On July 5, 2009 two monorails collided that resulted in one fatality (CBS News 1). Monorail accidents is not a common occurrence, but even if it is, the significance of this tragedy is made more dramatic by the fact that it occurred in Walt Disney World, one of the major Disney theme parks in America and around the world.
The accident tarnished the image of Walt Disney Theme Parks because it was supposed to be a safe place for children and adults. A deeper look into the accident revealed safety issues that Walt Disney World was compelled to rectify.
The Accident
The Walt Disney monorail system that can be found at Walt Disney World was considered as one of the safest transportation systems in the United States. This assertion is supported by facts. First of all, the said monorail system was in operation since 1971 (Walt Disney World’s Monorail Accidents and Mishaps 1). Secondly, it was the only fatality in more than three decades of service. However, what was not made clear in the initial discussion was that the monorail system had three accidents in the past.
The only thing highlighted was the fact that no one was fatally injured in these three accidents. But a similar accident occurred in August of 1991 when a monorail collided with a tractor as the tractor was too close to the train (Walt Disney World’s Monorail Accidents and Mishaps 1). The tractor was used to film the monorail system for a TV commercial. This incident indicated that a lack of coordination and the absence of standard operating procedures for moving monorails during closing time can spell disaster.
In this case, the driver died on the spot. He was identified as Austin Wuennenberg. Aside from the death of the driver, the monorail crash cost $24 million in damages (CBS News 1). Wuennenberg was the driver of the purple monorail and he had with him six passengers. The pink monorail had no passengers and it was driven by an operator so that it can be moved into the maintenance facility of the said monorail system.
The operator of the pink monorail survived the incident unscathed because he was backing up the monorail and therefore it was the tail-end of the vehicle that collided with the purple monorail. Since, Wuennenberg was driving the monorail forward, the front operating cab slammed into the rear operating cab of the pink monorail.
The Investigation
After the accident, the company’s Vice President of Communications Michael Griffin assured the general public that the accident was extremely rare (NBC News 1). In fact, the monorail system carried an estimated 150,000 riders on a daily basis (Zibart & Hoekstra 92). When made to comment on how long Wuennenberg had been with Disney, Griffin did not answer this particular question (NBC News 1). But the investigation of the National Transportation Safety Board (NTSB) revealed that it was not the driver who was at fault.
It is important to point out that the accident occurred at 2 o’clock in the morning. In other words the Magic Kingdom Park where the monorail was located was already closed. However, the monorails continue to operate because of the need to transport customers to the parking area or to the hotels within the said theme park. In a typical day the monorails are allowed to operate only an hour or two after closing time. Two hours after closing, the said vehicles are returned in order to perform maintenance checks.
The pink and purple monorails were in a closed loop called the Epcot Beam. At that time there were five monorails in operation and these were called: Pink; Purple; Red; Silver; and Coral. But it was the pink one that was ready to be returned via the Express Beam.
Thus, the pink monorail had to be positioned at the Spurbeam Connection and Switchbeam 9 so that it can proceed to Switchbeam 8; and from that point move forward to the Express Beam. At exactly 1:53 a.m. the monorail central coordinator gave the go signal to the operator of the pink monorail to move it past Switchbeam 9 on the Epcot Beam.
When the pink monorail was in position, the next step was to coordinate the alignment of Switchbeams 9 and 8. When the alignment procedure is completed the pink monorail can begin backing up until it reaches the Spurbeam. The operator of the pink monorail waited for further instructions. The central coordinator instructed the shop panel coordinator to complete the alignment process. The coordinator removed power from that section so that the alignment procedure can be completed.
The monorail system employed at this particular theme park uses a Power Distribution and Monitor System (PDMS) and it has a graphical prompt that helps the shop panel operator monitor the alignment process. But if the said operator did nothing, the system will time-out and the prompts will disappear (National Transportation Safety Board 5). If the shop panel operator failed to align the switch-beams there is no other indicator that will help him point out the error.
It was at this point when a series of human errors resulted in an accident.
The NTSB investigators discovered the reason why the shop panel operator failed to align the switch-beams. The report said that “Two minutes after the central coordinator requested for the alignment of the switch-beams, and a minute or so after the shop panel operator removed power, the operator of the Silver monorail informed the shop panel coordinator that he experienced a left side door alert as it traversed towards the maintenance facility” (National Transportation Safety Board 5).
The said personnel had to record into a logbook that the vehicle was already in the repair facility. A minute later, at exactly “1:56 a.m., the operator of the Red monorail informed the shop panel operator that it was about to enter the maintenance facility but received instructions to hold at a designated location” (National Transportation Safety Board 6).
Thus, when the shop panel operator returned to the switch-panel, he did not realize that he was not able to complete the alignment process. Nevertheless, he restored power to the Epcot Beam and informed the central coordinator that the spur-line has power. The central coordinator instructed the pink monorail operator to override in reverse.
The operator of the pink monorail began to back-up. But it has to be made clear that these monorails travelled in a loop. Since the switch-beams were not aligned the pink monorail simply went back to the loop but only this time it was moving backwards. The purple monorail was in its path.
The failure of the shop panel operator to align the switch-beams was easy to correct because most of the time the central coordinator was stationed at the Concourse Tower where one can find display screens, the PDMS and video monitors. These devices and equipment enabled the central coordinator to see the repositioning of switch-beams from the tower (National Transportation Safety Board 10). However, the central coordinator was not at the tower.
Shortly before the accident, “the on duty central coordinator requested for a sick leave to his supervisor the monorail manager” (National Transportation Safety Board 10). His request was granted but it took some time before the replacement can take over. Thus, in the meantime the monorail manager took over as central coordinator.
The only problem was that he was in a local restaurant and communicated to the shop panel operator and the operators of the monorail through his radio, without visual confirmation of the information that he received.
Conclusion
The investigators were able to determine that the company’s procedures did not specify the need for the coordinator to observe the video monitors and electronic displays when issuing commands with regards to the movement of vehicles. There were also no procedures to ensure that the shop panel operator completed the alignment request.
These lapses were considered in the modification of the procedures. In addition, management made it a policy that the monorail drivers must always stay in the forward facing cab. The drivers are now trained to visually confirm the correct position of the beams (National Transportation Safety Board 14). Management also made it a policy to have a spotter or observer in radio contact with the monorail driver. Finally, management limited the power of the central coordinator when it came to moving monorails.
Approval from the monorail manager is needed and this limited the power of the coordinator to issue commands with regarding the movement of the same. They also upgraded the software of their management information system in order improve their capability to monitor switch-beam operations (National Transportation Safety Board 14). Finally, management devised a new radio signal that will direct all the vehicles to stop at once without delay.
Works Cited
Walt Disney World’s Monorail Accidents and Mishaps 2011. Web.
CBS News. NTSB Releases Report on Disney Monorail Death. CBS Miami, 2011. Web.
National Transportation Safety Board. Railroad Accident Brief. Washington, D.C.: National Transportation Safety Board, 2011. Print.
NBC News. Disney World Monorail Trains Collide, Kill Driver. NBC Southern California, 2009. Web.
Zibart, Eve and David Hoekstra. Unofficial Guide to Walt Disney’s World for Grown-ups. New Jersey: John Wiley & Sons, 2009. Print.