7/5/09 monorail accident - new info

[Altair]

More information has been released on the fatal monorail accident on 7/5/09.

OSHA cites Disney World for multiple safety violations following monorail investigation

Featured, Jason Garcia, News
OrlandoSentinel - Daily Disney

Federal workplace-safety investigators Wednesday charged Walt Disney World with multiple violations and proposed $44,000 in fines following a July accident on the resort’s monorail that killed a 21-year-old employee.

The U.S. Occupational Safety and Health Administration cited Disney for one “serious” safety violation that contributed to the July 5 accident, which occurred as one of Disney’s trains was driving in reverse during a botched track switch and backed into another train, killing driver Austin Wuennenberg of Kissimmee.

The agency said Disney failed to recognize the potential hazards of driving the trains in reverse, noting, for instance, that resort did not follow a 20-year-old operating guide written by the train’s manufacturer, Bombardier Inc., which recommended that, any time a train is reversing, an observer be positioned watching the opposite end. Disney on Sunday began requiring spotters when a train is backing up.

OSHA also charged Disney with three separate safety violations that were discovered during the monorail investigation but unrelated to the accident. OSHA cited the resort for exposing workers in the monorail’s maintenance shop to a fall of more than 8 feet without adequate protections and for not training monorail employees in the use of portable fire extinguishers, both of which OSHA said were repeat violations for Disney World. The agency also cited Disney after discovering a drill press in the monorail maintenance shop that did not have a guard installed.

In addition, OSHA issued a recommendation – though no safety-violation citations – following an investigation into the death of another Disney worker, Mark Priest, who died after falling during a stage performance in the Magic Kingdom in August.

OSHA said Disney should ensure employees rehearse on new stages before their first live performance. Priest, 47, was injured after stumbling into a wall during a performance of “Captain Jack’s Pirate Tutorial” in the Magic Kingdom.

“With the monorail, Disney should have put procedures in place that would have prevented the fatal crash from occurring,” OSHA Assistant Secretary David Michaels said in a prepared statement. “Employers need to take effective and ongoing corrective action to protect the health and safety of their workers. In the case of the actor’s death, OSHA feels that greater familiarity with the new stage might have changed the outcome.”

OSHA is still investigating the death of a third employee at Disney this summer: 30-year-old Anislav Varbanov, who died after breaking his neck while rehearsing for the “Indiana Jones Epic Stunt Spectacular” at Disney’s Hollywood Studios.

Disney has 15 business days to accept or challenge OSHA’s findings.

“We have just received OSHA’s findings and are in the process of reviewing them,” said Greg Hale, chief safety officer and vice president for worldwide safety and accessibility for Walt Disney Parks and Resorts. “We will address any concerns and next steps directly with OSHA. We have already made several enhancements to the operation of the monorail and will review these findings to determine whether any additional steps are necessary.”

The National Transportation Safety Board is still investigating the crash; its probe isn’t expected to be complete for about another six months.

Of the $44,000 in fines proposed by OSHA, $35,000 was for the two repeat violations. The agency recommended a $7,000 fine for the violation directly related to the monorail crash.

The crash occurred at about 2 a.m. on July 5 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 and colliding with Wuennenberg’s train.

According to people familiar with details of the events, the chain of events leading to the crash began when a worker in the maintenance bay, who was responsible for activating track switches, 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 role of the central coordinator, who directs the entire system by radio, 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 coordinator’s console where a display grad would have shown the track switch had not moved.

OSHA broadly cited Disney because it “did not furnish employment and a place of employment which were free from recognized hazards that were causing or likely to cause death or serious physical harm to employees.”

The agency outlined several ways it Disney World could address the safety violation, such as the use of a spotter as was recommended by Montreal-based Bombardier. Among other remedies it said would be acceptable: Requiring the coordinator to be at his console at all times; ensuring clear visibility is maintained on monorail windshields; providing a way to use the trains without overriding an automated anti-collision system (which must happen during track switches); and providing written instruction, training and exams for the master operator in the monorail’s maintenance shop.

In an interview, Hale said Disney World has made a series of changes since the accident, including several that were suggested in OSHA’s report.

In addition to adopting the spotter requirement Sunday, for example, Hale said Disney now requires the central coordinator to remain at his console at all times. That change was made soon after the accident. Hale said workers in the maintenance shop have also been provided with new written training materials detailing the transfer procedures.

Further, workers on the platforms at monorail stations are now trained to use handpacks that can instantly cut off power to the track in the station – and stop a train from entering – in all emergencies. Previously, he said, workers had been trained to use them in more limited situations such as when a guest wanders too close to the edge of the track.

When a train is being transferred between beams, the central coordinator must now actively verify that the appropriate switches have been realigned. When the train must pass through the switch in reverse, drivers must now drive from the rear cab.

[DizneyRox]

The whole process just sounds prone to mistakes, Human error and mechanical failures.

I'm surprised something like this hasn't happened before, especially the way Disney looks to save a buck here and there. And I can't imagine that it won't happen again unfortuantely, Maybe not as bad, but as time goes on, people will get lax again and mistakes will happen.

[GrumpyFan]

Any process is prone to mistakes if the people executing don't follow it to the tee, which it sounds like what happened. It sounds like this was an unfortunate chain of mistakes that happened here, and if any one of them had not happened, this might have been avoided. I would imagine that fatigue will also play into the final findings on this.

[CaptainSad]

I am surprised they didn't suggest video camera's to use when they back up or for any other reason. They have them on cars. I know it has helped me a lot.

[Goofy4TheWorld]

OSHA cites Disney World for multiple safety violations following monorail investigation

Among other remedies it said would be acceptable:... providing a way to use the trains without overriding an automated anti-collision system (which must happen during track switches);

I think this should have been a no-brainier years ago. It is a terrible design to make these trains unable to switch tracks unless the driver disables the collision avoidance system. Just a plain stupid design in my opinion, and had the Monorail been able to switch tracks but still have had an active collision avoidance system, Austin Wuennenberg would still be alive today depsite all of the other human errors involved.

I hope this tops the list of changes to be made.

[Zawadi]

I am surprised they didn't suggest video camera's to use when they back up or for any other reason. They have them on cars. I know it has helped me a lot.

When the train must pass through the switch in reverse, drivers must now drive from the rear cab.

Since each Monorail train is double-headed (cab at each end) then why were such manoevers done in reverse? Lazyness of the pilots to switch the control from one cab to the other then walk from one end to the other? The use of a reversing camera is not a substitute for the view from the pilot's seat.

[DizneyRox]

Having to drive from the "front" of the monorails will cost Disney money. That's probably why it's not been done until now. The Epcot switch to the lagoon loop requires a drive out past a switch and then a reverse back onto the new beam, the switch is far enough out that you will need to load the back cab with a pilot before performing the switch. An extra pilot means more people on staff which means more money in admin expenses.

It makes perfect sense that you would want actual eyes looking in the direction of travel, but the bean counters don't alway$ u$e the $ame $en$e$ as the re$t of u$.

[Joannelet]

OSHA said Disney should ensure employees rehearse on new stages before their first live performance. Priest, 47, was injured after stumbling into a wall during a performance of “Captain Jack’s Pirate Tutorial” in the Magic Kingdom.

This confused me a little bit considering he wasn't on a stage when he fell..he was on the sidewalk performing and fell. I dont' know how performing on new stages before their first live performance would have helped. Plus Marc had been there for many years doing that same act. It defintely was not his 1st performance.

The crash occurred at about 2 a.m. on July 5 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 and colliding with Wuennenberg’s train.

According to people familiar with details of the events, the chain of events leading to the crash began when a worker in the maintenance bay, who was responsible for activating track switches, 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 role of the central coordinator, who directs the entire system by radio, 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 coordinator’s console where a display grad would have shown the track switch had not moved.

This whole paragraph just doesn't sit right with me.

[Zawadi]

The Epcot switch to the lagoon loop requires a drive out past a switch and then a reverse back onto the new beam, the switch is far enough out that you will need to load the back cab with a pilot before performing the switch.
... bean counters don't alway$ u$e the $ame $en$e$ as the re$t of u$.

Good point. I overlooked the fact that you cannot walk from car to car inside the train.

It's a sign of the times that most companies appear to be run via spreadsheets for short term gain

[CaptainDisney]

Having to drive from the "front" of the monorails will cost Disney money. That's probably why it's not been done until now. The Epcot switch to the lagoon loop requires a drive out past a switch and then a reverse back onto the new beam, the switch is far enough out that you will need to load the back cab with a pilot before performing the switch. An extra pilot means more people on staff which means more money in admin expenses.

It makes perfect sense that you would want actual eyes looking in the direction of travel, but the bean counters don't alway$ u$e the $ame $en$e$ as the re$t of u$.

This policy was in place as a time saver, which of course, is also a money saver for the company (less labor hours). Nevertheless, the motivating factor in allowing trains to travel in reverse through a switch was time.

The trains can never be driven from both cabs at the same time; it's either one or the other. To go through a switch now, the driver simply "switches ends" at a station one or multiple times so as to always be driving in forward through the switch. No extra manpower is required.

The process now takes about two to three times as long as it used to, and this is a major headache for guests when it needs to be done during operating hours (standard switches to accommodate need, unscheduled maintenance, etc.)

Wanna know the other reason? IMHO, it's complacency. Couple the desire for speed with the idea of invincibility, and an unforeseeable chain of errors like this is more foreseeable than you'd think.

At any rate, I just wanted to point out that not EVERY decision made at this company is motivated by money and money alone. I'm not saying this is a good thing. A young person lost his life because of this horrible prioritization. It is the worst kind of tragedy imaginable. I just don't think the almighty dollar is to blame...

[joanna71985]

This confused me a little bit considering he wasn't on a stage when he fell..he was on the sidewalk performing and fell. I dont' know how performing on new stages before their first live performance would have helped. Plus Marc had been there for many years doing that same act. It defintely was not his 1st performance.

From what I've heard, during the show he was on the stage, slipped, and hit his head/neck on the wall right by the stage. That's why Disney went back to performing on the ground near PotC after the accident.

[Cinderelley]

The whole process just sounds prone to mistakes, Human error and mechanical failures.

I'm surprised something like this hasn't happened before, especially the way Disney looks to save a buck here and there. And I can't imagine that it won't happen again unfortuantely, Maybe not as bad, but as time goes on, people will get lax again and mistakes will happen.

I agree. It will eventually happen again.

[CaptainSad]

Since each Monorail train is double-headed (cab at each end) then why were such manoevers done in reverse? Lazyness of the pilots to switch the control from one cab to the other then walk from one end to the other? The use of a reversing camera is not a substitute for the view from the pilot's seat.

How can you say a camera is not like being in the pilots seat. I bet you anything that if the Monorail had camera hook-ups front and back and a monitor in with the driver backing up, we would not be talking about this right now. Of course if everybody was doing their job that night, we wouldn't be talking about it either.

[crltkcagle]

I am surprised they didn't suggest video camera's to use when they back up or for any other reason. They have them on cars. I know it has helped me a lot.

Thats a really good idea!

[handmaidenofprincesses]

I've got to admit, reading through all of this makes me slightly glad I didn't get my first choice of transportation in the DCP after all...

[Altair]

From what I've heard, during the show he was on the stage, slipped, and hit his head/neck on the wall right by the stage. That's why Disney went back to performing on the ground near PotC after the accident.

They are using the stage now.

[brownie]

It sounds like operational failures related to management and supervision. People need to be held accountable for following policies and procedures. You can have the greatest policies and procedures on paper, but if they aren't accompanied by action you might as well burn the paper.