New NTSB Documents of Monorail Accident

[googilycub]

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.

I still maintain that the blind shove was the real lack of policy in this whole thing. With a cab on both ends there is no excuse for not having someone on the point of the move. If someone is on the head end watching the movement, all the other things don't matter. It does not matter that there was no one in the control tower or that the person did not complete the reversal of the switch, as the operator would be able to SEE if the switch is lined for for his movement. I will maintain to the day that I die that if the railroads can have someone hanging off the side of a boxcar when its 15 degrees below zero protecting a shove, Disney can have someone in the cab leading the direction of movement at all times........

 

[Tom]

I still maintain that the blind shove was the real lack of policy in this whole thing. With a cab on both ends there is no excuse for not having someone on the point of the move. If someone is on the head end watching the movement, all the other things don't matter. It does not matter that there was no one in the control tower or that the person did not complete the reversal of the switch, as the operator would be able to SEE if the switch is lined for for his movement. I will maintain to the day that I die that if the railroads can have someone hanging off the side of a boxcar when its 15 degrees below zero protecting a shove, Disney can have someone in the cab leading the direction of movement at all times........

Also a valid point.

However, the setback to this - as I understand it - would be that you can only control the train from one end or the other at a given moment. Couple that with the fact that if someone is on the radio or you can't get the Direct Connect signal to complete, the spotter wouldn't be able to warn the driver of impending doom or stop the train on his own.

But I guess if he saw that the switches were never thrown, his lack of confirmation would have prevented Pink from ever backing up. But once you're moving, the spotter may not do much good in avoiding an actual collision unless everything worked perfectly, and they edited the software to allow some sort of operation from both cabs.

 

[googilycub]

Also a valid point.

However, the setback to this - as I understand it - would be that you can only control the train from one end or the other at a given moment. Couple that with the fact that if someone is on the radio or you can't get the Direct Connect signal to complete, the spotter wouldn't be able to warn the driver of impending doom or stop the train on his own.

But I guess if he saw that the switches were never thrown, his lack of confirmation would have prevented Pink from ever backing up. But once you're moving, the spotter may not do much good in avoiding an actual collision unless everything worked perfectly, and they edited the software to allow some sort of operation from both cabs.

So you edit the software, it can be done. The other option is to pull into the station and have the operator switch ends there. There are other options to. On the railroad when the conductor is on the rear protecting the shove, he is responsible to be calling out distance in 50 ft car lengths. If you listen to the radio of a railroad you will hear, 99cars, 98 cars, and so on. If the engineer looses comunication with the conductor, but is still moving, he will stop the movement until he can regain communication. Same thing can apply hear, if communication is lost with the spotter in the other cab, stop the movement until it can be regained. Could this make switching take longer? You bet. We have a saying that we use all the time on the railroad, "take the safest course" and if that means stopping everything until one can confirm that the movement is safe, so be it.

 

[lazyboy97o]

Also a valid point.

However, the setback to this - as I understand it - would be that you can only control the train from one end or the other at a given moment. Couple that with the fact that if someone is on the radio or you can't get the Direct Connect signal to complete, the spotter wouldn't be able to warn the driver of impending doom or stop the train on his own.

But I guess if he saw that the switches were never thrown, his lack of confirmation would have prevented Pink from ever backing up. But once you're moving, the spotter may not do much good in avoiding an actual collision unless everything worked perfectly, and they edited the software to allow some sort of operation from both cabs.

I would think a manual override that would engage the emergency brakes would remove the need for changing the software. The other option would have been to just make the EPCOT Line wait while the train was rebooted to be piloted from Car 6.

 

[Tom]

So you edit the software, it can be done. The other option is to pull into the station and have the operator switch ends there.

I agree. Edit software. That would solve a lot of their problems with the monorail system. But I'm not holding my breath. It took how many years to update the reservation system so that their departments can actually communicate?

 

[s8film40]

I still maintain that the blind shove was the real lack of policy in this whole thing. With a cab on both ends there is no excuse for not having someone on the point of the move. If someone is on the head end watching the movement, all the other things don't matter. It does not matter that there was no one in the control tower or that the person did not complete the reversal of the switch, as the operator would be able to SEE if the switch is lined for for his movement. I will maintain to the day that I die that if the railroads can have someone hanging off the side of a boxcar when its 15 degrees below zero protecting a shove, Disney can have someone in the cab leading the direction of movement at all times........

The problem with comparing this to traditional rail systems is that it truly is a blind shove when you have very long trains, with a 200' train rear view mirrors work just fine.

 

[parkgoer]

Also a valid point.

However, the setback to this - as I understand it - would be that you can only control the train from one end or the other at a given moment. Couple that with the fact that if someone is on the radio or you can't get the Direct Connect signal to complete, the spotter wouldn't be able to warn the driver of impending doom or stop the train on his own.

But I guess if he saw that the switches were never thrown, his lack of confirmation would have prevented Pink from ever backing up. But once you're moving, the spotter may not do much good in avoiding an actual collision unless everything worked perfectly, and they edited the software to allow some sort of operation from both cabs.

This is partly true. The train can only be operated from one cab. nothing in the non operating cab will work, not even the horn. The operating cab needs to be powered down, and back cab powered up. This can take 30 seconds or more, and you NEVER power a train down on the beam. Never. Only in a station. There is one button that works tho. That's the Emergency stop mushroom. Epcot (where this accident happened) is really the only switch where you NEED someone observing from the back cab, which is now standard protocol today. when you are back cab observing, something you must do, and spiel over the radio to central is that "you are hovering the e-stop, no trains, unusual conditions, or open switches *color* clear to reverse." the other switchs can be done by switching ends at a station. Only express needs to switch ends with the direction the trains move. Switches 8 and 9 require the pilot to reverse through the switch. thankfully now there is also a requirement for a back cab observer.

 

[thelookingglass]

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.

You are right - if it does what it is supposed to do, why bother with something more expensive that does the same thing? They test these things every day, anyway.

Plus, keep in mind that the killpack's purpose is not to prevent two trains from colliding head-on, and it most likely would not have in this scenario.

 

[unkadug]

The problem with comparing this to traditional rail systems is that it truly is a blind shove when you have very long trains, with a 200' train rear view mirrors work just fine.

Obviously not.

 

[TRONorail10]

Can't believe they released their record cards to public. You can see every incident, reprimand, clocking errors, late arrivals and coaching & counciling that was given to them since they've been employed. I don't think that was needed in a public file.

Agreed. The employee record card has absolutely nothing to do with the specific accident that took place. I thought it was illegal for companies to disclose employee files to the public.

 

[unkadug]

Agreed. The employee record card has absolutely nothing to do with the specific accident that took place. I thought it was illegal for companies to disclose employee files to the public.

The Company did not release this to the public....the NTSB released this as part of an investigation.

Totally different laws apply.

 

[peachykeen]

Software has been added to make the non-operating cab Emergency Stop button active. In the past, that was not the case. The E-Stop in the back cab could be hit and the train would still move as if nothing happened. Now, if the non-operating cab's E-Stop is pushed down, the train Emergency Stops. So there is now a "spotter" position anytime the train reverses. That person calls over the radio that the beam is clear and he/she is hovering over the e-stop. Central then directs the train to move in reverse and the person in the non-operating (but "forward facing") cab can now hit the e-stop if he/she sees anything.

Also, a train NEVER goes THROUGH a switch in reverse now. IE a train never MAPO Overrides in reverse. The spotter is used to get the train to the switching point, and then the actual operator takes the train through the switch in forward, using MAPO override.

In the event of an unplanned reversing (such as a breakdown, etc) they can either have a Monorail on the parallel beam observe the track and "pace" the Monorail that is reversing, or they can have a person on the ground literally running behind the train making sure nothing gets in the way. In either case, a 10-100 is called over the radio by Central which means that only if your train is basically on fire does anyone else use the radio. During an unplanned reverse with no back-cab observer, no one is to use the radio, so that is something does show up on the track, the ground-based observer has a clear radio channel to stop the train.

 

[parkgoer]

Software has been added to make the non-operating cab Emergency Stop button active. In the past, that was not the case. The E-Stop in the back cab could be hit and the train would still move as if nothing happened. Now, if the non-operating cab's E-Stop is pushed down, the train Emergency Stops. So there is now a "spotter" position anytime the train reverses. That person calls over the radio that the beam is clear and he/she is hovering over the e-stop. Central then directs the train to move in reverse and the person in the non-operating (but "forward facing") cab can now hit the e-stop if he/she sees anything.

Also, a train NEVER goes THROUGH a switch in reverse now. IE a train never MAPO Overrides in reverse. The spotter is used to get the train to the switching point, and then the actual operator takes the train through the switch in forward, using MAPO override.

In the event of an unplanned reversing (such as a breakdown, etc) they can either have a Monorail on the parallel beam observe the track and "pace" the Monorail that is reversing, or they can have a person on the ground literally running behind the train making sure nothing gets in the way. In either case, a 10-100 is called over the radio by Central which means that only if your train is basically on fire does anyone else use the radio. During an unplanned reverse with no back-cab observer, no one is to use the radio, so that is something does show up on the track, the ground-based observer has a clear radio channel to stop the train.

Since we are on the topic, why not add camera's to the trains for situations like this. Sure, it wont beat a pair of eyes, but you could incorporate things to make sure the camera is real time and not frozen. Sure it wouldn't be cheap, but it would make the trains that much more safer.

What about utilizing gps in all the trains and having a map layout for central to see. I mean, my crappy cell phone has a gps that puts me within inches on the google earth maps.. Could put the same map in the shop too.

I don't think either of those should replace any of the current procedures, but again, it would just make it that safer. for example, if a pilot violates centrals command, they may catch it in time on their map.

 

[fosse76]

Agreed. The employee record card has absolutely nothing to do with the specific accident that took place. I thought it was illegal for companies to disclose employee files to the public.

Yes, it does. They show whether or not the employee has a history of accidents. They show whether or not he has been inattentive in the past. The reasoning for looking at those records is there. They were released NOT because the investigators found them to be relevant, but BECAUSE they were part of an investigation, and the American public has the right to know what the government knows.

 

[s8film40]

Obviously not.

Obviously you didn't read the documents the driver of Pink clearly described using the mirrors, the problem was his ability to identify his surroundings. He wasn't able to identify his location when standing in the station with a full 360 degree range of vision, mirrors won't help at that point.

 

[Tom]

Since we are on the topic, why not add camera's to the trains for situations like this. Sure, it wont beat a pair of eyes, but you could incorporate things to make sure the camera is real time and not frozen. Sure it wouldn't be cheap, but it would make the trains that much more safer.

What about utilizing gps in all the trains and having a map layout for central to see. I mean, my crappy cell phone has a gps that puts me within inches on the google earth maps.. Could put the same map in the shop too.

I don't think either of those should replace any of the current procedures, but again, it would just make it that safer. for example, if a pilot violates centrals command, they may catch it in time on their map.

Cameras would definitely help. They work great in SUVs for backing up.

Also, I've never understood why they don't have some sort of train tracking/locating system already. Each train could send a low voltage signal through the bus bars, or they could add sensors to the beams that detect transponders as they cross checkpoints (much like Indy Race Cars for timing). GPS would even work, since they could use software to narrow the field and eliminate false readings that showed the thing out in the trees somewhere.

Sure, real train systems still use old fashioned methods, but if the technology is there and safety is a MUCH greater concern (yes, people are a much more valuable cargo than cars and coal), why not take advantage. I guess until now, everything has been peachy so why waste the money, eh?

 

[devoy1701]

I saw someone else mention it, but I just finished reading the transcripts of the interview with the monorail Pink driver. I did not like his response to how he describes operating the monorail in reverse, that he doesn't feel that he is in control but that he is only pushing the pedal because someone else tells him to. I'm not sure that I like that kind of thinking concerning that process. I'm glad that there are now spotters in the back of the monorail.

Also, I had read the radio transcripts before I read the interview and I too wondered why no one had answered the "is there supposed to be 0 volts?" question. I also wondered why the transcript read that as unidentified.

 

[Tom]

I saw someone else mention it, but I just finished reading the transcripts of the interview with the monorail Pink driver. I did not like his response to how he describes operating the monorail in reverse, that he doesn't feel that he is in control but that he is only pushing the pedal because someone else tells him to. I'm not sure that I like that kind of thinking concerning that process. I'm glad that there are now spotters in the back of the monorail.

Yeah, after re-reading his interview, and after reading all of the posts on here after my initial assessment, I've come to realize that his apathy is definitely dangerous. He clearly understands that it's a dangerous movement, and instead of focusing all of his concentration on it, he just says, "Oh well, it's someone else's problem. I'm just a button pusher." Wrong attitude. It's still your train, buddy.

Also, I had read the radio transcripts before I read the interview and I too wondered why no one had answered the "is there supposed to be 0 volts?" question. I also wondered why the transcript read that as unidentified.

I'm not sure if you're still wondering, or if you're just agreeing with previous posts about the wonderment...but know the details now.

In case it's the former, seems like the anonymous person was probably just "some kid" at a panel with a radio who had never experienced a switching procedure before (at least not while working platform). Ignored because it's a rookie question that doesn't merit wasting radio time answering or explaining.

 

[s8film40]

Yeah, after re-reading his interview, and after reading all of the posts on here after my initial assessment, I've come to realize that his apathy is definitely dangerous. He clearly understands that it's a dangerous movement, and instead of focusing all of his concentration on it, he just says, "Oh well, it's someone else's problem. I'm just a button pusher." Wrong attitude. It's still your train, buddy.

This is my biggest concern with the new spotter positions is it has greatly increased this attitude of someone else is making sure everything is OK so I don't have to pay attention. Meanwhile the people being used for these spotter positions a lot of the time are not even trained to drive a monorail and probably don't even know what to look for assuming that is they are even looking. It all looks good on paper know and that's what Disney cares about.

 

[Tom]

This is my biggest concern with the new spotter positions is it has greatly increased this attitude of someone else is making sure everything is OK so I don't have to pay attention. Meanwhile the people being used for these spotter positions a lot of the time are not even trained to drive a monorail and probably don't even know what to look for assuming that is they are even looking. It all looks good on paper know and that's what Disney cares about.

Agreed.

Only real solution = only drive forward. If that means you have 2 pilots in the train while it drives past a switch, then change "control" to the other cab, so be it. Write a damn software patch that lets someone log in to the other cab without a complete reboot of the train.