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A monorail transportation system is an example of a complex system that requires astute management. On July 5, 2009 two monorails collided and one person was killed in the said accident (CBS News 2011). This particular event generated great intereste from the general public because of two major reasons. First of all, an accident that involves a monorail system is not a common occurrence. Secondly, the significance of the tragedy was made more dramatic by the fact that it was a monorail system that can be found inside Walt Disney World. The accident happened in one of the major Disney theme parks in America. It was a world renowned tourist attraction. The collision tarnished the image of Walt Disney Theme Parks. It was supposed to be a safe place for children and adults. It created doubt in the minds of the visitors. For others it was time to review the technology behind monorails. The accident prompted an in-depth investigation into the reliability of the monorail system inside the Walt Disney World. At the end it was discovered that the root cause of the accident was human error exacerbated by weak safety protocols.

            The purpose of this study is to determine the circumstances behind the monorail accident that occurred at Walt Disney World. The proponent of this study will critically evaluate the technical aspect of the operation and the human error that contributed to the failure of the system. Finally, the proponent of this study will evaluate available information from the perspective of a key technical decision-maker and provide suggestions as well as alternative solutions to the problem if necessary.

The Accident

            The Walt Disney monorail system located within the Walt Disney World theme park had a reputation for safety. The said transportation system was considered as one of the safest in the United States. The claim was based on verifiable facts. Consider for instance the fact that this particular monorail system was in operation since 1971 (Walt Disney World’s Monorail Accidents and Mishaps, 2011, p.1). Furthermore, the collision was the only fatality in its more than three decades of service history.

A background check of Walt Disney World and its monorail system will reveal a problem that the management does not want the general public to know. In the past there were at least three accidents involving the monorail system (Walt Disney World’s Monorail Accidents and Mishaps, 2011, p.1). This information did not generate a great deal of media exposure because no one died in the said accidents. However, it should have prompted Disney executives to look into the standard operating procedures of their monorail system. The accidents that occurred in the past were proof that human error, lack of coordination, and weak safety protocols can increase the probability of a mishap.

            The 2009 accident attracted significant media attention because someone died. Two monorails collided and the driver of one vehicle died on the spot. The fatality was identified as Austin Wuennenberg. The death of the driver shattered the long-held belief that the monorail system at Walt Disney World is accident-proof. It was a tremendous blow to the image and reputation of the company and there was reason for concern because a large number of visitors is comprised of families and their children. The company had to restore trust to their transportation systems.

There is another reason why the executives at Disney World wanted a thorough investigation in order to determine how to prevent another tragedy at the monorails. It was made clear that aside from the death of the driver, the monorail crash cost $24 million in damages (CBS News, 2011, p.1). At the same time there is great probability that if the accident is replicated, Disney World may have to shut down or reduce its efficiency to operate. If this will occur then the cost of failure is magnified and the company may lose significant amounts of money in revenues.

In the initial investigation it was discovered that Wuennenberg was the driver of the purple monorail and he had with him six passengers. The purple monorail collided with the purple monorail of the said system. The investigators also found out that the pink monorail had no passengers and it was driven by an operator. The reason why the purple monorail had no driver can be explained by the fact that the official run of the said monorail was over since the accident occurred at 2 a.m. The operator was there not to drive the monorail as a normal driver was supposed to do but he was there simply to guide the purple monorail into the designated maintenance facility for Disney World’s monorail system. The driver of the pink monorail was able to survive the impact. He survived the ordeal unscathed because ashe was backing up the monorail he was seated in the tail-end of the vehicle . Therefore, when the pink monorail collided with the purple monorail, the driver was far from the point of impact. However, Wuennenberg was not so fortunate. He was driving the monorail in a forward position. Wuennenberg was at the front operating cab, and he was in that position when his purple monorail slammed into the rear operating cab of the pink monorail.

A Complex System

            Before going any further it is important to clarify the complex nature of a monorails system as well as its benefits. Monorails boasts of its safe track record, therefore, it is more important to find out why an accident occurred at the Magic Kingdom even if a monorail system's primary purpose is to provide a safe and efficient transportation system.

            A monorail is a complex system because it uses a single rail that serves as a track for passenger vehicles. At the same time, most monorail systems are elevated. In the case of Walt Disney's monorail system the cars are elevated. It also straddles a narrow guide way. As a result there is a need to construct a reliable structure that will allow for the monorail to function properly. The construction of the said railway system is just one of the reasons why this particular rail system is a complex one.

            Aside from the engineering skills required to create the elevated railway, another reason why a monorail is a complicated system is due to electrical system required to move the cars from one point to the next. The developer of Magic Kingdom's monorail system had to consider the electrical requirement so that the said transporters can run safely and efficiently.

            The engineering aspect of the monorail system is a daunting task. But there is another critical component of the Magic Kingdom's monorail that made it a complex system. The monorail system at this theme park carries over a hundred thousand passengers daily. Even if the monorails were engineered for safety, the need to move people from one station to the next is a challenging process and it has to be done on a daily basis.

            In the case of Walt Disney World's monorail service there are three loops (Zibart & Hoekstra, 2009, p. 92). The first loop is an express route that moves passengers in a counterclockwise fashion – from the Magic Kingdom all the way back to the Ticket and Transportation Center (“TTC”). The second loop runs clockwise along the first loop and this enable passengers to make all the stops from TTC to the Polynesian Resort, Grand Floridian,  Magic Kingdom, Contemporary Resort-bay Lake Tower, and then it goes back to the TTC (Zibart & Hoekstra, 2009, p. 92). The third loop moves southeast and it connects the TTC with Epcot. The hub for loops 1 to 3 is the TTC where visitors park their cars to visit the Magic Kingdom (Zibart & Hoekstra, 2009, p. 92). Here is an overview of the monorail system which gives a basic frame of reference for investigators who will attempt to find out the weakness in the system and how it can be rectified.

            The complexity of the system is due to the fact that Walt Disney World wanted to assure the safety of the visitors. Before the accident, the managers of the Disney

theme park were justified with their decision to construct a monorail system. For many years of operation the said transportation system was proven safe. The fact that Walt Disney World used the suspended variety assures them that derailment almost an impossible scenario. At the same time the elevated position of the monorail ensures the low-probability of accidents with surface traffic. Furthermore, the elevated position of the vehicles ensures that there are no accidents with pedestrians. The same thing cannot be said about trains and other forms of transportation that has to go through land and had to cross an intersection.

The Investigation

            After the accident, the company’s Vice President of Communications Michael Griffin assured the general public that the accident was only an aberration and that in the entire history of Disney World there was no record of any fatality except this one (NBC News, 2009, p.1). Griffin and his fellow executives asserted the fact that the monorail system carried an estimated 150,000 riders on a daily basis (Zibart & Hoekstra, 2009, p. 92). When the press compelled Griffin to comment on how long Wuennenberg had been with Disney, the said executive did not answer this particular question (NBC News, 2009, p. 1). This particular reaction should prompt investigators and future planners to look into the importance of experience and find out if drivers and operators are allowed to drive and operate the monorail cars without a partner. However, it must be made clear that the official investigation conducted by the National Transportation Safety Board (NTSB) revealed that it was not the driver who was at fault.

            A critical point of information was the fact that the accident occurred at 2 o’clock in the morning. The time of the accident indicated that Magic Kingdom Park was no longer in operation and the work of the personnel were winding down. The visitors already left the park and the monorail system that were still in operation were allowed to continue the service because there were guests staying in one of the Disney hotels. Therefore, the monorail system was allowed to extend its operation 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 were allowed to operate only an hour or two after closing time. Two hours after closing, it was standard practice that the said vehicles are returned in order to perform maintenance checks.

            The NTSB investigators said that the pink and purple monorails were in a closed loop called the Epcot Beam. They also made the comment that 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. It was discovered that, 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. They also found out that 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.

            One of the critical incidents occurred during this period. Investigators were able to determine that the proper procedure was that when the pink monorail was in position, the next step was to coordinate the alignment of Switchbeams 9 and 8. When the alignment procedure was completed the pink monorail was supposed to begin backing up until it reaches the Spurbeam. The operator of the pink monorail should have waited for further instructions. The investigators found out that these initial steps were followed. In the course of the investigation it was found out that the central coordinator instructed the shop panel coordinator to complete the alignment process. At this point, the coordinator removed power from that section so that the alignment procedure can be completed. The investigators noted that 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. The investigators noted that if the said operator did nothing, the system will time-out and the prompts will disappear (National Transportation Safety Board 5). A critical point in the process was identified and the investigators said that if the shop panel operator failed to align the switch-beams there is no other indicator that will help him point out the error.

There were so many things that were left to human judgment and the investigators learned later that on that it was at that point when a series of human errors resulted in the death of Wuennenberg. The NTSB investigators wrote in their report that they discovered the reason why the shop panel operator failed to align the switch-beams. Their 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, 2011, p. 5). The first action that contributed to the human error was brought about by the fact that the said personnel had to make a record of the incident. He had to record into a logbook that the vehicle was already in the repair facility.

A short time 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, 2011, p. 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 but there was no visual aid that could have made him realize his error. Without any idea that he was about to commit a serious mistake, the shop panel operator restored power to the Epcot Beam and informed the central coordinator that the spur-line has power. Without delay the central coordinator instructed the pink monorail operator to override in reverse.

The operator of the pink monorail had also no idea that the direction of movement was wrong and he began to back-up. But since these vehicles are in a loop, the vehicles are still within that loop and, therefore, a collision was imminent. It had to be pointed out that 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 about to collide with the pink monorail. 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 but that fateful day the central coordinator was not at his post. It is imperative to point out that these devices and equipment enabled the central coordinator to see the repositioning of switch-beams from the tower (National Transportation Safety Board, 2011, p.10). But there is one major problem, the central coordinator was not at the tower.

The investigators discovered that shortly before the accident, “the on duty central coordinator requested for a sick leave to his supervisor the monorail manager” (National Transportation Safety Board, 2011, p. 10). The request made 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 even if it was not supposed to be his job to take-over as central coordinator. The carefree attitude of the monorail manager was exacerbated by the fact that he was not in the tower and enjoying a meal in a local restaurant. It was understandable why he was there since it was already 2 a.m. and he was probably hungry. But he did not realize the grave importance of his role as coordinator. Even without visual confirmation he gave orders and communicated to the shop panel operator and the operators of the monorail through his radio. He was giving orders based on the assumption that everything went well. But he did not realize that he had sent two monorails in a collision path.

            The NTSB investigators were able to prove that the company’s procedures did not specify the need for the coordinator to observe the video monitors and electronic displays when issuing commands. The coordinators gave orders with regards to the movement of vehicles even if they have no confirmation that the necessary procedures were followed. It was also noted that there were no procedures to ensure that the shop panel operator completed the alignment request. The investigators said that these lapses were considered in the modification of the procedures. As an added precaution, management made it a policy that the monorail drivers must always stay in the forward facing cab. At present the drivers are now trained to visually confirm the correct position of the beams (National Transportation Safety Board 14). Walt Disney executives also made it a policy to have a spotter or observer in radio contact with the monorail driver. Finally, the corporate leaders limited the power of the central coordinator when it came to moving monorails. In the revised guidebook, 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. Management also upgraded the software of their management information system in order improve their capability to monitor switch-beam operations (National Transportation Safety Board, 2011, p. 14). Finally, management created a new radio signal that will direct all the vehicles to stop at once without delay.

Summary

            The history of success at Walt Disney world proved to be the undoing of the company when it comes to lax procedures. They were overconfident because they knew the safety record of monorails. It would take a great deal of human error before someone can be killed riding in a monorail. One has to consider the safety benefits of a loop. The vehicles travel in a loop. The drivers did not have to worry about incoming traffic and the need to negotiate an intersection. There were no other vehicles in the elevated platform and there were no pedestrians that will suddenly cross the street. Everything was designed to reduce failure.

            The only thing that they did not count on was human error and the hubris of human leaders. The central coordinator and the monorail managers were leaders who were supposed to take care of their people. But they were overconfident. If given the chance to review the safety protocols of Disney World the proponent of this study will suggest a complete review of the manuals and guide book followed by operators and coordinators. The primary addition to the rules and procedures will be to increase the importance of visual confirmation and the need to rely on technology to provide needed data on safety protocols. The drivers, operators, and coordinators should never assume that everything was followed in accordance to procedure. There must always be anticipation towards failure in order to develop redundant systems that will provide added layers of protection.

            Another important addition to the rules and procedure of the monorail system is the need for the central coordinator and the monorail manager to be always in their post. There is no excuse to go to the comfort room or the restaurant to satisfy their personal needs. They cannot leave their post. There is no justifiable reason for doing so. There must be strict compliance when it comes to the observation posts and the management of monitors. Someone must be in their proper places in order to assure a smooth operation. In addition, there must continuous training and drills. It is easy for those who work in amusement parks to feel secure and overconfident. There must be continuous training sessions in order to keep their skills sharp and their levels of alertness must be always at an optimum level.

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