New NTSB Documents of Monorail Accident

[Tom]

Well there goes Thanksgiving...I'm going to be up non-stop reading all of this.

 

[thelookingglass]

fire someone yes, re-assign them, no

I haven't read the documents yet, but I've mentioned this before that the qualifications for being a monorail driver, according to when I called Casting back in 2008, were 2 things:

1.) 18 years or older
2.) Valid drivers license

It just seems like it's pretty low standards for such an important position. Bus and Ferry drivers have MANY more requirements, although that's part of state requirements as well.

You're acting like they just start driving right off the bat without any training or assessments!

 

[parkgoer]

You're acting like they just start driving right off the bat without any training or assessments!

He's also coming off as if it were one of the drivers faults. When driving a monorail, especially bringing them from shop in the morning or going back at night, you have to rely monorail central that what you are being told over the radio is accurate. You have to trust them. It seems the problem here was that A: the driver of purple notified central he was on the spurline by trusting that the switch beam was off the mainline, and B: Switch beam operator notified central that in was locked on the spurline with power, when in actuality it was still on the mainline.

That plus there are a handful of other "minor" things that all fell into place at the same time that led to this unfortunate situation. Had this happened at any of the other switches that would be one thing. But this happened right under Central's nose (had someone been in the central tower) well, it's an eye opener. Now anytime there are trains on the beam, someone has to be in central tower, as they should have before..

Funny what you can learn just by reading (regarding my earlier post)


There are things I'm interested in knowing. For example the driver of pink. How long was he in the cab for? how did he end up getting out. What did he observe when he got out? Where's the rest of the radio transcripts?

 

[s8film40]

I think you got Purple and Pink mixed up.

He's also coming off as if it were one of the drivers faults. When driving a monorail, especially bringing them from shop in the morning or going back at night, you have to rely monorail central that what you are being told over the radio is accurate. You have to trust them. It seems the problem here was that A: the driver of purple notified central he was on the spurline by trusting that the switch beam was off the mainline, and B: Switch beam operator notified central that in was locked on the spurline with power, when in actuality it was still on the mainline.

That plus there are a handful of other "minor" things that all fell into place at the same time that led to this unfortunate situation. Had this happened at any of the other switches that would be one thing. But this happened right under Central's nose (had someone been in the central tower) well, it's an eye opener. Now anytime there are trains on the beam, someone has to be in central tower, as they should have before..

Funny what you can learn just by reading (regarding my earlier post)

One of the big misconceptions is that when the driver receives their instructions that it's ok to follow them blindly, the Pink driver even stated he was "flying blind" at no point should a monorail ever be moved blindly, that's just common sense. The instructions for this particular procedure are not simply back up till you get to this point, and that is the reason there is more to it than that. The instructions say back up go through the switch through the spur line and through the other switch to "Base". Obviously they don't need to say all of that but they do to reaffirm what and where the driver should be going. The driver is responsible for ensuring he is in those locations. The driver stated that even after he got out of the train and was standing in the station that he still did not know he was in the wrong station, so it's very like the same outcome would have come even if he had driven in forward except of course he likely wouldn't have survived either. He also stated that the instructions "clear" meant he didn't have to pay attention to where he was going, this is not the case and represents a fundamental flaw in his understanding of his responsibilities. Now again I want to say I don't directly blame the driver, he was put in this position probably without much of an interview and determining if it was right for him and there were also many warning signs in his record.

There are things I'm interested in knowing. For example the driver of pink. How long was he in the cab for? how did he end up getting out. What did he observe when he got out? Where's the rest of the radio transcripts?

In the Pink drivers interview he said the fire truck got him out with a ladder he didn't say how long though. He did say that he observed some of the damage the first time he got out in the station but didn't realize what had happened. I don't think he said anything about what he observed the second time he got out. I believe from the statements that somehow the accident itself caused at least one of the radios to transmit static and blocked the frequency.

 

[JEANYLASER]

thanks!

 

[peachykeen]

I think you got Purple and Pink mixed up.




One of the big misconceptions is that when the driver receives their instructions that it's ok to follow them blindly, the Pink driver even stated he was "flying blind" at no point should a monorail ever be moved blindly, that's just common sense. The instructions for this particular procedure are not simply back up till you get to this point, and that is the reason there is more to it than that. The instructions say back up go through the switch through the spur line and through the other switch to "Base". Obviously they don't need to say all of that but they do to reaffirm what and where the driver should be going. The driver is responsible for ensuring he is in those locations. The driver stated that even after he got out of the train and was standing in the station that he still did not know he was in the wrong station, so it's very like the same outcome would have come even if he had driven in forward except of course he likely wouldn't have survived either. He also stated that the instructions "clear" meant he didn't have to pay attention to where he was going, this is not the case and represents a fundamental flaw in his understanding of his responsibilities. Now again I want to say I don't directly blame the driver, he was put in this position probably without much of an interview and determining if it was right for him and there were also many warning signs in his record.



In the Pink drivers interview he said the fire truck got him out with a ladder he didn't say how long though. He did say that he observed some of the damage the first time he got out in the station but didn't realize what had happened. I don't think he said anything about what he observed the second time he got out. I believe from the statements that somehow the accident itself caused at least one of the radios to transmit static and blocked the frequency.

That's correct. Pink's Cab 6 radio was keyed after the collision. You can hear, if you listen to the video posted taken just after the accident, the feedback from the radios being keyed for so long and so close together. It sounds like a siren, but is in fact the feedback from Pink's Cab 6 radio, being broadcast over all the radios on the frequency. It went on like that for about 7 minutes until the radio stopped being keyed, and then the other trains/platforms started to find out what happened by the radio traffic that followed.

Nowadays, when someone keys a radio too close to another, and that sound gets broadcast over the frequency, it sends chills up everyone's back who is familiar with that night.

 

[raven]

The information was relevant to the investigation. All indications pointed to an operational error, therefore procedure manuals and employee records are essential. And while I agree that it mostly no one's business what my employment files look like, if it is part of an investigation, that's too bad for me. Should the police not look at the criminal history of suspects during a criminal investigation? Should they not be able to ask the employer about work habits, attendance, and if any money ever disappeared while they were working? The employment records, in this case, were very relevant, even if you don't think so. It's too bad for them if they are embarassed by their release.

Certain records maybe. But I don't think the public needs to know that the employees forgot to clock out several times (which in most cases is a timeclock error at Disney). That information is no judge of character nor relevant to the case.

 

[parkgoer]

One of the big misconceptions is that when the driver receives their instructions that it's ok to follow them blindly, the Pink driver even stated he was "flying blind" at no point should a monorail ever be moved blindly, that's just common sense. The instructions for this particular procedure are not simply back up till you get to this point, and that is the reason there is more to it than that. The instructions say back up go through the switch through the spur line and through the other switch to "Base". Obviously they don't need to say all of that but they do to reaffirm what and where the driver should be going. The driver is responsible for ensuring he is in those locations. The driver stated that even after he got out of the train and was standing in the station that he still did not know he was in the wrong station, so it's very like the same outcome would have come even if he had driven in forward except of course he likely wouldn't have survived either. He also stated that the instructions "clear" meant he didn't have to pay attention to where he was going, this is not the case and represents a fundamental flaw in his understanding of his responsibilities. Now again I want to say I don't directly blame the driver, he was put in this position probably without much of an interview and determining if it was right for him and there were also many warning signs in his record.


.

I agree, and disney does too, which is why they have someone standby the e stop in the rear cab when a train is coming off the epcot line now.

peechykeen- It sounds as if you work, or have once worked in monorail operations. You have some good information. I'm curious how many other trains where out when this happened. if so, did they bring in the other trains to the shop, or did the drivers park at a station?
Also, I can imagine the thoughts it brings up when the feedback is heard over the radio...

 

[Main Street USA]

One of the big misconceptions is that when the driver receives their instructions that it's ok to follow them blindly, the Pink driver even stated he was "flying blind" at no point should a monorail ever be moved blindly, that's just common sense....He also stated that the instructions "clear" meant he didn't have to pay attention to where he was going, this is not the case and represents a fundamental flaw in his understanding of his responsibilities.

While I don't solely blame the driver of Pink, I believe from these statements which came directly from his mouth, that he should clearly hold some blame for this accident. It's ridiculous to say something like 'clear means clear, and I don't have to pay attention.' That's not a direct quote, but it's basically what was said. In your post you called it a "fundamental flaw in his understanding of his responsibilities," but I think it's a complete and total lack of common sense. Who in the world would be at the helm of something as valuable and large as a monorail and not pay attention to what was going on around them? That's ridiculous.

I push airplanes around from one spot to another all the time. When I do this there is a man underneath the wing with a wand in the air telling me it's clear. There is NO WAY I would push an aircraft based solely on him holding his hand in the air. I'm the one pushing the plane, and I'm the one responsible. Period. I would be an idiot to say "well he had his hand in the air so I figured I didn't need to look."

I've never driven a monorail, but I would certainly know if I had not switched tracks in that area. Is there a track to your right now? No? Ok, you didn't switch. The driver of pink wasn't even looking out the window. Ugh.

 

[Tom]

I disagree with the argument that Pink Pilot should have not put blind trust in his co-workers.

Now, I haven't read Monorail Ops Policy, and I'm not saying whether Pink Pilot shares any blame or not, but I'll (again) give an example that there is indeed such a thing as trusting your co-workers, and it being OK.

A tower-crane or other large crane operator is often working blind. He might be able to see where he's picking up a steel beam from a stockpile, but since crane's don't usually move once they've set up on a jobsite, he'll put together the entire building from one spot.

This means that for many pieces of the building, he'll be lowering a beam or column down on the other side of the building, or in a location that he absolutely cannot see. It is literally impossible for a crane operator to have a visual on every one of his picks.

So, he replied on spotters. He'll be in radio communication with guys in the lay-down area, who will tell him when they've secured the next piece to his hook. Then he'll either get radio or visual cues from a guy positioned somewhere where he can see both the pick and the crane operator. He'll tell the operator to boom left, right, up, down, in or out, and when to raise and lower the cable. It is at these times that a blind man could literally operate the crane - and he's literally relying on his spotters to tell him what to do.

And guess what? It's 100% legal and safe. If that crane operator crushed someone with a beam during a blind pick, and he had followed all radio and visual cues properly, he is not at fault.

Again, I'm not saying that Pink Pilot is exempt from responsibility, because I haven't read the Monorail Ops Manual, but it is 100% reasonable for him to rely on his co-workers when making a blind move (like driving a train backwards at 2am with windows that are 90% fogged up).

Now, I've also never backed a monorail into base from Epcot, and it seems like you would notice if you DIDN'T go through the two switches. The little jogs in the track on the Epcot line can knock a filling loose. I can only imagine how jerky it SHOULD be going through two switches.

While he was probably justified in trusting his comrades, he was probably also too apathetic about the task at hand and neglected his duty to ALSO be prepared for anything.

 

[peachykeen]

I agree, and disney does too, which is why they have someone standby the e stop in the rear cab when a train is coming off the epcot line now.

peechykeen- It sounds as if you work, or have once worked in monorail operations. You have some good information. I'm curious how many other trains where out when this happened. if so, did they bring in the other trains to the shop, or did the drivers park at a station?
Also, I can imagine the thoughts it brings up when the feedback is heard over the radio...

A couple Express trains were going to Shop as the accident happened. Once the radio cleared back up they were brought the rest of the way in. The Resort trains cycled down shortly after. As you might have read in the documents, one of the pilots pointed out the switching procedure to the Guests in her cab, and the accident happened as she watched.

Coral was the other train on the Epcot beam and had left Epcot and was on its way to TTC when power was killed on the entire Epcot loop by the coordinator who got to the tower. That train was empty and the driver was retrieved by bucket truck. They tried to cycle down as quickly as possible.

 

[Main Street USA]

I disagree with the argument that Pink Pilot should have not put blind trust in his co-workers.

Now, I haven't read Monorail Ops Policy, and I'm not saying whether Pink Pilot shares any blame or not, but I'll (again) give an example that there is indeed such a thing as trusting your co-workers, and it being OK.

A tower-crane or other large crane operator is often working blind. He might be able to see where he's picking up a steel beam from a stockpile, but since crane's don't usually move once they've set up on a jobsite, he'll put together the entire building from one spot.

This means that for many pieces of the building, he'll be lowering a beam or column down on the other side of the building, or in a location that he absolutely cannot see. It is literally impossible for a crane operator to have a visual on every one of his picks.

So, he replied on spotters. He'll be in radio communication with guys in the lay-down area, who will tell him when they've secured the next piece to his hook. Then he'll either get radio or visual cues from a guy positioned somewhere where he can see both the pick and the crane operator. He'll tell the operator to boom left, right, up, down, in or out, and when to raise and lower the cable. It is at these times that a blind man could literally operate the crane - and he's literally relying on his spotters to tell him what to do.

And guess what? It's 100% legal and safe. If that crane operator crushed someone with a beam during a blind pick, and he had followed all radio and visual cues properly, he is not at fault.

Again, I'm not saying that Pink Pilot is exempt from responsibility, because I haven't read the Monorail Ops Manual, but it is 100% reasonable for him to rely on his co-workers when making a blind move (like driving a train backwards at 2am with windows that are 90% fogged up).

Now, I've also never backed a monorail into base from Epcot, and it seems like you would notice if you DIDN'T go through the two switches. The little jogs in the track on the Epcot line can knock a filling loose. I can only imagine how jerky it SHOULD be going through two switches.

While he was probably justified in trusting his comrades, he was probably also too apathetic about the task at hand and neglected his duty to ALSO be prepared for anything.

I understand and agree with the crane spotter scenario, but in that case, there is no other way to do it. In this case, the driver can easily pay attention and know what is going on, even when going in reverse.

Also, the crane operator, blind or not, still concentrates on what he's doing. The driver of Pink really didn't.

 

[s8film40]

I disagree with the argument that Pink Pilot should have not put blind trust in his co-workers.

Now, I haven't read Monorail Ops Policy, and I'm not saying whether Pink Pilot shares any blame or not, but I'll (again) give an example that there is indeed such a thing as trusting your co-workers, and it being OK.

A tower-crane or other large crane operator is often working blind. He might be able to see where he's picking up a steel beam from a stockpile, but since crane's don't usually move once they've set up on a jobsite, he'll put together the entire building from one spot.

This means that for many pieces of the building, he'll be lowering a beam or column down on the other side of the building, or in a location that he absolutely cannot see. It is literally impossible for a crane operator to have a visual on every one of his picks.

So, he replied on spotters. He'll be in radio communication with guys in the lay-down area, who will tell him when they've secured the next piece to his hook. Then he'll either get radio or visual cues from a guy positioned somewhere where he can see both the pick and the crane operator. He'll tell the operator to boom left, right, up, down, in or out, and when to raise and lower the cable. It is at these times that a blind man could literally operate the crane - and he's literally relying on his spotters to tell him what to do.

And guess what? It's 100% legal and safe. If that crane operator crushed someone with a beam during a blind pick, and he had followed all radio and visual cues properly, he is not at fault.

Again, I'm not saying that Pink Pilot is exempt from responsibility, because I haven't read the Monorail Ops Manual, but it is 100% reasonable for him to rely on his co-workers when making a blind move (like driving a train backwards at 2am with windows that are 90% fogged up).

Now, I've also never backed a monorail into base from Epcot, and it seems like you would notice if you DIDN'T go through the two switches. The little jogs in the track on the Epcot line can knock a filling loose. I can only imagine how jerky it SHOULD be going through two switches.

While he was probably justified in trusting his comrades, he was probably also too apathetic about the task at hand and neglected his duty to ALSO be prepared for anything.

The key differences here are that the driver of pink did have visuals. With the cool and defog setting he described using, he described that there was an opening to look through also the side windows very rarely fog and indeed in this instance he described looking through them and described what he saw. When backing this should be his primary visual since he was going in reverse and actually in this scenario with the window fogged he actually had better visuals than if he had been going in forward through the switches. The other key factor is that his instructions were to go through the switches and the spur, the simple fact is he was not following his instructions if he was unsure of were he was, his responsibility was to stop and notify of his inability to determine his location.

 

[s8film40]

I agree, and disney does too, which is why they have someone standby the e stop in the rear cab when a train is coming off the epcot line now.

peechykeen- It sounds as if you work, or have once worked in monorail operations. You have some good information. I'm curious how many other trains where out when this happened. if so, did they bring in the other trains to the shop, or did the drivers park at a station?
Also, I can imagine the thoughts it brings up when the feedback is heard over the radio...

This is a great example of Disney trying to solve the symptom and not the problem. Having all the extra observers while is good just adds extra layers of complacency, why bother looking when someone else is supposed to do that for you.

This sheet shows the locations of the trains. It's a little hard to read I think the ones with "S/O" means they stayed out that night but I'm not 100% sure on that.
http://www.ntsb.gov/Dockets/RailRoad/DCA09FR008/447546.pdf

 

[Tom]

I understand and agree with the crane spotter scenario, but in that case, there is no other way to do it. In this case, the driver can easily pay attention and know what is going on, even when going in reverse.

Also, the crane operator, blind or not, still concentrates on what he's doing. The driver of Pink really didn't.

Good point. Based on his interview, it's clear that he was not aware of his surroundings - for whatever reason.

The key differences here are that the driver of pink did have visuals. With the cool and defog setting he described using, he described that there was an opening to look through also the side windows very rarely fog and indeed in this instance he described looking through them and described what he saw. When backing this should be his primary visual since he was going in reverse and actually in this scenario with the window fogged he actually had better visuals than if he had been going in forward through the switches. The other key factor is that his instructions were to go through the switches and the spur, the simple fact is he was not following his instructions if he was unsure of were he was, his responsibility was to stop and notify of his inability to determine his location.

Understood. I really have no basis to argue for or against this exact scenario, because I've never driven a monorail backwards through 2 switches and into a station. I can only imagine that if you've done it before (as Pink Pilot had done - to the exact description - the night before), you would notice if you didn't break your neck going through two switches.

If you're ONLY looking in your mirror to watch for station lights, sure, it probably looks the same in that tiny mirror no matter which line you're coming in on (a traffic signal and lots of glowing lights).

I'm only on Document 5, but I can already see the assortment of loopholes that were discovered by this tragedy. And what's really scary is that David - who is supposedly a trainer - doesn't really understand the system or when you should use the kill switch (other than if a kid is running toward the beam). If you're a trainer, you should actually UNDERSTAND the system you train for, and no just regurgitate information like a monkey. My opinion, based on his interview, is that he was not at all qualified for his job.

 

[ChrisFL]

I haven't read the documents yet, but I do recall something about the monorail pink driver complaining of condensation on the mirrors/windows which obstructed his visibilty.

 

[Tom]

I haven't read the documents yet, but I do recall something about the monorail pink driver complaining of condensation on the mirrors/windows which obstructed his visibilty.

He did indeed.

 

[s8film40]

Good point. Based on his interview, it's clear that he was not aware of his surroundings - for whatever reason.



Understood. I really have no basis to argue for or against this exact scenario, because I've never driven a monorail backwards through 2 switches and into a station. I can only imagine that if you've done it before (as Pink Pilot had done - to the exact description - the night before), you would notice if you didn't break your neck going through two switches.

If you're ONLY looking in your mirror to watch for station lights, sure, it probably looks the same in that tiny mirror no matter which line you're coming in on (a traffic signal and lots of glowing lights).

I'm only on Document 5, but I can already see the assortment of loopholes that were discovered by this tragedy. And what's really scary is that David - who is supposedly a trainer - doesn't really understand the system or when you should use the kill switch (other than if a kid is running toward the beam). If you're a trainer, you should actually UNDERSTAND the system you train for, and no just regurgitate information like a monkey. My opinion, based on his interview, is that he was not at all qualified for his job.

Actually the view through the mirrors is pretty good you can see quite a bit the key think he would have seen differently aside from the beams and surroundings would be the large tower.

I have to disagree about David I think he is widely considered one of the best and most qualified coordinators/pilots. The thing they were going back and forth about with the kill pack was weather he believed it was generally know that it could be used to stop a train collision, it was hard for him to answer that since there had not been a collision recently, it just wasn't something a lot of people even though about. At least that was my impression of that part of the interview.

 

[Tom]

Actually the view through the mirrors is pretty good you can see quite a bit the key think he would have seen differently aside from the beams and surroundings would be the large tower.

I have to disagree about David I think he is widely considered one of the best and most qualified coordinators/pilots. The thing they were going back and forth about with the kill pack was weather he believed it was generally know that it could be used to stop a train collision, it was hard for him to answer that since there had not been a collision recently, it just wasn't something a lot of people even though about. At least that was my impression of that part of the interview.

Gotcha.

And that was just the impression I got from the interview. Of course, whoever transcribed his interview did a TERRIBLE job. They left out several words, and typed wrong words in several places. But the back-and-forth about the kill switch just made it sound like he didn't know what the Ops Manual actually said, or what all the appropriate situations for use would be. But like you said, could just be because I'm reading what some minimum wage stenographer typed and have no personal knowledge of him or his possible expertise.

 

[thelookingglass]

While he was probably justified in trusting his comrades, he was probably also too apathetic about the task at hand and neglected his duty to ALSO be prepared for anything.

To be fair to the Pink driver, all of these actions and previous procedures were probably so routine to them, that they probably were in the mindset of "nothing bad has ever happened doing this, why would it happen now?" that I can totally understand why he just trusted his radio commands.

How much visibility he actually had is another story, as we will never really know.

I'd still like to know what caused the shop person to say that the switches were in place when they weren't. Was this ever released?