Originally Posted By sjhym33 The Orlando Sentinel is reporting that the maitenance person who was supposed to have actived the spur line switch thought he had moved the switch before radioing the Monorail Coordinator who then cleared Monorail Pink in reverse though the switch hadn't moved. The NTSB found no mechanical problem with the switch. Other information includes that the manager in charge was at Perkins having dinner when the Monorail Coordinator radioed and said they were ill and wanted to leave. The manager ok'd the coordinator to leave and another person was put in charge of the system. The train transfer happened before the second person took over and the manager radioed instructions from the restuarant. The manager was permitted to be off property for dinner since he or she was working till 5 am and there was no other food locations open at the time. The article is an interesting read: <a href="http://www.orlandosentinel.com/orl-disney-monorail-crash-071509,0,5258965.story" target="_blank">http://www.orlandosentinel.com...65.story</a>
Originally Posted By sjhym33 I need to make a correction. The maitenance person radiod the coordinator but spoke to the manager who was running the system at the time.
Originally Posted By disney pete it's all bad i think a few heads will roll when it all comes out in the wash,i hear the drivers mum is to sue Disney but money is no substitute for a son,my heart goes out to this family.
Originally Posted By ORD84 ^^I second that the money is no substitue for a son, and some heads will roll for this one that for sure... I wonder why the Manager was permitted to be off of property and allow this switch to happen, you would think that they could simply radio the other trains to hold until the new coordinator had taken over, or that they wouldn't permit the coordinator to leave without first seeing their relief..This whole situation just boggles the mind.
Originally Posted By Anatole69 The whole thing sounds like a cluster f***. It seems like a series of things went wrong, not just one. Not sure what blame Disney has in this. - Anatole
Originally Posted By Spirit of 74 ^^What blame? How about all of it?! This was a Disney transportation system maintained, managed, operated and run by CMs trained and following Disney procedures. ... It's all on Disney. This was a systematic failure years in the making due to Disney deciding that safety didn't always have to be No. 1 IF they could get away with it ... and they did ... for many years ... until early in the morning on July 5th. I hope they fix their mistakes and go back to doing things the old way ... the more costlier in the short term ... the Disney Way ... my fear is they'll just pay everyone off and go right back to what they've been doing. I really want to be wrong.
Originally Posted By trekkeruss <<I wonder why the Manager was permitted to be off of property and allow this switch to happen, you would think that they could simply radio the other trains to hold until the new coordinator had taken over>> If I recall the original story, there were a few guests still on one train that they were trying to get to their destination. This put an element of urgency in the movement of trains, which likely contributed to the events that culminated with the accident.
Originally Posted By Sport Goofy << This was a systematic failure years in the making due to Disney deciding that safety didn't always have to be No. 1 >> And I suppose you are an expert in the field of safety management and have vast experience in working in a industrial environment where hazards like this exist? No. Save us all the hyperbole. I get up and go to work in an industrial environment for a living. Safety is always #1. But it's impossible to avoid accidents. There is no safety program on earth that eliminates all risk or accidents. There is no safety program on earth that can ensure there will be no death in the workplace or damage to equipment.
Originally Posted By Sport Goofy <<I wonder why the Manager was permitted to be off of property and allow this switch to happen, you would think that they could simply radio the other trains to hold until the new coordinator had taken over>> << If I recall the original story, there were a few guests still on one train that they were trying to get to their destination. This put an element of urgency in the movement of trains, which likely contributed to the events that culminated with the accident. >> I don't think there was any sense of urgency, but probably too much leniency on the part of the supervisor for the monorails. It was certainly in his power to halt monorail operations until the new coordinator showed up on the platform, but he didn't want to be the "bad guy" to make that call. I see it every day in my work organization. Supervisors allow subordinates to leave their assigned duties for any number of reasons without requiring a replacement or reporting the personnel shortfall. It doesn't matter if it is a vital position or one on the periphery, I've had supervisors shrug their shoulderns when I have shown up to ask why certain individuals weren't present to perform their job. It really takes dogged oversight to keep people from disappearing from the job. I'm sure this wasn't the first time this happened, or the first time this supervisor allowed a gap to occur. I've found that making sure the right people are working at the right positions at the right time in accordance with job assignments to be the absolute hardest thing to manage in my work. You have to watch things like a hawk 24 hours a day to ensure people are where they are supposed to be, and you have to be willing to be the "bad guy" from time to time to bring everything to a halt when someone isn't present in their job assignment.
Originally Posted By trekkeruss <<I don't think there was any sense of urgency, but probably too much leniency on the part of the supervisor for the monorails.>> Perhaps urgency is too strong a word, but if the guests had not been on the train, there would have been less of a reason for someone to have to be the "bad guy" and hold up operations.
Originally Posted By Goofyernmost I don't claim to know the whole story, as some of you seem to imply, but my life has taught me that unless there is a way to eliminate human error there will always be problems. Even electronics fail from time to time. Whether or not the "supervisor" was having a quick bite to eat or standing next to it, there is still a real possibility that this might have happened. Supervisors are human too. That said, the one thing that does bother me is that the safety safeguards can be so easily overridden. That should be set up so only the supervisor or above can actually deactivate them. Would that have prevented the wreck from happening? Well, my inability to be clairvoyant or infallible correct all the time, makes it impossible for me to say. Might have helped though. Then if the supervisor was away from his/her post (bathroom breaks are required on occasion as well) then the safeguards would not have been overridden and perhaps there would have been a completely different outcome. Who knows?
Originally Posted By Sport Goofy << Perhaps urgency is too strong a word, but if the guests had not been on the train, there would have been less of a reason for someone to have to be the "bad guy" and hold up operations. >> If there were any urgency at all, I think it might have been to get the monorails back to the garage so that the platform workers and drivers could clock out of their shift and go home. I find that the urgency to go home drives a lot of decisions made in the workplace.
Originally Posted By sjhym33 The problem was complacency. It was a movement that was done a couple of times a day, everyday. Everyone assumed that everyone was doing their job. Tha manager didn't think he needed to be at Base to complete the switch because the driver of Pink had left Concourse and was holding at the designated hold point to be moved to the MK line. Maitenance called in and said the switch was moved and the manager cleared Monorail Pink to move. Since the manager couldn't see the switch to see if it had in fact been moved either from either the restaurant or even Base he accepted the fact that the switch had been moved because maitenance told him it was so. Even if a coordinator had been at Base he was required to be in the console OR to watch Pink back into the station. This problem was caused by Disney. As I said before...a coordinator used to be tied to the console to watch the system. That was their job. When Disney decided that the coordinator could coordinate the system AND load trains or walk the platform they put this in motion. There should be one person whose job is to exclusively watch the system. That was not the case anymore. I expect that it is now or at least during train switches.
Originally Posted By sjhym33 Shouldnt type without coffee. Should read: Even if a coordinator had been at Base he was NOT required to be in the console...
Originally Posted By Sport Goofy << When Disney decided that the coordinator could coordinate the system AND load trains or walk the platform they put this in motion. >> Good point. I don't know who "Disney" is that decided this, though. Was this decided at a high up executive leadership level? Within the monorail organization? Or among the cast members working the rails who modified a way of doing the job? Was there ever a written procedure defining the role of the coordinator? Did that procedure change, or was it an unwritten procedure that evolved over time? Did the procedure change all at once when someone decided to change it, or did it change as practices in the monorail station changed over time?
Originally Posted By sjhym33 I believe that it was an SOP change. In the old days that decision would be made by the monorail supervision with approval from their upper management. Today there is a department that handles all SOP changes with input from various depts including monorail managers and upper managers. It used to be a bottom up change and now it is a top down change. The whole coordinator thing is an odd position. Years ago the system was run by a group of people called Leads. They were in charge of the system and the people working in the system. They had some authority but since they weren't managers they had no disiplinary capabilities. A Lead made $1.00 more an hour than the highest paid CM in the area. At some point the union stepped in and filed a grievance that basically said that Leads were a group that was in noncompliance with the union agreement since you can not have hourly CM's managing hourly CM's. Disney disolved the Lead program and promoted most Leads into manager. This swelled the management ranks in a dept from 6-8 managers to in some cases 30 managers. For instance...a Lead group of 4 people were in charge of a group of attractions like Wedway/Starjets/COP. When the Lead group was disolved there were now 3 managers for the same group of attractions. As you can imagine a year or so later someone in accounting looked at this and said you have got to be kidding. Not only were people making more money with the promotion but also more benefits. So Disney then turned around and consoledated departments and either demoted or let go tons of managers. What happened next was you had an area (like Tomorrowland) that now had 10 managers for all attractions and they were in charge of everything. They soon realized that it was impossible to keep tabs of all 100-200 CM's working at any given time in an area. This is when CDS (Cast Deployment System) was implemented which is a computer system that tells CM's what position to work, breaks, bump outs, etc. CM's hated it (they still do in many cases). That helped some but not completely. To have someone physically at a location Disney negotiated a new role called a Coordinator. Officially their only role was to make sure the operation ran smoothly. Any personnel issues or maitenance issues were to be deferred to a manager. Over time Coordinators took on more and more duties and basically Disney has returned to the old Lead system with a new name...though by contract a manager is the only person who can deal with personnel and maitenance issues. I have seen many Coordinators make decisions well outside their job description and managers are ok with that since it relieves them of having to be there for every decision. Over the years the Coordinator role allows managers to spend more time in the office and less time in the area since they have tons of paperwork to do. Though there may be 4 managers on duty in an area it is not uncommon for only one of them to be in the area at any given time. Under the contract a Coordinator makes $1.00 more an hour than they would if they were just a regular CM. So you may have a Coordinator making $8.75 an hour in charge of CM's making upward of $12-$15 and hour.
Originally Posted By Sport Goofy << I believe that it was an SOP change. >> I don't have any idea. But on other boards, former monorail cast members going back to the late 70s and early 80s recollect different things on what was "SOP." Some say the coordinator should have been at the console. Others say that there was never a hard and fast rule about it. There are monorail pilots from 1982 who remember backing through the EPCOT to Resort switch in the first year the line was opened, and others who say that backing through a switch was strictly forbidden. As an outsider, it's hard to decipher what is real and what is made up. It would be interesting to see what procedures are actually in writing and what procedures are just part of cast member lore and tradition. I'm sure the NTSB has copies of all written procedures and will shed some light on this in their final analysis of the accident.
Originally Posted By sjhym33 As an insider and former Lead in monorails I can say that until 1984 when I moved to a different dept we were supposed to be at the Console at all times especially during switches. Monorail base had the ability to shut power down to the entire system with a push of a button. There were some occasions that you left the console (guest issues, discussion with a CM or on a rare occasion to close doors to get a monorail out) but for the most part you were in the console. We would have NEVER back a train into a station during a switch. On the EPCOT beam the driver would pull into the TTC station, change ends, back out of the station to the whole point, when the switch was moved(which the driver could see) and maitenance gave clearance they would pull onto the MK beam going forward. Once in the TTC station they would change ends again and be on their way again. That was SOP. I know. I was a trainer and a Lead.
Originally Posted By SuperDry <<< Even if a coordinator had been at Base he was NOT required to be in the console... >>> That's the point I keep trying to make. Even though it sounds bad and makes for a great soundbite to say that the manager/coordinator/PersonInCharge was at Dennys or Perkins or wherever he was, that really has no bearing on the accident if the current procedure was that he not be at the control console and not have to visually watch the train back up. It may have been more likely that he would have noticed had he been on the platform, but by no means assured or even likely.
Originally Posted By Spirit of 74 ^^All I know is that post-accident, I have never seen more CMs (including obvious management 'suits') manning the stations and that it looked like the 70s-90s in that I never saw a control console that didn't have at least 1-2 CMs actively at it. It sure 'looked' like the old days ... and far from what has/had become SOP over the past decade or so. Ultimately, a fish rots from the head down ... and there's been an awful smell coming from TDO for years now. Maybe this tragedy (and the bus accident ... and -- more importantly to Disney -- the bad PR and lawsuits) may just encourage people to go back to the old ways. They did after all ... work.
