Report: Disney Monorail Crash Operator's Fault, Led to Changes
By JARED SHELLY, senior editor/web editor of Risk & Insurance®
Fault for a fatal monorail crash at Walt Disney World Resort lies in the hands of the shop panel operator, the monorail manager and the resort's "lack of standard operating procedures leading to an unsafe practice when reversing trains on its monorail system," according to a new report by the National Transportation Safety Board.
The July 5, 2009 crash at the Lake Buena Vista, Fla. park killed Austin Wuennenberg, a 21-year-old monorail operator and caused $24 million in damages. Wuennenberg had been operating the Pink monorail car (one of five at the park) and drove the car onto what he had thought was a safe and clear track after talking with the monorail operator. The car, however, was on a different track and collided with the Purple monorail car, leading to the fatal injury.
The situation was complicated due to the monorail's central coordinator becoming ill and his replacement not being able to work from an enclosure at the concourse station, as was normally the case.
"When the monorail manager issued these instructions, he was not in the Concourse Tower, but was instead at a local restaurant," according to the report. "He was not in the tower and could not use the display screens to monitor or confirm any of the movements."
Inspectors from the Occupational Safety and Health Administration visited the Walt Disney World Resort 27 times between 2000 and July 2009 -- although none of the visits involved the monorail operations, the report said. After the accident, OSHA fined Disney an undisclosed amount.
Since the accident, however, Disney made some serious strides toward safety, according to the NTSB. Now, monorail drivers must be in the forward facing cab when switching from one track to another. When monorails travel in reverse from the driver's perspective, a dedicated spotter/observer is assigned to monitor the movement and is in radio contact with the driver. Also, the monorail central coordinator must remain inside the designated control tower when running the operation.
Disney also instituted a series of visual checks by the driver, monorail central coordinator and monorail shop panel operators that are now required to be conducted before trains can switch tracks. The company also installed video cameras so employees can further monitor the process.
The company has also trained its monorail operations employees on the best ways to deal with condensation on monorail windshields, including rinsing the windshields and the use of the defogger on the climate control system, although that wasn't an issue during the 2009 accident.
December 6, 2011
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