Jason Garcia and the Sentinel is piling on in Today's paper.
JasonGarcia said:A spotter is 'strongly recommended' when backing up; Disney now has a new, stricter policy in wake of fatal July collision
By Jason Garcia
Orlando Sentinel
12:24 AM EST, December 22, 2009
The manufacturer of Walt Disney World's monorail trains warned against the kind of reverse driving that contributed to the system's first fatal crash this past summer, according to documents obtained by the Orlando Sentinel.
An operating manual written for the Disney trains by Bombardier Inc. warned that driving the vehicles in reverse "is a potentially hazardous operation even under the best conditions" and "strongly recommended" that an observer be stationed at the opposite end of a train whenever one is backing up.
The July 5 accident occurred as a Disney train was supposed to be moving off of the resort's Epcot loop at the end of a work day, a process that requires the train to move in reverse through a track switch and onto a short spur leading to one of the system's Magic Kingdom loops. But the track switch was not activated that night, so the train wound up reversing back down the Epcot loop instead, hitting another train and killing the second train's 21-year-old driver, Austin Wuennenberg of Kissimmee.
At the time of the crash, Disney's monorail policies did not require that someone be watching the back of the train being driven in reverse. So there was no spotter in place who could have warned the driver that the switch had not moved and the train was backing down the wrong track.
Disney said it had multiple other safeguards in place that night to monitor trains being driven in reverse. Yet on Sunday the resort instituted a new policy forbidding trains from backing up unless a spotter is watching the opposite end.
The policy is strict: Even a train that overshoots its stopping point by a foot or two as it pulls into a station cannot back up to align with the passenger gates until a spotter on the platform has given radio clearance.
Greg Hale, chief safety officer and vice president of worldwide safety and accessibility for Walt Disney Parks and Resorts, said in an interview Monday that the change is part of an ongoing effort to improve monorail safety. The July crash was the first fatal accident in the system's 38 years of operation.
"We've continued — and will continue — going through every scenario and making sure we have the best safety procedures we can," Hale said. "I think we feel confident we've taken every step that's prudent and will continue to do so."
The 20-year-old operating manual was unearthed by federal investigators examining the crash. The U.S. Occupational Safety and Health Administration and National Transportation Safety Board have each launched probes; OSHA is expected to release its findings within the next two weeks.
Representatives of OSHA and NTSB both said Monday that they would not discuss specifics of their reviews. "The investigation is continuing," OSHA spokesman Michael Wald said. NTSB spokesman Peter Knudson said his agency's investigation is expected to take about six more months or so to complete.
No one else was hurt in the July crash. It happened at about 2 a.m., with only six guests aboard Wuennenberg's train and no one aboard the other train.
Disney's current generation of monorail vehicles, known as Mark VI trains, were put into service in 1989. The vehicles were built by Bombardier based on specifications provided by Disney, which designed the trains.
Driving the trains in reverse can be dangerous because drivers in the front cab have a limited view of the track behind them. And reversing through a track switch is especially hazardous because traversing the switches requires drivers to manually override the trains' automated anti-collision systems, which rely on sensors built into the monorail's main track, or beam.
As such, the operating guide that Bombardier supplied with the trains includes the warning about reverse driving and the recommendation to use an observer. The disclaimer is printed in bold lettering immediately under the heading of a section titled, "Moving the train in reverse direction."
A spokeswoman for Montreal-based Bombardier would not comment.
Disney acknowledged that its policies at the time of the accident did not require an observer to watch the rear of trains that were backing up. But it said it had other safety policies in place designed to accomplish the same goal, including several specific measures for trains reversing through track switches.
For example, Hale said, there are a series of sensors that monitor the position of the locks that hold a switch in place and indicate which sections of track have power. That information is then displayed on a grid in the monorail's maintenance shop, where it is visible to the employee who controls the switches. When activating a switch, the employee is supposed to use that grid to verify that the track has actually moved from the loop to the spur or back again.
A similar grid is displayed on a console in the Transportation and Ticket Center, the monorail's central hub, for monitoring by the monorail's "central coordinator," who oversees the entire system by radio. But Disney's policies at the time of the crash did not require the coordinator to be positioned at that console; the resort has since begun requiring coordinators to remain there at all times.
Hale also said that most track switches — including the one linking the Epcot loop to the spur — are monitored by video camera. As with the track sensors, the video images are visible on monitors in the maintenance shop for the worker who activates the switches. And the moving of a switch, he said, requires a strict, step-by-step protocol of radio communication between the train driver, the central coordinator and the maintenance bay to ensure that everything is in position.
"We've got nearly 40 years of operating experience and of operating the entire monorail system, and we've evolved our procedures based on that collective experience," Hale said.
According to people familiar with details of the accident investigations, the chain of events leading to the crash began when the worker in the maintenance bay mistakenly radioed that it was clear for the train to begin backing up and transferring off the Epcot line — even though he had not realigned the track. The central coordinator's role was also in flux that night — an employee had gone home ill, so the job was being handled temporarily by a manager on his dinner break — so no one was at the console in the Transportation and Ticket Center.
The rule added Sunday, requiring spotters whenever a train is reversing on a track, applies to all reverse driving, not just during track switches. Hale said Disney's trains typically travel in reverse when they are being taken in or out of service and must transfer between tracks, when they slightly overshoot loading gates in a station, and during malfunctions that require rapid unloading.
Hale said the spotter's role can be filled by different employees depending on the situation, including workers on a station platform, drivers of a train on another beam, or by an extra employee dispatched to ride in the rear cab.
Jason Garcia can be reached at jrgarcia@orlandosentinel.com or 407-420-5414.
Copyright © 2009, Orlando Sentinel
