NTSB releases final report on monorail accident

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amejr999

Member
Original Poster
Didn't see this posted anywhere, but the NTSB has released its final report on the monorail accident in 2009.

http://www.ntsb.gov/doclib/reports/2011/RAB1107.pdf

Here's the bottom line:

The National Transportation Safety Board determines that the probable cause of the July 5, 2009, collision between two monorails at Walt Disney World Resort in Lake Buena Vista, Florida, was the shop panel operator's failure to properly position switch-beam 9 and the failure of the monorail manager acting as the central coordinator to verify the position of switch-beam 9 before authorizing the reverse movement of the Pink monorail. Contributing to the accident was Walt Disney World Resort's lack of standard operating procedures leading to an unsafe practice when reversing trains on its monorail system.
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I think Disney came off looking somewhat better than they could have. The report could have opened up into a larger inquiry into Disney's "tone at the top" and corporate emphasis on safety, but I didn't see any major reference to that in the report, except for the contributing factor mentioned in the quote.
 
C

COProgressFan

Well-Known Member
amejr999 said:
Didn't see this posted anywhere, but the NTSB has released its final report on the monorail accident in 2009.

http://www.ntsb.gov/doclib/reports/2011/RAB1107.pdf

Here's the bottom line:



I think Disney came off looking somewhat better than they could have. The report could have opened up into a larger inquiry into Disney's "tone at the top" and corporate emphasis on safety, but I didn't see any major reference to that in the report, except for the contributing factor mentioned in the quote.
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A horrible tragedy all around. I think the findings are consistent with much of the discussion on this site and others. The conclusions seem to be what most of us have concluded here.

That said, I'm not sure that a report like this would address things at a corporate level. The culture of an organization and the way it is run certainly has an effect, but for reports like this they generally need more concrete causes.

That said, the culture of "safety at all costs" certainly was not the priority in the way monorails were run. Instead, the incessant push to cut costs continually is a mantra which permeates the Walt Disney Company, and especially parks and resorts.

I really truly hope this brings about major changes to monorail operations and operations throughout the parks. Unfortunately, I am not sure it will.
 
jakeman

jakeman

Well-Known Member
Contributing to the accident was Walt Disney World Resort’s lack of standard operating procedures leading to an unsafe practice when reversing trains on its monorail system.
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This is the root cause.

SOPs should be regularly reviewed for improvements and a system of consistent and periodical retraining should be in place.

It doesn't seem like either (although that is an assumption) was in place for the monorail accident based on the final report and what we have been told about monorail operations since the accident.

I'll refrain from pointing fingers though. I'm sure enough people will be in here shortly to do that.
 
C

COProgressFan

Well-Known Member
Tom Morrow said:
um, they DID make major changes in procedure to prevent this from ever happening again.
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I guess I should have been more clear. The changes that have been made address the direct causes of the accident. Disney had no choice but to make these changes, especially given the involvement of OSHA and the DOT investigation.

But wholesale changes to the way the division is run is another story. Does the "safety first" mentality permeate every aspect of the operation? Does the division recognize that staffing, training, and maintenance are all critical components of safety, even if they are not directly addressed in the report (and even if it means the cost of operations goes up)? Is transportation given the necessary resources?
 
PirateFrank

PirateFrank

Well-Known Member
amejr999 said:
I think Disney came off looking somewhat better than they could have. The report could have opened up into a larger inquiry into Disney's "tone at the top" and corporate emphasis on safety, but I didn't see any major reference to that in the report, except for the contributing factor mentioned in the quote.
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Not likely....government reporting agencies usually try to stick with objective causes of system failure. Subjective findings are very easily contested and generally water down the impact of the whole report.

Frankly, it is exceptionally difficult to cite 'tone at the top' as the root cause, without chronic issues that would suggest such a thing. Also, Disney likely had plenty of safety procedures in place (just not the right ones) and the right language in both policy and procedure to suggest 'tone' was far less of a concern than a break down or absence of necessary procedure.

It might be sexy for some to try to bash Disney here...oooh, big bad corporation, doesn't care for the little man. But I think claiming that big, bad evil Meg and her evil henchman Tom, doesn't care about the health and wellbeing of cast members.....is such a ridiculous reach. Austin's death was a truly terrible thing....as is every accident that has occurred on Disney property, but given the sheer amount of cast members and guests that travel on, stay in and enjoy WDW on a daily basis....I think you'll find that Disney has a very, very good safety record.

Let's try to focus on the real causes here, and hope that Disney has addressed them sufficiently....It seems the NTSB report has done that. Hopefully, others will take a cue....
 
C

COProgressFan

Well-Known Member
PirateFrank said:
It might be sexy for some to try to bash Disney here...oooh, big bad corporation, doesn't care for the little man. But I think claiming that big, bad evil Meg and her evil henchman Tom, doesn't care about the health and wellbeing of cast members.....is such a ridiculous reach. Austin's death was a truly terrible thing....as is every accident that has occurred on Disney property, but given the sheer amount of cast members and guests that travel on, stay in and enjoy WDW on a daily basis....I think you'll find that Disney has a very, very good safety record.

Let's try to focus on the real causes here, and hope that Disney has addressed them sufficiently....It seems the NTSB report has done that. Hopefully, others will take a cue....
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I think Disney does have an excellent safety record. But any excellent safety record can always be better.

The issue I think is not that they Disney makes the necessary improvements to procedures/policies, etc. (they have already done that) but that they are willing to make changes to the way the department is run and funded to make sure that safety is priority, even it means having to spend more money on training, or keep extra positions on the payroll, etc. It's not an issue of evil Meg or Tom, but whether they are truly pro-active in continually assessing the safety of their operations and making changes if/when necessary, rather than becoming complacent because they feel they system is safe since they never had a major accident before.
 
nace888

nace888

Well-Known Member
COProgressFan said:
I think Disney does have an excellent safety record. But any excellent safety record can always be better.

The issue I think is not that they Disney makes the necessary improvements to procedures/policies, etc. (they have already done that) but that they are willing to make changes to the way the department is run and funded to make sure that safety is priority, even it means having to spend more money on training, or keep extra positions on the payroll, etc. It's not an issue of evil Meg or Tom, but whether they are truly pro-active in continually assessing the safety of their operations and making changes if/when necessary, rather than becoming complacent because they feel they system is safe since they never had a major accident before.
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They are rather safe... They could consider so many things, but they are stepping in the right direction.
 
JeffH

JeffH

Active Member
Disney needs to change its overall safety mindset

The Monorail accident (a CM death which occurred while switching tracks)...
They should have taken steps to eliminate an accident from ever happening again (with step-by-step no exception policies like described above);
instead they changed their front cab policy to no longer allow guests up front with the drivers in case it happens again.
The Parade accident (a CM death, which happened 'off-stage')...
They should have taken steps to make sure a CM would never get run over again (by installing shutdown sensors on the front of the floats, and/or supplying CMs with panic buttons)
instead, they ADDED (unthemed MIB) CMs to the parade route who watched out for guests(?!?) increasing the number of CMs in the line-of-danger who weren't watching out for other CM or themselves (they looked towards the crowd and not at the dangerous floats).
AND they eliminated the parade stops (which the kids loved)?!? Unnecessary...when the floats aren't moving they pose no danger...it wasn't a guest who was killed and the fatal accident occurred off-stage and it was while the parade was moving.

Disney's attitude should be to eliminate accidents from happening, not to minimize damages and responsibility when they do happen.
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Disney's lost child procedures are also very insane where they immediately take the parent or child inside (so they can't be found, essentially making you unfindable) I was sitting a few feet from my daughter eating my food sample as she colored at the Germany Kidcot station, when she said to the CM where's my dad (I was right behind her). The CM instead of trying to locate me, took my daughter inside the pavilion and when I looked up from my plate she was gone!!!!!! I panicked running back to Italy then forward to China where I stayed until a CM 'located' her...where she was...when I returned to Germany she was back sitting at the kidcot station...they essentially lost her. So if you lose your kid, how long do you look for them before assuming they've been schlepped up by the Disney kid-nappers and sent off to the lost kid center on the other side of the park???
 

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