Monorail guide warned of hazard when trains backed up without a spotter
Featured, Jason Garcia, News — By Jason Garcia on December 21, 2009 at 11:30 pmThe 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 new 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 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 another six 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 none 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 declined to 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 series of sensors that both 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.
Tags: Accident, monorail, Safety, transportation
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40 Comments
One accidental death — thirty-eight years. Isn’t the O-S beating up on Disney a tid-bit to much? Is it something WE need to know or is it something that YOU want to over report?
….and so it goes~~
Once accidental death (owing to a poorly trained and careless driver), a number of serious injuries, more close calls than can be mentioned, plus thousands and thousands of dollars’ worth of damage to the trains over the years. In my opinion, Disney has chosen to take the path of saving money instead of ensuring safety for many, many years, so I for one am glad to see that the Disney Way is starting to get a little bit more light put on it, instead of having things swept under the carpet like they’re used to getting.
You must own DISNEY STOCK.
A life was lost in an incident that was totally preventable had Disney followed the manufacturer’s recommended procedure. This will cost them big bucks when the suit hits.
One accidental death? So the 3 in two months over this past summer are what? purposeful. Disney gets to face the same scrutiny as an airline in this case. The accidental piece went out the window when Disney didn’t follow the manufacturers warnings. And it would be to our advantage that they start with the rail system, just so we don’t have an accident at sea one day…
Operating a train from the cab at the opposite end without a spotter is just a lack of common sense, even it it weren’t in the manual (not on the pilot’s part, he was just doing as instructed.)
And leaving the central console unmanned during switching operations is inexplicable. A properly trained manager should have covered the missing coordinator until a replacement could be called in. Lunch breaks can wait.
Disney chose to save money by operating with fewer cast members than prudent. In no way is the Sentinel beating up on this story.
No, the pilot was *not* doing as he was instructed. There were at least four indications that he should have picked up on that would have told him he wasn’t where he was supposed to be. There were a lot of people that screwed up that night, but IMO the main problem was an idiot driver that wasn’t paying attention when backing up a 70-ton piece of heavy equipment.
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Dude, if this is some kind of satirical poem, it is hilarious. If not, ride your paranoia train back to medication town.
you lost, get over it
You won — and you won’t be able to get over it…
There is no such thing as 100% efficiency, there will be accidents period.
I would like to see any of you try to run a business. Its easy to comment, hard to do the actual job!
As tragic as the July accident is, I would put monorail’s safety record up against ANY of USA’s light rail systems, which are being shoved down our throats in cities far and wide. Those in-the-street systems have accidents all the time with pedestrians and vehicles, but don’t get anywhere near the attention monorail does when there’s an accident. I call that double standard.
You need to take your druggy-druggies. Or have you already and that’s why you wrote this?
Enoght already with the Disney bashing from the OS. They need to move on. Just because Disney no longer distributes their paper on property is no reason to keep up with the sour grapes reporting. A tragic accident happened and it is being investigated. The OS is like a sleeze rag now.
This reminds me of Final Destination:
1) Maintenance Bay worker radios track is clear when it is not, 2) He does not realign the track, 3) Employee goes home ill, 4) Untrained manager is called to man Central Coordination, but he is away at dinner.
Sounds like Death had his number that night.
I am quite a rail and monorail fan. Have been on WDW monorails many times. These are double-ended monorails. I might need some explanation from someone, but why is it necessary to back the train up when the operator could simply go to the other end and the train could go forward instead of reverse? I realize it takes another minute or two to walk the length of the train…..but it seems really simple to me. Unless there are systems/signals that would not provide accurate info if a train was going forward instead of reverse.
WDW experts, please fill me in.
Thanks!
Joe (Phoenix, AZ)
re: Joe
The accident and switch that was taking place was not at a platform station where the pilot could not have walked back to the other car. They were out in open track and there would have been no where to walk, the monorail cars do not have pass thru doors like traditional trains. You cannot move thru the train from car to car.
Hope this helps.
It’s not necessary to back the train up, but it *is* more convenient. To switch ends, the driver has to shut the train off, walk the 200 feet to the other end, turn the train back on, wait for the computer to boot and for a few other systems to come up, and do a radio check. This takes a few minutes which often means delaying other trains on the same beam that may have guests on board. Driving the train in reverse is identical to driving it forward, except for the visibility issue, but that’s mitigated by three rear-view mirrors available to the driver at both ends of the train.
Pirate – Pink wasn’t holding at a station, but the Concourse station was only a quarter-mile away, and the driver could easily have been told to switch ends there. He’d still have to have backed the train up in the other direction (north) past switchbeam 9 though.
If the “one death in 38 years” was someone from your family you would take this much more seriously!
ok seriously enough disney bashing- the rules in place PRIOR to the incident didnt require the spotter at the other end-
did anyone stop to think that MAYBE there wasnt another person on board to act as a spotter?
get all your facts before you bash Disney and their policies
theyve been in the industry for almost 55 years
so chill out
they know what they’re doing
unless you young kids have 50 years experience – SHUT UP
First, what industry are you talking about? The safety industry? Disney is in the safety industry for the past 55 years?
Well, they are sure doing a good job then. Let’s look at that track record. A boat cleat right through the head of a lady at Disney Land, a cast member who was cleaning around the skyway (this might be before your time, back in the late 90’s) that when the ride was turned on without first checking the platforms, it took him up until he fell and died, Tigger getting ran over by a parade float, the monorail crash, the fatal slip and fall during a street performance, along with the other performer who landed wrong and died during a practice session, and the cast member who fell at the primal whirl attraction and died. Those are not even all of them, and they over shadow such things as the bus accident this summer that injured many people when one WDW bus slammed into the other, and so many others.
I am in the safety industry, and more than likely have been for longer than you have been alive. The true fact is you do not have your facts straight; and that is the point. It is not the intent of any company to broadcast their safety (or lack thereof) issues. It takes something like the monorail that cannot be hidden; and now they will be a large target for the media when anything happens. It should prove to be a good thing as safety should be number one. Now they know that the PR for their next accident will be amplified by the monorail accident and all the other deaths.
So, now you can “chill out dude” as you now have more facts; such as that you don’t have a clue as to declare that you know what they are doing. You just think the company’s age (it’s not 55 by the way) means it’s safe?
I wish you the best of luck finding a safe place of employment once you finish high school.
Happy Holidays
THEtruth: the company isn’t 55 years old, but Disney has been operating theme parks almost that long – Disneyland in CA opened in July of 1955.
I’ve got all my facts, thank you very much. I drove monorails for years and trained people how to drive them. I fought with the company regarding people being allowed to drive that, in my professional opinion, were not qualified to be doing so, and I believe I’m more than qualified to pass my own personal judgment on the company’s actions that resulted in this unnecessary and totally avoidable accident. Sorry if you feel like it’s “Disney bashing”, but I daresay I’ve got a little bit more knowledge of how things are done there than most.
Whether there was a spotter or not really doesn’t matter – the driver obviously wasn’t looking in his mirrors and wasn’t paying enough attention to notice he WASN’T EVEN ON THE CORRECT BEAM, much less noticing the train behind him. I’ve backed through that same switch many, many times, and visibility is absolutely NOT a problem if you’re looking in your mirrors like you’re *supposed* to have been trained to. In my opinion, the root cause here isn’t that there wasn’t a spotter, it’s that the drivers aren’t being properly trained, and this has been a worsening issue for years.
I am just a frequent guest, but I would know if I was on the wrong monorail beam. It blew my mind when I first read the story and I could see Pink clearly hadn’t taken notice of where he was. At that time I didn’t even know about the mirrors you mentioned. That makes it even more obvious that he wasn’t pay any attention whatsover. Too horrible.
I challenge anyone else to name a single company that can match the Disney Company’s safety record.
This is no way excuses any accident, oversight or lax behavior. But just look at what the company has done one the incredibly rare occasions that accidents or fatalities happen.
We do not live in a perfect world. But I’ll bet the farm on Disney’s safety record v. any other company’s record, any day.
I don’t want to argue either side of this argument, I just want to point out something that is not being said. Disney has thousands upon thousands of employees, operating thousands of mechanical equipment. Whether that equipment be ride vehicles, transportation, floats in a parade, or even cast members acting in a role, there are bound to be accidents. There are accidents at EVERY workplace. Because of the nature of a theme park business, as well as the number of employees Disney has and the number of machines that are being operated, Disney will have a higher possibility of accidents happening. Performers slipping or falling because of them losing their footing can hardly be blamed on the Disney company…accidents such as the Primevil Whirl could probably be blamed on the company for not having those sensor mats around the area (you can’t trust that people are going to follow procedure). Just wanted to make my point about the size of the company as well as the amoun of people they employ and the greater possibility of accidents due to the larger amount of people employed and machines worked with.
Jonathan, I agree that a company with the labor force the size of Disney will, from a statically speaking standpoint, be at a higher probability for injury and fatalities.
However, in recent years (7-5ish years) The Company has been slowly outsourcing many of the jobs to contractors. Such as custodial duties during third shift, etc. A smart move in my opinion as the responsibility of safety then falls on the employer of the outsourced operation; however, on the same note Disney has a massive Health Services building.
The Health Services Building is staffed with 4-5 Doctors, nurses, health techs, and the list goes on.
There are injuries, accidents, and illnesses that stay within the walls of the building. I do not know and can’t speculate if they report the injuries and illnesses as required by law; but I do know that it is very rare to have a “slow” day in the building.
If they do report the illnesses and injuries correctly, then their DART rate would be through the roof (DART = Days Away, Restricted, and Transferred; a calculation used by OSHA).
Who knows what goes on behind the walls; the OS and the other media can only report on what goes on that can’t be kept behind the walls, such as the monorail accident.
It’s not bashing, it’s reporting on leaks in the DAM of companies such as Disney and others. Heck, look at the park visitor that got killed when the boat cleat went through her head at Tom Sawyer’s island in Disney Land CA. They had the area cleaned and cleared before investigators even got there.
Most people that say this is “bashing” are merely in a world of magic themselves. The reality is most large labor instinctive companies will cut on safety due to the costs, or at the least, they will keep their dirty laundry (aka: safety incidences) from airing out of the house in public.
It’s sad but business is business… and business is not always good.
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Those who site the safety record of ‘just one death’ are minimizing this incident. “Just one” if it is your friend or loved one is one too many – especially when the person who was supposed to be on duty was “taking a break.” Disney has quite the reputation for hiding or excusing the many ‘accidents’ which have injured or worse people who work at their park. Disney should be and is finally being held accountable for this time. However, the fine is chump change to them. I believe the family is suing and they should. This is an ‘accident’ that could/should have been prevented. Many of you probably work there or know someone who does, so you defend their ignoring the safety rules.
Please don’t forget. It is Christmas and because of this unnecessary accident, his mother is without her only child. There is no money, no words, no apology that could ever come close to replacing her loss. As with any tragedy, there are those who are left behind to make sense of the senseless. Love your children, help someone who needs it, be kind whenever you are able. Merry Christmas.
Disney’s entire transportation system is a waiting deathtrap. They are more interested in their “image” than the safety of their guests. It was only a matter of time before a fatal accident happened. Impropertly trained operators, incompetent supervisors and image protecting employees is what they have.
I still shake my head in disgust at the monorail accident video. You have a person trapped in a serious accident and the Disny employee is more interested in chasing the person with the camera away. That idiot probably got a medal for choosing to protect the company from a negative video instead of being concerned about a trapped human being. Sickening.
Article title restated: “Disney to increase pricing on ticketing and many in-park items to allow visitors to absorb the cost of this stupid fine!”
Here’s what I don’t get, at ALL. How many cameras are there at Disney, and how much would it have cost to put a small camera at each end with a small monitor on the console at the opposite end, so that wherever you are you can see out both sides? These days, HD widescreen cameras and monitors are cheap, there’s no excuse.
Anyone watch motor racing? There are several HD cameras in every car and they transmit all that video (usually) perfectly to multiple locations.
And how many computers and computer engineers are there at Disney? There should be a very good automatic safety system that covers every inch of track and every possible scenario. That’s not difficult for a company with the resources that Disney has.
This whole incident is just incredible, really incredible.