At approximately 2.00 am 5th July, 2009, an accident occurred at the Walt Disney Resort. It involved a collision of two monorails that were moving on the Epcot beam, next to the Concourse station in Lake Buena Vista, Florida. The accident took place after one of the monorails (the Pink monorail) reversed via an improperly aligned-beam, in effect hitting the Purple monorail (National Transportation Safety Board 2). Although the six passengers did not sustain any injuries, the operator was seriously injured and he later died.
On the other hand, the Purple monorail only had the operator as the sole occupant. He was rushed to hospital and upon examination, was discharged (National Transportation Safety Board 2). At the time of the accident the weather was very clear. The damage as a result of the monorail accident was estimated to have amounted to $ 24 million.
Cause of the accident
The federal investigators who were commissioned to initiate a probe into the probable cause of the monorail accident reported that lack of sufficient safety protocols may have contributed to the occurrence of the two monorails in Walt Disney Resort. These investigations were conducted for almost two-and-a-half years. The National Transportation Safety Board (NTSB) released a 14-page report on the accident, in which a couple of employee errors were highlighted as the main causes of the accident (National Transportation Safety Board para. 1).
This report appears to somewhat contradict with the investigations conducted by the federal government investigators, who noted faulted the lack of standard operating schedules at the Walt Disney World Resort, arguing that this could have played a significant role in establishing an unsafe environment, in effect causing the accident when the train reversed and hit the other one.
How the monorail system in Disney World works
There are two areas set aside to facilitate servicing of the monorails in Disney World. The first designated area is referred to as the Epcot, while the second designated area is referred to as Magic Kingdom Park. On the one hand, the Magic Kingdom Park service area is made up of two monorail beams.
The two monorail beams run parallel, effectively forming a complete loop (National Transportation Safety Board 4). The Express beam is on the outside, while the Lagoon/Resort beam is on the inside. On the other hand, the Epcot service area is made up of the Epcot beam. The Epcot beam has also formed a complete loop.
When the accident took place, there were a total of five monorails operating at the Walt Disney Resort and they were identified the Purple, Pink, Red, Coral, and Silver colors (National Transportation Safety Board 6). A spur beam acts as a link between the two service areas. Switch beam 9 lies at one end of the spur-beam, while switch-beam 8 lies at the other end. If you want a monorail to move from one beam to another, all you have to do is reposition them accordingly.
The closure of the Magic Kingdom Park does prevent the monorails from undertaking their duties as there is a time allowance allocated to facilitate this. By and large, the Express beam monorails may operate for about an hour once the park has closed. After 3 hours following the closing of the park, the monorails on the Resort beam can no longer work, and this have to be returned for nightly maintenance at the mechanical facility via the Express beam.
When this particular accident took place, three monorails were operating on the Epcot beam. They include the Purple, Pink, and Coral monorails. Because all the passengers had already disembarked from the Pink monorail, it was directed to the Express beam first so that it could be serviced overnight.
It is important to note that the Pink monorail could have only accessed the mechanical facility via the Express beam. At approximately, 1.53 am., the central coordinator of the monorail issues instructions to the Pink monorail operator to enable him get onto the Express beam and back to the mechanical facility. However, the Pink monorail did not stop until it had moved beyond the switch-beam 9.
That is when the operator communicated with the central operator and told him that switch-beam 9 had been cleared. This prompted the central coordinator to get in touch with the shop panel operator so that he could line “switch-beams 8 and 9 to the spur-line with power” (National Transportation Safety board, 2009). Power was then switched from the Epcot beam to facilitate the switch-beam realignment.
Upon conducting further investigations, the National Transportation Safety Board concluded that the shop panel operator may have failed to position switch-beam 9 properly, and this could have led to the collision. The board also took issues with the monorail manager who is supposed to play the role of a central coordinator in determining the position of switch-beam 9 prior to authorizing the driver of the Pink monorail to reverse.
The investigations further revealed that once the operators had switched off power to the beam, there was no prompt initiation of the switch-beam realignment. The shop panel operator received a call from the operator of the Silver monorail at 1:55 Am., so that he could be guided while entering the mechanical facility. At 1:56 Am., the shop panel operator received another call from the Red monorail operator who also wished to enter the facility but he was requested to first hold at a given location (Orlando Business Journal para. 4).
During the interrogation, the shop panel operator told the investigator that the reason why he switched on power to the Epcot beam was because according to his understanding, there was proper alignment of the switch-beam.
At 1:57 Am., the Pink monorail operator was given the clearance to reverse by the central coordinator, having been informed by the shop panel operator that “Switch-beams 8 and 9 are on the spur-line with power” (National Transportation Safety Board 6).
When the operator of the Pink monorail started to reverse, switch-beams 9 and 8 were yet to be repositioned and as a result, he ended up colliding on the Epcot beam. It is important to note that the Pink monorail was previously travelling on the Epcot beam, and the Purple monorail was also following the same beam.
Verdict of the investigators
The National Transportation Safety Board has also taken issue with Walt Disney over the accidents on three fronts. According to the investigations, employees from the World Resort are not obliged to observe specific operating guide. This means that monorail drivers are not obliged to shift to the back cab first before they can drive in reverse. This way, they are in a position to drive the trains in a ‘forward-facing’ position (National Transportation Safety Board 8).
Moreover, the investigator noted that the management at Disney World had not implemented a rule that would ensure that the central coordinator did not leave the central tower. At the tower, there is an emergency shutdown switch and a grid that shows the alignment of all the monorail beams and as such, the central operator would have been in a position to prevent the collision had he been at the control tower when the collision occurred.
Finally, there were no procedures at the resort that demanded monorail shop operators to certify that indeed the beam had already been aligned once they had activated the switch command (National Transportation Safety Board 9).
Although there are video monitors at the shop that enables the shop operators to view the positions of the switch beams, nonetheless, the shop operators informed the investigators that they mainly used the monitors when they needed to determine if there was any train on the beam prior to activating the switch, as opposed to certifying if there had been a realignment of the track once the command had been entered.
Investigations into the collision of two monorails at Walt Disney Resort confirmed that the accident took place due to the failure by poor operating procedures by the personnel in-charge of the monorail maintenance shop that is charged with the responsibility of controlling the switches at the track system.
Also, investigations revealed that at the time of the accident, the central operator had left the central tower and as such, he could not have been able to manage the accident promptly. From the control tower, the monorail systems coordinator would have been in a better position to detect that there was an improper alignment of the track system, and this could have prevented the collision.
National Transportation Safety Board.2009. Railroad Accident Brief. 2009. Web. 31 March 2012 http://www.ntsb.gov/doclib/reports/2011/RAB1107.pdf p. 1-14
National Transportation Safety Board. 2011. NTSB releases final report on 2009 monorail collision at Walt Disney World. 2011. Web http://www.ntsb.gov/news/2011/111031_3.html
Orlando Business Journal. 2011. NTSB issues report on Disney monorail crash. Web. 2011. http://www.bizjournals.com/orlando/morning_call/2011/11/ntsb-issues-report-on-disney-monorail.html