different system that I don't think it mattered how the old Mark IVs functioned.

 

[MarkIV_railie]

On a similar note, the 0 volts thing is the one kink I see in the otherwise clear-cut verdict. If they were indeed seeing 0 volts at one time in base, that means the power WAS cut in order to do the switch. With this said, I'm thinking that Mike cut the power, and was THEN distracted by Silver. Once he returned to the panel, it had timed out and gone back to default. He logged in (expecting to do so, since it times out during a switch as well - which I think is pretty stupid), and saw the lights weren't blinking, and called the CLEAR (having never actually moved the switches).

Interesting analysis... which leads to the unfortunate conclusion that Shop energized a track in the wrong configuration, then radio'ed Central a directly contradictory statement (line 94 in the transcript). It would be interesting to hear the real radio and see if that is EXACTLY what Shop said or if there is a transcription error there?

And one more thing that really bothers me is the mystery person who got on the radio and asked if their track was supposed to be at 0 volts. I REALLY hope that was the College Program kid, or someone else equally new to the system. It would seem to me that if you work monorails for any length of time, you would know that the station/track would lose voltage during a switching operation.

Where is this "zero volts" documented? I don't see it in the radio transcript.

According to transcript line 97, Pink was clear in MAPO bypass all the way to GF? Is that the normal procedure? Or was that command really supposed to mean/imply "MAPO bypass to Base, THEN normal visual to GF"?

 

[peachykeen]

Interesting analysis... which leads to the unfortunate conclusion that Shop energized a track in the wrong configuration, then radio'ed Central a directly contradictory statement (line 94 in the transcript). It would be interesting to hear the real radio and see if that is EXACTLY what Shop said or if there is a transcription error there?



Where is this "zero volts" documented? I don't see it in the radio transcript.

According to transcript line 97, Pink was clear in MAPO bypass all the way to GF? Is that the normal procedure? Or was that command really supposed to mean/imply "MAPO bypass to Base, THEN normal visual to GF"?

It is implied "MAPO Override in reverse to Base, then clear [since its in Reverse] to the GF."

Once you recieve a green MBS entering Base you are supposed to release MAPO override, which is another signal Pink's driver should have noticed; he still had a Red MBS all the way into Concourse. I can't believe he was able to EXIT the train and STILL not realize he was at Concourse and not Base! Central's tower is RIGHT there!

There was no transcript error in that line, Shop radioed the exact opposite position of the switches from what they were actually in. I have heard it. As I have always thought, the majority of the blame falls on Shop for this.

The "zero volts" comment was made by a, most likely, College Program CM who didn't pay attention to the proceding radio calls of Central asking Shop to move the switches, and was suprised when he heard the alarm go off and power drop on Express. It's a rookie mistake and, to be honest, Central half the time doesn't even answer, especially with so many switches going on.

Also, for those that are thinking Silver's door alert may have distracted Shop, from the transcripts it can be seen that Silver had a door alert but it cleared. So Shop never had to direct the train to do anything in terms of Door Bypass, etc. Silver was just calling to pretty much say "So I know you saw me on the camera stop, but it was because a door alert."

The reason you can tell he kept moving was because, when Shop asked what door it was, the driver said "I'll let you know once I park." ie the train reset itself and kept moving. So that SHOULDN'T have been as big of a disruption as to cause Mike to forget to move the switches. Not saying it didn't, but it shouldn't.

From what I've been told, Austin got the train into Reverse but either a) got a Train Control because he was still moving forwards when he put it in Reverse or b) couldn't get the train moving in time.

What makes me cringe is to think that, in his final few seconds, Austin may have tried to get onto the radio to tell Pink to stop, but the radio was being used up by Pink incorrectly calling in that he was 10-7 Epcot and 10-8 Express. I can't imagine how it would have felt, to hit the mic button and hear "Beeeeeeeep" and then hear the train coming right towards me calling in that it was on another beam.

 

[Tom]

I hope I don't get flamed for this, and I am not being mean-spirited here, but it is somewhat surprising (to me) to read a number of cast members statements that seem to be in clear violation of everyone elses perspective. I know guests are always confused about the monorails with no obvious head or tail, so I don't expect guests to be able to say/know which way a train "should" move on each beam. But I would expect a transportation CM to know "normal" direction of train travel. I guess this is just a perfect example of how multiple eyewitnesses can give such conflicting statements about anything that happens unexpectedly in the blink of an eye.

Interesting point. Even being someone who's an avid WDW monorail fan, I ALWAYS have to stop and think about which direction the trains travel on each line. A veteran monorail CM should find it very unfamiliar for a train to be traveling through base on the Epcot line, going the wrong direction.

Has anybody deciphered the train logs or found a clear statement to indicate if Purple (RIP Austin) actually managed to get motion in reverse? Many years ago, I made many 40 PSI stops, but I never immediately tried to go in reverse. And the "new" trains are such a totally different system that I don't think it mattered how the old Mark IVs functioned.

I stopped reading the train logs - made my head hurt. But the eyewitness statements from the people riding Purple made it sound like their train never actually changed directions. I'm not going to dig them up and cite verbatim, but they indicated that the train was rocking and shaking fiercely (implying he was at B4 and the tires were locking up and/or skidding), and then the train lunged, throwing them off of their seats (implying that the impact happened at the end of the braking action).

I've never driven a monorail, but I imagine it takes a few keystrokes to switch the train into reverse from forward (plus, perhaps, some sort of MAPO override, depending on whether there's another train behind you somewhere). When you're panicking and trying to look at the train coming at you, not even the best pilot could come to a full stop, switch to reverse, AND begin traveling in reverse in that short amount of time. I'm not even sure you could do it in a controlled environment after practicing it.

Interesting analysis... which leads to the unfortunate conclusion that Shop energized a track in the wrong configuration, then radio'ed Central a directly contradictory statement (line 94 in the transcript). It would be interesting to hear the real radio and see if that is EXACTLY what Shop said or if there is a transcription error there?

I'm guessing that's an accurate transcript. It does indeed appear that shop confirmed a switch movement that had not happened.

Where is this "zero volts" documented? I don't see it in the radio transcript.

Line 85 - UNKNOWN: "Is Express Beam at Base supposed to be at zero volts?"

I'm guessing a newbie for sure. It was made pretty clear in the CM interviews that when someone asks that, they're ignored, because it's SOP. The person who asked that was definitely ignored.

It is implied "MAPO Override in reverse to Base, then clear (since its in Reverse) to the GF."

Once you recieve a green MBS entering Base you are supposed to release MAPO override, which is another signal Pink's driver should have noticed; he still had a Red MBS all the way into Concourse. I can't believe he was able to EXIT the train and STILL not realize he was at Concourse and not Base! Central's tower is RIGHT there!

I'm really starting to think that Pink was in a complete daze during all of this. Just based on his interview and all of the comments made on here from previous/current Monorail CMs.

There was no transcript error in that line, Shop radioed the exact opposite position of the switches from what they were actually in. I have heard it. As I have always thought, the majority of the blame falls on Shop for this.

Unfortunately

The "zero volts" comment was made by a, most likely, College Program CM who didn't pay attention to the proceding radio calls of Central asking Shop to move the switches, and was suprised when he heard the alarm go off and power drop on Express. It's a rookie mistake and, to be honest, Central half the time doesn't even answer, especially with so many switches going on.

Right. There was indeed no response to his question.

Also, for those that are thinking Silver's door alert may have distracted Shop, from the transcripts it can be seen that Silver had a door alert but it cleared. So Shop never had to direct the train to do anything in terms of Door Bypass, etc. Silver was just calling to pretty much say "So I know you saw me on the camera stop, but it was because a door alert."

The reason you can tell he kept moving was because, when Shop asked what door it was, the driver said "I'll let you know once I park." ie the train reset itself and kept moving. So that SHOULDN'T have been as big of a disruption as to cause Mike to forget to move the switches. Not saying it didn't, but it shouldn't.

I see this now. In Mike's interview, he indicated that he had given Silver specific instructions on how to override the door alarm so that he could get the train into the shop. But according to the radio log, this conversation never happened. Could Shop have perhaps called Silver on a separate line to help him out without eating up radio traffic? That would definitely explain a distraction.

Also, Shop was communicating with Silver, Red and Central during all of this time. He was assisting two trains on their way to Shop (Silver and Red). He specifically spoke with each of them between the REQUEST for the switch movement, and when he CONFIRMED the switch movement. Even more opportunity for distraction.

Lastly, if he was bringing two trains into shop (Silver was almost there, and Red was holding at the Chiller), he most assuredly was moving switches 3-7 (or some combination) during the night - and also 1 & 2 as required. I don't know if he would have been doing this during the few minutes that the incident occurred, but we wouldn't know because he probably doesn't need to radio anyone when he's moving the switches at Shop. But, I'm just guessing here.

From what I've been told, Austin got the train into Reverse but either a) got a Train Control because he was still moving forwards when he put it in Reverse or b) couldn't get the train moving in time.

What makes me cringe is to think that, in his final few seconds, Austin may have tried to get onto the radio to tell Pink to stop, but the radio was being used up by Pink incorrectly calling in that he was 10-7 Epcot and 10-8 Express. I can't imagine how it would have felt, to hit the mic button and hear "Beeeeeeeep" and then hear the train coming right towards me calling in that it was on another beam.

That BEEEEEEEP when Nextel Direct Connects has always grated on my nerves. Now it's even worse after thinking about what you said. Sickening.

 

[s8film40]

It is questionable as to whether the kill pack would have been effective that night. Tests were ran that showed that, in the position Purple was in, Purple would have "bridged" power from outside the kill zone and kept the station zone energized. The kill packs kill power immediately within the station and a few pylons out on either side. I believe tests showed that where Purple was, it was just at the boundary, and power would have traveled through the train and into the station, where Pink was approaching from.

The trains will emergency stop if power is killed on them as they enter the station. It's 80psi versus a normal 50psi stop, and the train rocks back and forth from the force of the stop. At 15mph it would probably take less than one pylon to stop.

Using a kill pack when a train is bridging most often will actually give the train an emergency stop but not kill the power. The train will come to a stop and the driver can then move it but once they move to the point they are no longer bridging the power will then drop out.


By the way these are the kill packs that Disney uses.

While I'm sure Disney pays a little more they usually go for around $30 each.
http://www.homesecuritystore.com/p-1595-wt102-visonic-12bit-two-channel-transmitter.aspx

 

[Tom]

By the way these are the kill packs that Disney uses.

While I'm sure Disney pays a little more they usually go for around $30 each.
http://www.homesecuritystore.com/p-1595-wt102-visonic-12bit-two-channel-transmitter.aspx

Wow. Seriously? Scary to think that a tool that can be life-saving is just a $30 chunk of plastic. I figured they were rugged and had huge internal transmitters or something.

But I guess if they work, then who cares. And for $30, seems a tad irresponsible not to give one to every Monorail CM on duty. Of course, they'd have to remember to use it, and not just wave at the drivers of colliding trains.

 

[parkgoer]

Good question. I wonder if they just start a shutdown process, or if they are literally hardwired to the power grid and absolutely KILL the power to the local track.

If they kill the power, do the monorails then use onboard batteries to engage emerg brakes, or do they coast to a stop?

If power is dropped the train will stop faster than you can stop it in normal operation (braking 5 on)

I left something out in my description of dropping power. There are actually THREE ways. 1)Handpack 2) Station disconnect which is the same as the handpack, but hardwired. and 3) The zone power off. In this situation pressing the zone power off would have been appropriate. When the station disconnect is pressed, power can easily be restored by turning a key on the console. When the zone power off is pressed It will completely kill the power, and at further distances out of the station than the S.D/H.P. Maintenance needs to come flip switches/circuit breakers on the pylons. If Z.P.O is used, you can bet the entire beam will be shut down for a while whereas using the other methods power can be restored without a hiccup.

Basically what i'm trying to say is that I don't think we know what was used when the power was dropped. My theory is that had the Z.P.O been pressed first, purple might not have bridged the electricity.

 

[parkgoer]

Didn't know all that about the kill packs. I'm sure Disney doesn't trust all of their CMs to carry the kill packs, because of mis-use, but I'd rather be safe than sorry. While hitting one too often would be a nuisance, we've proven that hitting one too seldom is fatal.

I'm unclear on whether the off-site manager really affected this outcome. Someone was ill and went home, but they were at Central, not shop (I think). Shop is where the failure actually happened. If the ill CM hadn't left, and he'd been where ever he was supposed to be, would that have actually prevented this from happening? Would he have been in the tower and hit the master kill switch when he saw the impending doom?

Sure, he was making calls from off-site, but if he had been on-site, would he have had the resources available to know that the switches weren't actually thrown, or would he have just been making the same calls regardless?

I honestly don't know, and can't figure it out based on the evidence.

I believe in Central They can see which positions the switches are in. Had someone been in there they may have noticed the switches never moved, may have seen the collision course the trains where on, and would be right there to drop power. But this is just all theoretical. This is now the reason there is absolutely ALWAYS someone in central.

 

[parkgoer]

about the rookie comment and CM's not noticing the trains traveling in the "wrong direction" Just like there's only 1 handpack/killpack, there is also only 1 handheld radio for the each station, and the console radio. Generally there is more than one person working the station. So if you're the one without the radio, you may not know whats going on, so to say. For example at the end of the night, if you have a radio/can hear the radio/paying attention, then you know when the express monorail is shutting down and going to shop. So when you see what appears to be and train on the resort beam on a collision course with a train in the station, is actually the express train going to shop. Sure there's the beacon light to differeniate the trains, but you can't always see it, and sometimes the beacon hasn't been changed, or is split, so instead of being green, it's flashing half green/half amber (green express, amber resort, red epcot). It's hard to tell at night which beam the trains are on when looking at them from a distance.

 

[Tom]

I believe in Central They can see which positions the switches are in. Had someone been in there they may have noticed the switches never moved, may have seen the collision course the trains where on, and would be right there to drop power. But this is just all theoretical. This is now the reason there is absolutely ALWAYS someone in central.

I've been unclear from the start: they guy who went home sick...was he the one who was supposed to be in Central? That would explain the other half of why the pseudo checks-and-balance system failed. Shop didn't throw the switches, but Central should have seen that - except that there was no central.

 

[Tom]

about the rookie comment and CM's not noticing the trains traveling in the "wrong direction" Just like there's only 1 handpack/killpack, there is also only 1 handheld radio for the each station, and the console radio. Generally there is more than one person working the station. So if you're the one without the radio, you may not know whats going on, so to say. For example at the end of the night, if you have a radio/can hear the radio/paying attention, then you know when the express monorail is shutting down and going to shop. So when you see what appears to be and train on the resort beam on a collision course with a train in the station, is actually the express train going to shop. Sure there's the beacon light to differeniate the trains, but you can't always see it, and sometimes the beacon hasn't been changed, or is split, so instead of being green, it's flashing half green/half amber (green express, amber resort, red epcot). It's hard to tell at night which beam the trains are on when looking at them from a distance.

Interesting point.

Has the updated policy allowed for more radios and/or kill switches among platform CMs? Seems like a no-brainer to me.

If they're worried about too much chatter or pre-mature kills, a simple policy of "stay off the damn radio and just use it for emergencies" can be written. Simple fix and an additional failsafe.

 

[s8film40]

I've been unclear from the start: they guy who went home sick...was he the one who was supposed to be in Central? That would explain the other half of why the pseudo checks-and-balance system failed. Shop didn't throw the switches, but Central should have seen that - except that there was no central.

There was never a real requirement for the person in that position to be in the tower. In fact had he not gone home sick it's entirely likely that he would not have been in the tower and might have instead stayed downstairs so he could be closer to a restroom.

 

[s8film40]

Interesting point.

Has the updated policy allowed for more radios and/or kill switches among platform CMs? Seems like a no-brainer to me.

If they're worried about too much chatter or pre-mature kills, a simple policy of "stay off the damn radio and just use it for emergencies" can be written. Simple fix and an additional failsafe.

No I don't hink they want to spend the money to buy that many kill packs and radios.

Also this doesn't really relate to the accident but there are also power disconnect buttons on each of the little consoles by the automatic gates 4 total one on each end on each side of the track, but there are none of these on the EPCOT line.

 

[Tom]

There was never a real requirement for the person in that position to be in the tower. In fact had he not gone home sick it's entirely likely that he would not have been in the tower and might have instead stayed downstairs so he could be closer to a restroom.

So, if I read between the lines in all of this, could it be said that - in hindsight - the lack of a policy requiring someone to be in the tower at all times was a severe loophole in the safety of the entire system?

That's my interpretation anyway. In addition to a myriad of other small loopholes that have since been discovered because of all of this, like perhaps over-taxing Shop during shut-down time and having a poorly written Switch software with no failsafes.

 

[Tom]

No I don't hink they want to spend the money to buy that many kill packs and radios.

Also this doesn't really relate to the accident but there are also power disconnect buttons on each of the little consoles by the automatic gates 4 total one on each end on each side of the track, but there are none of these on the EPCOT line.

Kind of sickening to think that their reason for not assigning $200 radios and $30 kill packs to everyone would be to save a few dollars, when those tools COULD save lives.

Had no idea about the console-mounted kill switches, or the lack of them on the Epcot line. Did they just never get around to them?

 

[parkgoer]

Interesting point.

Has the updated policy allowed for more radios and/or kill switches among platform CMs? Seems like a no-brainer to me.

If they're worried about too much chatter or pre-mature kills, a simple policy of "stay off the damn radio and just use it for emergencies" can be written. Simple fix and an additional failsafe.

No what I mentioned about the radios and hand packs are still current. This seldom happens, but say for example you're working the Polynesian station and someone comes to relieve you for your break. You hand off the radio and handpack. Well we are all human. There are instances when CM's leave with the handpack and or radio. It's the responsibility of both CM's to make sure that I hand you both items, and if you are relieving me, you recieve both items.

I may have these mixed up, it's been a while, but a call of 10-100 would mean emergency radio traffic only, and a call of 10-400 would be an immediate stop of all monorail traffic on all beams. Although if a radio is being keyed (which seems to be the case at this time) those codes would be useless.

 

[s8film40]

So, if I read between the lines in all of this, could it be said that - in hindsight - the lack of a policy requiring someone to be in the tower at all times was a severe loophole in the safety of the entire system?

That's my interpretation anyway. In addition to a myriad of other small loopholes that have since been discovered because of all of this, like perhaps over-taxing Shop during shut-down time and having a poorly written Switch software with no failsafes.

Possibly however the responsibility of track switching was on the shop. While oversight is good I don't think it should be required I think it's better to focus on getting the right people to the job right to begin with. There isn't always going to be someone looking over someone else's shoulder all the time. As it stands now there are nine switches in the monorail system and Central is now responsible for watching four of them the other five it's still up to the shop to handle by themselves with no one else watching. The same could be said for requiring someone to be in the base console where they could also see that the switch is lined up or not, there is not a requirement for someone to be there now.

 

[parkgoer]

Kind of sickening to think that their reason for not assigning $200 radios and $30 kill packs to everyone would be to save a few dollars, when those tools COULD save lives.

Had no idea about the console-mounted kill switches, or the lack of them on the Epcot line. Did they just never get around to them?

Only the stations with automatic gates. it's on the console that opens/closes the gates, completely separate from the main console. concourse and epcot gates have to be manually pulled open, so there's just the main console.

 

[Tom]

Only the stations with automatic gates. it's on the console that opens/closes the gates, completely separate from the main console. concourse and epcot gates have to be manually pulled open, so there's just the main console.

Gotcha.