More than two years after the fatal crash of two Walt Disney World monorail trains, the National Transportation and Safety Board (NTSB) has issued a report identifying the probable cause of the monorail collision. The NTSB has found that employee error and a flawed monorail operations policy led to the accident that caused the death of monorail pilot Austin Wuennenberg.
Monorail pink and monorail purple, which have since been repaired and reintroduced as monorail teal and monorail peach, were involved in a tragic crash in the early hours of July 5, 2009, at the close of the busy July 4 holiday.
According to the NTSB report, the main factors that contributed to the crash were the long-standing Disney World practice of allowing monorail operators to back onto a switch track without a spotter (although the monorail manufacturer’s instruction manual warns against the practice), the failure of the monorail shop panel operator to properly realign the switch beams before monorail pink was cleared to back onto a spur-beam as it went offline for the evening, and the remote location of the manager who gave the monorail operator clearance to back onto the spur-beam. The report indicates that the manager issued the clearance instructions while dining at a restaurant located off Disney property.
The NTSB report is excerpted below:
“The National Transportation Safety Board determines that the probable cause of the July 5, 2009, collision between two monorails at Walt Disney World Resort in Lake Buena Vista, Florida, was the shop panel operator’s failure to properly position switch-beam 9 and the failure of the monorail manager acting as the central coordinator to verify the position of switch-beam 9 before authorizing the reverse movement of the Pink monorail. Contributing to the accident was Walt Disney World Resort’s lack of standard operating procedures leading to an unsafe practice when reversing trains on its monorail system.”
The NTSB estimates that the crash, which resulted in the death of monorail operator Austin Wuennenburg, resulted in $24 million in damages. Wuennenburg’s mother, Christine Wuennenburg, filed suit against Disney World for reckless conduct that her attorneys contend led to the death of her son. The case was settled out of court last spring.
Disney World has made several policy changes since the monorail crash. One of the most visible of these is the cessation of the practice of allowing guests to ride in the front cab of the monorail train. Groups of up to four guests were able to ride in the front of the monorail in the past, but this practice was stopped days after the fatal crash.
In response to a request from the NTSB, Disney World has listed several additional changes to its monorail operating procedures. A partial list follows:
- The monorail manager on duty is required to remain on the premises of the Walt Disney World Resort when monorails are under his or her supervision.
- The normal operating procedure for monorail drivers who are required to switch tracks will be to switch to a forward-facing cab. (Each monorail train has a forward-facing and rear-facing cab equipped with operating controls.)
- When monorails travel in reverse from the driver’s perspective, a dedicated spotter/observer will be assigned to monitor such movement. The spotter/observer will remain in radio contact with the monorail driver or the monorail central coordinator. (This practice is recommended in the monorail manufacturer’s instruction manual.)
- Monorail drivers are required to visually confirm the correct position of switch-beams prior to switching from one beam to another.
- When monorail movement is under the direction of a monorail central coordinator, that coordinator must remain inside the designated control tower. Further, when a monorail central coordinator is directing switching operations, that coordinator must visually verify via an electronic Power Distribution and Monitoring System display and video camera monitor that the beams are in the proper switching position and that power has been applied appropriately.
- A second monorail shop panel operator must visually verify the switching process is properly performed by the primary monorail shop panel operator.
- A monorail tracking board that identifies the beams on which monorails are operating was installed for use by shop panel operators during switching procedures.
- Monorail operations has designated a new radio signal that, when called, will direct all monorails to stop immediately.
The NTSB’s report can be accessed here.