Originally Posted By sharpc <<There is pretty much no way to NOT know which track you are on. And plenty of room to stop after realizing you are still on the EPCOT beam and another Monorail might be behind you. This is so very sad.>> I think we are still not taking into effect the length of the train.. By the time the front car goes over the switch, there will only be a matter of seconds before the train goes through the station at 15 m.p.h. Seconds are not very long when you have to assess the situation, plan an action, and execute the plan. I'm not trying to find an excuse for the driver, merely point out the difficulty of what many people say is "easy" during night conditions after an extended shift.
Originally Posted By ImaginingDisney001 <<There is pretty much no way to NOT know which track you are on. And plenty of room to stop after realizing you are still on the EPCOT beam and another Monorail might be behind you. This is so very sad.>> >>>>>I think we are still not taking into effect the length of the train.. By the time the front car goes over the switch, there will only be a matter of seconds before the train goes through the station at 15 m.p.h. Seconds are not very long when you have to assess the situation, plan an action, and execute the plan.<<<<<<< After perusing the Map of the track switch in question, I can only agree with the above. The legnth of the train, I am guessing 70 feet long and the driver is in the very last car, blindly moving the monorail in reverse. How can this have been more obvious??? WELL we discussed putting the road bumps on the track switch as indication that the MonoRail was moving on the proper track. The MonoRail would vibrate when going over it but when the guests were aboard, they would never hear it. Another thing might be to put reflective tape on the track switch side so the lights from the monorail would reflect it back, indicating, even in the dark, that the MonoRail was not on the Switch and its current destination was incorrect. Again, this would depend on the Pilot paying attention to see the reflection or notice that the vibration did not occure when it should have. All this speculation is giving us an idea of what might have happened, but the only ones who know are the people involved. We have developed a thought of what might help in the future, but the system, either human or mechanical, or both, caused the problem. Frankly, It seems to me that the operation is flawed, has been for a while and it was a matter of time. Unfortunately, July 4, Actually July 5th, was when the flaw showed itself. Disney is relying on the MAPO system, and it has served them well for NORMAL OPERATIONS. The accident was during switching, which is done through humans and procedures. Something did not come through properly. EIther communication, mechanical movement of the track switch or both. The manager eating off property at the time really throws a wrench inthe investigation and I am guessing, hes gone from Disney. However the Maintenance man is involved, he may be gone too. If they can prove the Pilot on the rear ward moving MonoRail had a fault, he is gone too. I have done accident investigations in the past and they are comprehensive, take a lot of time and they expenct exact answers for what happened down to the second. The MonoRail incedent is no different, only more complicated because of so many people involved in it. You and I will not guess the exact cause, we can only come close to an estimation of what happened, and we may still be wrong. But we can offer thoughts of what may have prevented it. One last thought. It was said the MonoRails used to drive FORWARD off the switch to the Exp track. This indicates someone had a brilliant idea to change the procedure for taking an Epcot Center MonoRail off line and sending to the Garage. I am reasonably certain, that they will investigate WHY the change was made because it caused such a blind spot for the MonoRail Driver to get off of the Epcot Center Loop and onto the Express Loop. If they did it for a wrong reason, Disney may have to answer for that since it may have been part of the cause of the incedent. I am glad I am not taking part in THIS investigation and it will be a while before all the information is taken in and the cause decided. Be glad you are not having to decide this cause. ID
Originally Posted By sharpc <<Each cab is 40 ft 5 in (12.3 m) long and each intermediate car is 28 ft 2 in (8.6 m) long. The 6 car trains in the Walt Disney World Monorail System total 203 ft 6 in (62 m) in length.[2]>> <a href="http://www.monorails.org/tMspages/TPDisro.html" target="_blank">http://www.monorails.org/tMspa...sro.html</a> The monorails are nearly 3 times larger than thought. Given that the length of the spur line into the station isn't tons larger than the train (does anyone have an exact length?), there is still only a small amount of time for the pilot to have reacted, because he will not feel the change until his car reaches the spur. It would also be nice to know what kind of visibility he had on a dark night like the one in question. Also, as many have pointed out, the monorails have to go in reverse at some point no matter what. Yes, there has been a change in SOP at some point int he past, but it does not prevent the fact that the monorail will have to drive blind at some point.
Originally Posted By ImaginingDisney001 >>>> Yes, there has been a change in SOP at some point int he past, but it does not prevent the fact that the monorail will have to drive blind at some point. <<<< I am in agreement with you. Where the problem comes in, is someone at DISNEY decided to change the direction of the MonoRail at the Epcot Center Loop. Doing this and do to the vacinity the spur has to the Epcot Center Station, they had a responsibility to add a system, camera, alarm something to make up for the now dangerously little saftey factor for the Pilot to try to realize he was going down the wrong track. The more we look at this, the worse it is looking. The train had forward motion on the spur, the pilot would easily see if the MonoRail was on the siding to the Express track. After the change, and due to the length of the MonoRail, There was almost no safety factor that the Pilot could apply. It seems, by the time the Pilot can determine he is in trouble, there is no room for stopping. This accident was designed by Disney, inadvertant as it may be, but Disney caused it.. Looking at the Satelite photo, it becomes more and more obvious how dangerous this has become. It came down to relying on the procedural system to get the trains to other tracks safely. This night, that broke down. This is really getting ugly. ID
Originally Posted By SuperDry <<< I think we are still not taking into effect the length of the train.. >>> I've been taking it into account the entire time. <<< After the change, and due to the length of the MonoRail, There was almost no safety factor that the Pilot could apply. It seems, by the time the Pilot can determine he is in trouble, there is no room for stopping. >>> Not true. Look at the Google satellite view. You can see two monorails in front of the Poly in the same shot in order to see how long they are. There's just over 5 train lengths between the switch in question and the EPCOT loop station at TTC. So, once the front cab of the train crosses the switch, there's still four train lengths of empty beam between the back of the train and the entrance to the station. Even if it takes another train length of beam to realize there's a problem, I would think that three train lengths is still plenty of time to stop a train moving at 15mph. <<< By the time the front car goes over the switch, there will only be a matter of seconds before the train goes through the station at 15 m.p.h. Seconds are not very long when you have to assess the situation, plan an action, and execute the plan. >>> I've already said that I think there's plenty of time to stop the train. But to address your comment of "Seconds are not very long when you have to assess the situation, plan an action, and execute the plan", what I'd say to that is that the driver should never in this case be put in a situation where they have to do this. This isn't a sudden, unforeseeable situation like a tree trunk falling onto the track just in front of the train. The whole chain of events in fact is very foreseeable: trains are moved off the EPCOT loop and onto the spur in the normal course of business, and in doing so, MAPO is disabled. As we now know, a single error can create the situation that was created: the maintenance person at the barn incorrectly reporting that the switch had been moved into the proper position. There should not be a procedure such as this where a single human error, undetected, can cause such an accident. It seems clear to me that in this all-too-foreseeable situation, there should have been a procedure in place to detect the train being on the wrong beam as a check against a single-human error of the switch not being switched. It's a rather basic concept: make sure the train is on the right track. <<< I'm not trying to find an excuse for the driver, merely point out the difficulty of what many people say is "easy" during night conditions after an extended shift. >>> Again, were these unforeseeable conditions? Are trains not normally switched off the EPCOT beam during night conditions? Are they not normally switched off at the end of the day? Are extended shifts are driver/maintenance personnel fatigue not normally at their worst at the end of the day? It's precisely because of these foreseeable, routine conditions that a specific, affirmative check to verify that the monorail was on the right beam should have been part of the procedure. I do agree that if such a check is not part of the procedure, then that moves attention toward the procedure and away from the driver somewhat. <<< Doing this and do to the vacinity the spur has to the Epcot Center Station, they had a responsibility to add a system, camera, alarm something to make up for the now dangerously little saftey factor for the Pilot to try to realize he was going down the wrong track. >>> There's plenty of room to safely detect an improper switch. What was lacking was a procedure to take advantage of this time to actually make a check. <<< we can't really be sure how well he could tell the differences between the two tracks when driving. >>> <<< From what I've read on other threads, the feel of the tracks in this one location is very similar. It would be hard to tell just by feel alone whether he was on his old track or moving on to a new track. Plus, he was at the farthest point away from the switch, meaning that it would all feel the same to him right up to the point of the cab actually moving over to the new track. >>> ... all the more reason to have a specific, affirmative step in the beam switch procedure, above and beyond general situational awareness. That is, there should be a specific step that is taken each time this switch occurs that allows the pilot to verify he's on the correct beam while they still have plenty of time to stop. And it has to be something specific, not just general situational awareness of happening to notice the angle of the parking lot or the Contemporary out the window. Regarding stopping distances, I've already said above that I think there's plenty available. But in the event that there's not, then the solution is to have that part of the procedure: the train is only permitted to creep along in reverse until the affirmative check is done that it's past the switch on the correct beam.
Originally Posted By TMICHAEL >>>Not true. Look at the Google satellite view. You can see two monorails in front of the Poly in the same shot in order to see how long they are. There's just over 5 train lengths between the switch in question and the EPCOT loop station at TTC. So, once the front cab of the train crosses the switch, there's still four train lengths of empty beam between the back of the train and the entrance to the station. Even if it takes another train length of beam to realize there's a problem, I would think that three train lengths is still plenty of time to stop a train moving at 15mph<<< That is what I was thinking, SuperDry. Thanks. Pretty much as soon as the front cabin passed over the switch point you would realize the rail didn't switch like it should have and stopped the Monorail then hopped on the radio to find out the status and what went wrong before proceeding further. The rails are close enough together at that point that you would see the error unless there was a very dense fog or other blinding weather. Definitely blame to go around to more than just Monorail Pinks' pilot and I truly feel sorry for all involved.
Originally Posted By Kennesaw Tom <<There should not be a procedure such as this where a single human error, undetected, can cause such an accident. It seems clear to me that in this all-too-foreseeable situation, there should have been a procedure in place to detect the train being on the wrong beam as a check against a single-human error of the switch not being switched. It's a rather basic concept: make sure the train is on the right track.>> There is such a procedure, its the person on duty at Central Control. When a monorail pilot is backing up a monorail blind it places an additional burden for the person on duty at Central Control to be the "eyes and ( mouse ) ears" of the operation. The person at Central Control has the ability to press the kill switch to shut down power to the monorails in question if a collision was going to happen. Oh course we know that there was no one on duty at that time in Central Control. You also want to keep in mind that the investigation already reported there were no mechanical problems present. So this was all human error.
Originally Posted By Kennesaw Tom I just thought of a better way to say this. The person at Central Control is the "if all else fails" perosn. So if the switchman didn't move the beam and gave the proceed order to monorail pink, if the pilot of monorail pink wasn't watching carefully where he was going, then the person at Central Control is there to press the button to shut down power.
Originally Posted By Indigo So far we've all be talking about the three key immediate players. Driver, Monorail Central Manager, and Monorail Shop operator. Based on what we know right now, which admittedly is part conjecture, I think responsibility for this incident needs to move up the management chain. Who is the top level manager for operations at the resort and who on their team is responsible for knowing operational safety procedures. Those two should be held responsible for not keeping proper procedures for safety in the Monorail team, procedures that go above and beyond the need for guest (and cast member safety). Someone wasn't running a tight enough ship.
Originally Posted By SuperDry <<< The person at Central Control is the "if all else fails" perosn. So if the switchman didn't move the beam and gave the proceed order to monorail pink, if the pilot of monorail pink wasn't watching carefully where he was going, then the person at Central Control is there to press the button to shut down power. >>> But from what we've had described here by people with experience as monorail pilots, there was no specific requirement placed on Central during this beam-switch procedure, other than that they give radio approval to proceed once the beam switch confirmation is given by the barn. Since the switch position is not directly visible from the station, Central can't possibly directly observe the switch before giving approval, so there's no check there. I think it's been mentioned that there may be an indicator light on the control board in the booth, but that brings up two issues: 1) what if the indicator is incorrect?, and 2) it's been reported that Control isn't always in the booth, and may be anywhere in the station or nearby performing their duties when they give the radio OK to start backing up. So, the fact that Central *could* notice the indicator light should they happen to be in the booth, or if outside the booth *might* notice the train backing up on the wrong beam and hit the kill switch, this isn't the specific, affirmative safety step I've been talking about. The only specific, affirmative safety step in the process that I can see is that Central confirms to the pilot that they heard Maintenance say the track was switched. As far as has been reported, this specific step by Central was performed correctly in this case, even though they were at Denny's at the time. It's certainly true that Central would have been more likely to notice the problem and hit the kill switch had they been in the station at the time, but in the description of their roles we've had, it's by no means certain or even probable that this would have happened. What WOULD be a proper procedure would be for the monorail driver to back up over the switch, perhaps going another train length or two slowly, and then not proceeding any further until they get clearance from Central, who gives such clearance only after visually confirming that they see the monorail on the correct beam.
Originally Posted By skinnerbox <<Who is the top level manager for operations at the resort and who on their team is responsible for knowing operational safety procedures. Those two should be held responsible for not keeping proper procedures for safety in the Monorail team, procedures that go above and beyond the need for guest (and cast member safety). Someone wasn't running a tight enough ship.>> Which, for me, begs one simple question: Did the recent WDW management layoffs affect the leadership of the rails team? I wouldn't be surprised if it was later determined that senior staff members who understood the SOPs inside out, were let go earlier this year during the downsizing. Hundreds of senior management types with decades of work experience at WDW were terminated, so it's quite possible that those who 'ran a tight ship' in rails were no longer working for the Mouse when this tragic and preventable accident occurred.
Originally Posted By Indigo I agree that's important to know. I wonder if the NTSB will look at things like staffing levels and recent layoffs in management.
Originally Posted By Kennesaw Tom <<What WOULD be a proper procedure would be for the monorail driver to back up over the switch, perhaps going another train length or two slowly, and then not proceeding any further until they get clearance from Central, who gives such clearance only after visually confirming that they see the monorail on the correct beam.>> Excellent observation SuperDry. I'm going to have to agree with the above. Since no matter how you look at it, if your backing up onto any of those beams your going to eventionally run into something. This would have also been prevented if monorail pink had only backup enough distance so that monorail pink cleared the switch but left plenty of "wiggle" room between itself and any structure/ monorail behind it. It doesn't make sense for a monorail to just keep backing up.
Originally Posted By SuperDry And, to add in the experience and leadership issues that others have brought up, what I propose at the end of #330 works only if the supervisors and management are committed to making it work and follow through at all times. It would of course be important for Control to severely reprimand any pilot that backed up into the station without receiving the second clearance. But equally important would be Control's commitment to not give such clearance unless they actually saw the monorail in the correct position with their own eyes. That is, safety isn't something to be followed by workers 100% of the time even when inconvenient, but also must be followed by supervisors and management 100% of the time, even when it's inconvenient (or expensive) to them. If a supervisor yells at employees when they skip safety steps, yet is seen skipping safety steps themselves, instead of a "safety is #1" message, instead the message is "it's okay to take shortcuts - just don't get caught."
Originally Posted By sjhym33 Of course the old procedure (which I gather Disney is going back to) is the best one. The driver backs out of the TTC/EPCOT station to just past the switch beam and stops. He radios in his position. The beam is moved. The driver is cleared to proceed. He now drives foward facing into the TTC/Mk station at which point he shuts down his end of the train and moves to the other end which is now the front. That is the proper way that this works. While you always hope that the person working Monorail Base is in the console. This allows the driver to SEE where they are going at all times
Originally Posted By sharpc <<So far we've all be talking about the three key immediate players. Driver, Monorail Central Manager, and Monorail Shop operator. Based on what we know right now, which admittedly is part conjecture, I think responsibility for this incident needs to move up the management chain. Who is the top level manager for operations at the resort and who on their team is responsible for knowing operational safety procedures. Those two should be held responsible for not keeping proper procedures for safety in the Monorail team, procedures that go above and beyond the need for guest (and cast member safety). Someone wasn't running a tight enough ship. >> Sorry if I'm being a little bit of an idealist here, but the people running the monorail should already have that understanding and that drive to do their job correctly. It shouldn't be up to management to be on their butts every day to make sure they do their job right. I know that if I were in any position such as this, I would not need a micromanager to constantly remind me how to do my job. Bring on the flames lol
Originally Posted By Indigo No flames. Just I don't think you understand how most organizations like this work. When management tells you find a way to save 10 minutes off every monorail loop you make your suggestions and then accept whatever choice they make. When a manager is repeatedly away from their station, sometimes off property, and no one reports that up the chain of command, that's because they've given up on the chain of command after not being listened to before. When the whole atmosphere is one where efficiency comes before safety and show, and your suggestions to improve safety or show are shot down for costing too much, or shot down because they would take more labor hours than we have now, you eventually just give up, keep your head down, and hope that when something bad happens, it doesn't happen to you.
Originally Posted By sharpc Obviously, the system has the capability to function just fine without anything bad happening (as it has over the past however long it is). The problem comes when someone neglects one facet of their job. In this case, one of the three main people (or a combination) did not follow through with their responsibility, leading to this awful tragedy.
Originally Posted By Sport Goofy << When management tells you find a way to save 10 minutes off every monorail loop you make your suggestions and then accept whatever choice they make. >> Why does the desire to save time have to fall on upper management? What if the monorail drivers and platform workers came up with this method of switching to save time at the end of the day so they can clock out of their shift and get home earlier? If I were to wager where the desire to cut corners here came from, I would put more money on the bottom of the food chain than the top. At least that's how things seem to work in my organization.
Originally Posted By -em >>Sorry if I'm being a little bit of an idealist here, but the people running the monorail should already have that understanding and that drive to do their job correctly. It shouldn't be up to management to be on their butts every day to make sure they do their job right. I know that if I were in any position such as this, I would not need a micromanager to constantly remind me how to do my job.<< I'll agree with you and it falls in line with a conversation I had last night with another former 'railer about how the dynamics of the dept has changed over the years. Back when I was in 'rails (and maybe Sjhym could attest to it also) but it was a very high senority/hard to get in department, where for lack of a better term they were picky who got accepted and more than average never passed training,.. Now days I know of several people that were either new hires into 'rails or transfers after only being with the company 6 months and 'rails has become a pretty transient department- so where the dominance used to have age, wisdom and experience you now often have youth and inexperience as the majority, where in time things such as going through the switches backwards which used to be an absolutely not becomes daily practice because no one knows any different... -em
