Hectic moments preceded Disney World fatal monorail crash
Featured, Jason Garcia, News — By Jason Garcia on February 24, 2010 at 10:36 pm
At about 2 a.m. July 5, as the last of Walt Disney World’s theme parks was closing after one of the busiest days of the year, there was still much to do inside the resort’s monorail-maintenance shop.
An electrician there was juggling multiple tasks as he operated the track switches linking the monorail system’s Magic Kingdom and Epcot loops. Three of Disney’s 12 trains were waiting to transfer between tracks, and a fourth was approaching the bay where it was to be parked for the night.
So when the electrician received the radio call instructing him to activate the switch that would allow one of the trains to transfer off the Epcot loop, he logged in to do so. But then, apparently distracted by a call about a door alert from the train approaching the maintenance bay, he did not activate the Epcot switch.
The electrician radioed that he had, though. As a result, the waiting train, driving in reverse to traverse the switch, wound up returning down the Epcot line and crashing into another train, killing that train’s pilot, 21-year-old Austin Wuennenberg of Kissimmee.
Investigators with the U.S. Occupational Safety and Health Administration determined, according to an internal memo summarizing the accident, that the unidentified electrician was “over tasked” that night, though it is unclear whether the agency thought Disney had assigned him too many responsibilities or whether the electrician himself tried to do too much at once.
The internal report is among hundreds of pages of documents compiled by OSHA during a six-month investigation into the accident and reviewed by the Orlando Sentinel after a Freedom of Information Act request. The records provide new details and deeper context to the formal citation OSHA issued in December, when it charged the resort with four workplace-safety violations and proposed a fine totaling $44,000.
An OSHA spokesman characterized the memo as “a draft version” of the final citation. He would not elaborate on the comments within it. “The citations are what OSHA decided to actually cite the company with. … Anything before that is preliminary,” spokesman Mike Wald said.
Among other details from OSHA’s documents:
– Disney did not provide the electrician with written procedures for operating the computers that controlled the track switches. The electrician was given only oral instructions on the switching procedures sometime in September or October 2008. Disney has since provided written training materials to employees.
– The electrician operating the track switches that night was not the regular person in the job. He was substituting for another employee who has handled switching operations for 21 years — but who was on vacation.
– OSHA investigators considered the guest-service manager who was coordinating the monorail system via radio from an off-property restaurant “negligent” because he was not at a control console where he could have seen that the maintenance worker had not realigned the track. The manager, who was on a dinner break, had allowed the primary coordinator to go home sick and was temporarily handling coordination duties until a replacement worker could reach the central console. The ill employee clocked out at 1:47 a.m. — about 13 minutes before the collision — and his replacement was en route to the central tower at the time of the crash.
– The driver of the train that backed into Wuennenberg’s train had “limited visibility” at the time of the crash. The driver told investigators he could not see with his side-view mirrors because humidity and fog on the windshield “made it nearly impossible to see clearly.” Data from the National Oceanic and Atmospheric Administration showed that, at the time of the accident, the temperature was about 76 degrees, with 90 percent humidity.
– Disney’s own investigation of the accident appears to have placed the blame primarily on the electrician in the maintenance shop. Though OSHA did not provide Disney’s internal report as part of its documents, citing a federal public-records exemption governing trade secrets, a letter to OSHA from one of Disney’s lawyers said the company’s internal probe “demonstrates that the accident was caused when the maintenance panel operator improperly gave the command that the switch had been completed by him when, in fact, it had not been completed.”
A spokeswoman for Disney would not comment on issues raised in OSHA’s documents, saying the resort has agreed not to discuss the accident until the National Transportation Safety Board completes its own investigation. A representative for the International Brotherhood of Electrical Workers, the union that represents the electrician, also would not comment.
A representative for the Transportation Communications International Union, which represents monorail drivers, said the investigation demonstrated that neither Wuennenberg nor the other monorail driver was to blame for the accident.
“It was proven by multiple agencies that none of the Service Trades Council employees were found to be at fault, including either monorail pilot,” said Randall Sluder, a field representative for the union.
OSHA’s investigation ultimately led to a formal citation, issued Dec. 23, charging Disney with one “serious” workplace-safety violation that contributed to the collision.
In that citation, OSHA broadly criticized Disney for failing to provide a safe workplace, noting several policy lapses.
Among them: failing to follow a recommendation from monorail-manufacturer Bombardier that a spotter be used to watch the back end of any train driving in reverse, and failing to require the monorail’s central coordinator to be stationed at the main console whenever a track switch was occurring.
OSHA also cited Disney for three other, unrelated safety violations that it discovered during the monorail probe.
Disney has made a series of policy changes in the accident’s aftermath. The day after the crash, for instance, the resort began requiring that coordinators remain at the central console during track switches and that monorail drivers switch ends and drive from twin controls in the rear cabin of their trains when reversing direction through the Epcot switch.
In September, Disney said it had provided monorail-maintenance-shop workers with written instructions for the panel that controls the track switches. And in December, three days before OSHA publicly issued its citation, Disney began requiring spotters to watch the rear end of any train backing up.
Shortly after the accident, Disney placed the three employees directly involved with the sequence of events leading up to the accident — the electrician in the maintenance shop, the manager who had been filling in as central coordinator, and the driver of the second train in the collision — on administrative leave. The electrician and the manager recently returned to work in different roles with the company, according to a person familiar with their employment status; the driver has been offered a new job within Disney but has so far opted not to return.
Disney spokeswoman Zoraya Suarez would say only that two of the employees are back at work, while the other is “not yet” back.
OSHA ultimately fined Disney $35,200, a 20 percent reduction from the $44,000 in penalties it initially proposed. Disney paid with a check dated Jan. 22.
Jason Garcia can be reached at jrgarcia@orlandosentinel.com or 407-420-5414.
Tags: monorail, osha, transportation
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46 Comments
It is unbelievable that after all these years of monorail operation at Disney, this report shows a complete disregard of guest safety. It is just luck that there are more accident.
Guests were NOT involved in this accident. The guest safety comes first and foremost at Disney.
“Guests were NOT involved in this accident.”
Only by chance. Guests could easily have been in the front cab and would have been killed along with Austin. The entire driver cab was completely crushed. And even if guests were never in danger–is this to say that Cast Members’ lives are expendable?
“The guest safety comes first and foremost at Disney.”
You base this on… what? Personal experience? Conjecture? Disney PR? Having worked for Disney, I can tell you from first-hand experience that while they claim that guest (and Cast) safety is their number one priority, in practice, it often is not. I have personally witnessed safety taking a back seat to efficiency, cost-savings, even “show” many times.
Disney has changed many things from within since the accident including high up personnel changes, procedures and not allowing guests in the front cab. The list goes on and on of changes that have and will continue to be made. I hope all you Disney haters go on the Sea World board and blast them for allowing a whale that has killed “3″ people to continue to be part of the show. Apparently the almighty dollar is more important than protecting the Sea World workers. Now to me that’s even more tragic than the Disney accident. The safety record for the monorail is one death in over 50 years of use in more than one location with millions of riders having used the system. What excuse can Sea World use to allow a three time killing machine to keep being part of the show?
Jan, the point is that NEITHER death was acceptable. Recognizing Disney’s failures and their REVERSAL of procedures that kept monorail operations relatively safe for decades does not make one a “hater”.
The only (ONE) “high-up personnel change” was, according to Disney, wholly unrelated to the monorail and bus accidents. And it’s unclear whether or not even this–regardless of their motivation–represents a real change in thinking or just playing “musical chairs”.
As to the changed procedures, why did it take them 6 MONTHS to add a spotter for trains moving in reverse? Does this sound proactive to you? And who is to say how long these “new procedures” (many of which are a RETURN to OLD PROCEDURES) will last? They reversed them once, and they may well do so again once the spotlight is off of them.
It’s time to quit giving Disney a “free pass” on safety and hold them accountable for their actions.
you hit the nail on the head justin. this thing has been used for over forty years and there are still many dangerous aspects to it that should have been figured out years ago. did you know that if it catches your only option is to burn, jump or go out an escape hatch, walk the roof and crawl down the nose of one of those things. the fire dept cant even get a ladder up to you in a huge portion of this rail system. it is either too high or over water in most cases. its a joke, its not safe, but it is PERCEIVED safe.
Disney is not a Magical place & furthermore Disney in most areas do not provide any operational material because of there go green program. They have everything done on there computers, so if say a cast member is schedualed for training it is up to the manager to determan weather or not he can afford to loose that cast memeber to the computer training or just go out & show him himself gaining an extra body in his area. Trust me 5 years I have been out there & safty is far from what matters to them even in my area, we have the worst safty record this year & we share the roads with you guests every day.
gotta say, you can’t spell anonymous, probably not one of Disney’s highest quality employees. I am intimate friends with someone that works at Disney and I know that safety is of the utmost importance to them- if just for the fact that Disney attempts to prevent lawsuits with the utmost dedication. And when I was younger, I cracked my head open at Disney (my own fault, not Disney’s), and the immediate care and attention they showed proves how important not being sued is to them- which goes hand in hand with safety.
“intimate friends with someone that works at Disney and I know that safety is of the utmost importance to them”
I have to question your reasoning here, when you’re more concerned with the the poster’s ability to spell than to perform a job which in all likelihood does not involve spelling. Further, I question how being “intimate friends” trumps the first-hand experience of many–including myself–who have witnessed how sloppy Disney can be with regard to safety. Let me put it more bluntly: one several occasions, I had supervisors tell me and others that someone had to be directly in the process of being injured–not just in immediate danger of injury–before stopping a ride. I saw critical safety systems disabled. I saw known safety issues (which had caused grave injury) go unattended (ostensibly because it was less costly to settle lawsuits than to implement engineering changes).
I also have to question your assertion that “not being sued is to them- which goes hand in hand with safety”
No, it doesn’t. That may seem like an intuitive connection, but it’s not. In many cases (see my other comments) they have taken measures to shield themselves from liability rather than avoid situations where liability exists to begin with. To be sure, they are hyper-vigilant in some areas, but there isn’t sufficient consistency to enjoy a claim that safety in one area confers safety across the board. That simply is NOT the case.
If Disney is as safe as you believe it to be, why were they not forthcoming with documents in the monorail crash? Why have they consistently lobbied against external oversight? Most people don’t know that “permanent” amusements in Florida, such as Disney, are NOT subject to state or other external inspection. California used to be the same, until the Columbia accident–and Disney’s horrific response to it, keeping authorities at bay for HOURS as they cleaned up the scene and eliminated most evidence–spurred California lawmakers to amend the legislation. California’s OSHA now has much wider powers to require reporting, allow for inspections, and investigate accidents. It’s time that Florida did the same–don’t you think the hyper-safe Disney should be on board with this?
“do not provide any operational material because of there go green program”
So that’s the excuse they’re giving out now? Disney moved away from written procedures shortly after the Columbia riverboat accident at Disneyland. Previously they has supplied minimal operating guidelines known as an “SOP Study Guide”. Even this left a huge operational “hole” as it contained only a brief outline of the procedures in the full Standard Operating Procedures manual, but there were at least some specific procedures. Following Columbia, they eliminated even the printed “Study Guides” and now limit and jealously guard any printed material AND specific procedures. They were replaced with more general “guidelines” which were communicated verbally, never in print. Reliable sources reported at the time that this was Disney’s attempt to eliminate the “paper trail”. If there was no documentation and no specific procedures, how could anyone say that a procedure was inadequate or not followed properly? This was an attempt to shield Disney from liability, not to save paper. If that were not the case, why are Cast Members strictly forbidden to even see the few paper documents that do remain? And if they were concerned with safety, why not make procedures stronger, more precise, and better-communicated?
35k ??? I think I spend that on a burger and fries at Disney…
35k? Mickey probably paid the 35k out of his Goofy piggy bank.
A burger and fries at Disney are like $7-8, same as anywhere else. Why on earth would you pay $35,000 for them?
Anyone know how to spell?
Not “Annonimous”….
Apparently not. In addition to safety, educated employees is not a concern either…
Where are the comments about the train operators using their radios to communicate with each other? The incident could have been avoided if the train operators had been watching what was happening.
I completely agree, but sometimes the obvious doesn’t seem, well, obvious, until looking back on a situation.
LOL @ Tom!
Apparently not!
I think I’d want to be known as anonymous too if my spelling was that atrocious.
Let’s see, decades of operation, millions of passengers and one death…due to an inexcusible yet documentable case of literally everything going wrong at once.
I’ll take that safety record over any other form of transportation known to humans. It’s even safer than walking.
Perspective, people. Even from you Disney-haters.
“one death…due to an inexcusible yet documentable case of literally everything going wrong at once”
Clearly you didn’t read the entire article, nor do you know the history here. Disney USED to have procedures in place (such as pilots switching cabs, so they’re driving “forward” instead of backing in) which were much more consistent with the MANUFACTURER’S RECOMMENDATIONS (two important words!). They do have an enviable record of safety OVERALL with the monorails. But that safety record is based on operational procedures that were ELIMINATED to save time and/or money. This might seem like a “perfect storm” situation to a casual observer, but the unavoidable reality is, if they’d had even ONE of the old procedures in place (switching cabs, visual on the track switch, etc) this “perfect storm” could never have happened. When you eliminate ALL failsafes, you must expect the “perfect storm” scenario to eventually play out.
You don’t have to be a “Disney hater” to recognize the realities and history of this operation. I am anything but a “hater” myself, but I am also a realist.
It was a Perfect Storm, or combination of mistakes, plus the end of one of the longest days, no doubt, everyone was very tired.
Now here’s an interesting example regarding the new status established by the Supreme Court granting the the corporation the rights (and therefore the liabilities) of an individual: this is at best negligent homicide, so, who goes to jail?
I’m sure disney will will attempt to fix these problems the way they always do… by hiring scores more of minimum wage workers and throwing “bodies” (don’t you love it how they call their workers “bodies”) at the problem. Problem is the more underpaid bodies they have working there, the less motivation these employees will have to give a damn about their job. Way to go mr. rat.
How does Disney, just because they are an entertainment company, get to operate a rail transportation system without the oversite of the National Transportation Safety Board (NTSB) and the Federal Railway Administration (FRA)? Safety is a mandate, and not optional.
(See my reply below; it didn’t follow this message as I’d intended).
35,000 dollars is like pocket change to Disney.
$35,000 is what they take in on a busy day at Disney for Parking!!!! For crying out loud what a sham process. It is clear that they are far too intent of maximizing profits and cutting costs and have very little regard for how they overwork their “cast members”.
They can’t have fines too high. If this was a small company like a gas station this would be quite a hefty fine. They create these fines without regard to company size.
Good point, maybe the fines should be a percentage of the revenue of the company committing the violation. This would make the larger companies pay attention to real issues and not just write it off as the cost of doing business.
Wonder how large a fine would be for Sea World for letting a killer whale kill it’s third victim. To me that is very tragic that they apparently put entertainment for their guests above the trainers safety. At least Disney is now trying to internally change their operation to prevent another tragedy in the monorail department. Sea World apparently just kept the status quo.
I am amazed you can’t see a difference in the two situations. One is entirely man made and the other is due to the response of a trained but unpredictable wild animal in captivity. Everyone knew that there was still a level of danger and accepted those risks in the Seaworld accident.
“They can’t have fines too high. If this was a small company like a gas station this would be quite a hefty fine”
Fines should act as a deterrent. Whatever mechanism is needed to make that possible should be in place. If not, what is the point? Clearly the fines were not a deterrent to Disney, as some of the violations they were cited for were REPEAT violations. I think the fines should escalate dramatically for repeat violations or violations such as this that result in death or serious injury. This is pocket change to Disney. That they argued for and received a lower fine, would be laughable were it not so sad and utterly pathetic. To all the “Disney apologists” out there who think Disney cares about your safety–the very fact that they wouldn’t even accept full responsibility for this meager fine, shows where their values truly lie.
It is funny, as OSHA has fines that are very clear, just go to http://www.OSHA.gov and you will see in their news section they are slamming much smaller companies with fines $100,000+ and many did not have a death involved.
The citation amount is based on a formula; the amount of employees, the history of the company in regard to safety, and the category the citation is issued. This is clearly a “High Gravity Serious Willful violation”.
Don’t take my word for it, go to OSHA’s site and see for yourself. Just search “Field Operations Manual” in the site… you will see a nice easy to read layout of the fine amounts.
The $44k fine clearly shows that OSHA did not want to fine the amount that Disney should of received by OSHA’s own standards; why?
I have lost faith in OSHA; and as for Disney, I tip my hat to them for being able to work the system. Disney is smart, OSHA is just another example of the government doing what it does best. You be the judge go look for yourself.
Does anyone not see the ridiculous and shameful detail that these people are still working for Walt Disney World?! Or am I the only person who thinks this is an outrage…
“ridiculous and shameful… that these people are still working for Walt Disney World”
Which people? The electrician who failed to throw the track switch and the supervisor who was off-site? Or the management that systematically eliminated decades of safety procedures (at one time, that electrician would have been AT THE SWITCH ITSELF) and allowed the supervisor to manage operations off-site (by many accounts, this was standard procedure). Front-line Cast Members often get blamed for failures that have much deeper roots in management. While I absolutely advocate responsibility for all parties involved, that truly does mean ALL parties, not just the ones at the END of this horrific chain of failures.
Disney’s transportation systems are considered “private” systems. They are not even held to the same standards as a “common carrier”. For example, bus operations at Disney do not have the same legal standing or standards as those in outside municipalities. Both standards and liability for Disney are much lower than they would be outside of Disney.
The more curious question here is, since Walt Disney World consists of multiple legal municipalities (it’s not in Orlando, as many believe; it’s comprised of its own two cities, Bay Lake and Lake Buena Vista, and a county-like entity, the Reedy Creek Improvement District), how does it claim being a “private” system free from “common carrier” laws? For what it’s worth, even if it were, these laws (if not state or federal, and I don’t know the scope of jurisdiction here) would fall to the cities and RCID–which are, for all intents and purposed, “owned” and controlled by Disney.
Lets all pick on Disney, they are a company just like the rest. For the Most part they are better and safer than most. WDW is 47 square miles and at any given time there is up to 15,000 cast members working and at minimum 100,000 guests throughout the resort on a slow day. Accidents can and will happen, and the fact that so few deadly incidents have occured speaks volumes.
And no Im not a Disney Fan thats never worked there, I was a manager there for 6 years, saw both sides of the magic and would say it was one of the best companies I worked for, both safety wise and staff wise. The Guests safety is the ultimate first priority even from the inside. I was a hourly cast member, of the lowest low and worked my ass off and was a manager in 8 months, So I have been on both sides of the fence employement wise
stop hating geeez,
Why is it so hard to understand that being realistic and objective about Disney’s failures and concern for a human life lost unnecessarily, is not “hating”?
You can and did speak of your experiences. Good for you. I and others spoke of ours. They are no less real, no less relevant, no less objective for being different than yours.
Have a little respect for other people’s observations, experiences and perspectives, without trying to cast doubt on their veracity by labeling as “haters”. It only brings your own motives into question.
Oh Gary,
It is very clear…you are a hater! Now just accept it and embrace it.
There’s a familiar refrain here of citing Disney’s alleged safety record. Any such claims are virtually worthless on their face, as we really don’t know how many injuries and deaths there have been–we only know of the ones that make to the media or which we personally witness. I personally know of a great many serious injuries that never made it to the media.
But, for the sake of argument, let’s say that injuries and deaths are as extraordinarily rare as you suggest. Your comment, as well as others, suggest that statistically one death is acceptable. So I ask for someone with the courage to do so, answer in all honesty, what is the “magic number” that becomes no longer acceptable? How many people should be allowed to die unnecessarily? Please pose a specific minimum number.
This is an honest question. If you truly believe that one death is statistically acceptable, you should be able to answer it, and without subverting the question by calling me a “hater”. If you can’t answer it, it’s time to re-think your position.
Uh… yeah, Mark. It’s interesting that you (think) you know you me so well when we’ve never met or spoken.
Now, do you have anything RELEVANT to say?
As a former employee and also a lover of Disney, I have to respectfully disagree that Disney takes the utmost safety precautions with its employees. I have seen with my own eyes many safety violations throughout my time there. One specific incident I recall is when “Mickey” was getting strapped to a metal pole atop a float for the day parade during a lightning storm. “Mickey” refused and was worried about “his” safety. “Mickey” was told that if he did not do it, he would be fired and there were plenty of others that would take his place.
And so many other instances where characters were passing out, heatstroke, etc. Not too much response from management there. I am truly surprised there aren’t more serious injuries.
You all seemed to miss the most important part in this story. A promising, bright, young man with a wonderful future ahead of him, lost his life. My widowed sister lost her only son. There is no amount that Disney could pay.
Gary do you need a hug or were you dropped on the head as a child.