Sentinel: Monorail crash: Disney did not follow manual

[jakeman]

If you can't rely on someone to look out the rearview mirrors when backing up a monorail how can you rely on the same person to pay attention as a spotter. There just adding numbers to improve their odds of catching a problem. Keep in mind it took at least three people not paying attention to cause the accident. To me there are really only two options. One they could hire more skilled people instead of the bottom of the barrel people willing to accept $7.50 an hour, and put them through rigorous training. Or they could just automate the system.

Adding another set of eyes, should in theory at least, help avoid the same kind of incident. However, from the sound of it, the policies they had in place were sound, they just didn't follow them to the letter, and there was one person who wasn't there. I'm going to speculate that fatigue played a major factor in the failure of those who were on duty. Ultimately, this was a chain of errors that rests on several people's failures to properly and safely do their job. The extra set of eyes being added to the policy will certainly help, but if anything can be learned from this incident it's that people are going to make mistakes, especially when they're tired and it's late at night.

I would recommend one or more of the following. 1) Operators and controller, be restricted to working no more than 6-8 hours in the train and on the control board. If possible, a night shift supervisor/safety officer should be there for late night operations. 2)The trains should have cameras for operating in reverse. 3)More Automation. The sensor system (MAPO) should be improved and made "smarter". I understand it has to be disabled for backing operations, this indicates to me that it's a "dumb" system, probably a bit out of date. They can and should look into upgrading/replacing it.

There is no indication so far that fatigue was a factor in this accident.

It's easy to say, "Train them more. Pay them more. Limit their hours." but that may not address the core issue.

So far it appears that this was a break down in SOPs reaching back as far as 20 years.

That's not something that can be fixed overnight or without critical imput from multiple functional group.

It seems that the root cause analysis of this issue will not lend itself to a simple answer.

 

[wm49rs]

Why does it take a tragic mishap to drastically change policy? (lawyers and money)

Because it's the only time the farmers notice the barn doors are open....

Unfortunately for WDW, this article and the upcoming reports are part of the process. And personally, I don't have an issue with WDW having their feet held to the fire in this situation. I can understand how some can see it as "piling on," but it shouldn't take someone needlessly dying for the proper procedures to be implemented.

 

[s8film40]

If this can potentially save someone's life, then I don't mind a few minutes of inconvenience.

If you can explain to me how moving a train two inches in reverse can kill someone then I might be inclined to agree.

Also, if this would have been in place all along as it apparently should have been according to the manuals, then Austin would still be with us !!

Not necessarily, if the same incident had happened with someone riding in the back cab and that person also was not paying attention the only difference would have been two monorail pilots would have been killed instead of one.

 

[s8film40]

So far it appears that this was a break down in SOPs reaching back as far as 20 years.

This was not an SOP it was a recommendation from the manufacturer that was addressed with other methods.

 

[theadmiral459]

You know folks this is a sad issue i wish they just let this go and move on to other things .

 

[EPCOT Explorer]

*sigh*

Well, at least it looks like they are taking new safety measures, NOW...

But that's usually how these things go.

 

[jakeman]

This was not an SOP it was a recommendation from the manufacturer that was addressed with other methods.

You are right, but obviously the other methods were inadquate.

As an investigator, I would question why these other methods were put into place and not the spotter as recommended by the manufacturer.

And this:

But Disney's policies at the time of the crash did not require the coordinator to be positioned at that console...

Is an SOP inadequacy. Not really any other way to describe it.

 

[EpcotServo]

A question for those who are familar with the monorails--could they not install cameras similar to those now in many automobiles that provide the pilot with a video feed of the area behind the monorail while in reverse?

It would seem that would be a viable redundancy to a spotter at a reasonable cost.

The same kind of system was incorporated to Disneyland's new Monorail fleet. The lack of change, and looking to invest in change where it's REALLY needed, is the Achilles' Heel of how we operate down here.

 

[Space Mountain]

I wonder if there's a way we could get our hands on the manual?

It's out there.

 

[PhotoDave219]

The root problem is that they need to hire and cultivate personnel properly, from top to bottom of the department, or they need to make the system as automated as possible. All these added safety procedures will just add up to make the system inefficient and cumbersome, while not even really being effective and ignoring the real problem. Right now there are Cast Members who become complacent in their duties, and managers who don't have any real interest in the system beyond just serving their couple of years in the department, making some arbitrary change that superficially makes their time there look productive, and moving on and forgetting about the place. This is what needs to be fixed, and it's not happening.

If you have a competent and attentive Pilot in the chair, there's no reason you'd need a spotter.

I agree. Its more a problem with management culture and attitude then anything.

That being said, its really messed up that it cost someone's life for people to make changes. Of course, its not the first time in the past 5 years that has happened.

 

[EPCOT Explorer]

When was this policy implemented, by the way? It might explain something I saw this past visit.

 

[TOTGuy]

One they could hire more skilled people instead of the bottom of the barrel people willing to accept $7.50 an hour, and put them through rigorous training. Or they could just automate the system.

I take offense to this...
Even though I never worked in monorails I started in attractions.
I don't work at Disney for the money, never have, never will. I work there because I want to. Does that make me a bottom of the barrel person? I went to NYU and I scored high on my SATs. Now I am not going to say Disney's hiring system isn't flawed but don't take this out on the cast members. This was an accident caused by a series of mistakes that aligned. Could this have been prevented? Absolutely. Does the monorail system need an overhaul? Sure. Are the CMs entirely to blame? NO! You have no idea what it is like to be in that kind of situation, and until you do, do not judge us. Everyone is so quick to blame the cast member, when in fact a lot of these policies are made by people who don't even participate in operations.

 

[MAGICFLOP]

First of all, who knows best about operationing the monorail?

The Manufacturer or Disney?

I would say Disney. Why, becuase they have the experience of operating it for years, If that is not enough, they designed it. The manufacturer just built it for them.

2nd, what will this new backup policy create? Train operators will not over run and back up a couple of feet. They will stomp the break if it gets close and make people in the car fly. In my mind I would still allow the operators to back up as usual, but a maximum of 10 feet. No train should be that close anyway.

Sometimes a knee jerk response gets people kicked needlessly

 

[Wilt Dasney]

2nd, what will this new backup policy create? Train operators will not over run and back up a couple of feet. They will stomp the break if it gets close and make people in the car fly. In my mind I would still allow the operators to back up as usual, but a maximum of 10 feet. No train should be that close anyway.

Sometimes a knee jerk response gets people kicked needlessly

That I agree with. Maybe the new policy will be massaged over time to allow for some common sense exceptions, like backing into the station a few feet.

When you have trains backing up any real distance, it seems like a good idea to have a set of eyeballs on the ground to me, though. That doesn't seem like an overreaction, even if the previous policies would have prevented the crash had they been followed to the letter.

 

[lazyboy97o]

First of all, who knows best about operationing the monorail?

The Manufacturer or Disney?

I would say Disney. Why, becuase they have the experience of operating it for years, If that is not enough, they designed it. The manufacturer just built it for them.

2nd, what will this new backup policy create? Train operators will not over run and back up a couple of feet. They will stomp the break if it gets close and make people in the car fly. In my mind I would still allow the operators to back up as usual, but a maximum of 10 feet. No train should be that close anyway.

Sometimes a knee jerk response gets people kicked needlessly

Disney designed the look and configuration of the Mark VIs, they are Bombardier's products. Even the Mark Is were built using plans acquired from ALWEG. Bombardier is not some little fabrication company that landed a Disney contract. Disney hired Bombardier because of their experience in the transportation field.

 

[s8film40]

You are right, but obviously the other methods were inadquate.

As an investigator, I would question why these other methods were put into place and not the spotter as recommended by the manufacturer.

And this:
Is an SOP inadequacy. Not really any other way to describe it.

I think the main reason Bombardier would put this in is just to cover themselves legally, and their probably very thankful now that they did. Obviously moving a train in any direction entails a certain amount of risk, but these risk can be eliminated when the correct precautions are taken. I think the measures in the past were more than enough to cover potential risks, the problem arises due to complacency. The clearance measures in the past were effective enough that monorail pilots trusted them, if a driver was instructed to move in reverse to a certain point he knew that it had been confirmed the track was clear and everything ok. So while the driver is responsible for looking at where there going they knew it was clear ahead the procedure was routine and actually looking while important was unnecessary. Now these new procedures will only add to this complacency, A driver can realistically think they've been told the track is clear and now the person riding in the back will watch out for them, so there's nothing to worry about. They don't need to think about what their doing they can just drive as instructed. I think these new procedures will do more harm than good but will probably put Disney in a better legal situation should another accident ever happen which is ultimately why they have implemented this.

 

[PhotoDave219]

Sometimes a knee jerk response gets people kicked needlessly

Seems like a common sense response in this case. An extra set of eyes certainly cant hurt.

 

[s8film40]

I take offense to this...
Even though I never worked in monorails I started in attractions.
I don't work at Disney for the money, never have, never will. I work there because I want to. Does that make me a bottom of the barrel person? I went to NYU and I scored high on my SATs. Now I am not going to say Disney's hiring system isn't flawed but don't take this out on the cast members. This was an accident caused by a series of mistakes that aligned. Could this have been prevented? Absolutely. Does the monorail system need an overhaul? Sure. Are the CMs entirely to blame? NO! You have no idea what it is like to be in that kind of situation, and until you do, do not judge us. Everyone is so quick to blame the cast member, when in fact a lot of these policies are made by people who don't even participate in operations.

I agree with you completely. There are two very different types of cast members, there are the types who have sacrificed a decent paying job to do something they enjoy, but there are also the type who just couldn't get a job at WalMart and were forced to work at Disney. A team however is only as as strong as it's weakest link and in this case there were many cast members who performed flawlessly but the facts are some cast members made mistakes and this happened. Do I blame them directly of course not there are many aspects from training to job placement to hiring standards. This was a tragic accident brought about by several different problems and I really don't think any of them have been addressed yet.

 

[PhotoDave219]

I take offense to this...
Even though I never worked in monorails I started in attractions.
I don't work at Disney for the money, never have, never will. I work there because I want to. Does that make me a bottom of the barrel person? I went to NYU and I scored high on my SATs. Now I am not going to say Disney's hiring system isn't flawed but don't take this out on the cast members. This was an accident caused by a series of mistakes that aligned. Could this have been prevented? Absolutely. Does the monorail system need an overhaul? Sure. Are the CMs entirely to blame? NO! You have no idea what it is like to be in that kind of situation, and until you do, do not judge us. Everyone is so quick to blame the cast member, when in fact a lot of these policies are made by people who don't even participate in operations.

I - as well as a bunch of others - have been squarely pointing the finger of blame at management, including VP Kevin Lansberry, who was promoted to VP of DAK from VP of DTD, transportation, sports and golf operations. So its his policies, or rather under his watch, where a multimillion dollar fatal accident occurred - And they PROMOTED him.

As someone who has been a front line CM, i know that the policies are created by people behind desks, generally with ZERO front line experience.

I'm not hanging you out to dry. Rather pointing the blame where it should be.

 

[s8film40]

When was this policy implemented, by the way? It might explain something I saw this past visit.

It began Sunday Dec 20th. What did you see?