Investigators are still sifting through the pieces to discover exactly who did what to cause the fatal monorail crash at Walt Disney World early July 5. But one thing’s for sure: While the accident all happened within seconds, it was an accident years in the making.
This was a tragedy that could have been prevented by roughly a half-dozen cast members—by Shop flipping the switch properly, by Central being around to catch it, by the driver of Monorail Pink realizing he was backing up onto the wrong track, by the operators on Concourse killing power.
Or it could have been prevented by a system with more checks and balances—or at least by insisting upon and enforcing those in place. Unfortunately, a culture of carelessness has enveloped WDW’s monorails and other areas of the resort, which contributes to complacency and taking short-cuts deemed to have acceptable risk.
“There was no reason that this accident should have happened,” said a former monorail trainer. “And it breaks my heart that, in my opinion, the one person who was doing things the way he was supposed to paid for the incompetence and inattention of others with his life.”
But ask the individuals involved, and they’ll probably tell you they were doing what they always did; they were just following instructions. Those standard operating guidelines, or “SOGs,” coupled with the system that created them—from changes in hiring, training, staffing, technology and maintenance—were really to blame.
Hiring
Thirty years ago, WDW had fewer than 14,000 workers, and pay scales and benefits were competitive. The resort now employs four times that number. And nowadays, fry cooks at McDonald’s make more than first-year ride operators at the Magic Kingdom. Casting used to boast that they were so picky that they hired just one out of every 10 applicants. That luxury, too, has long vanished.
Back then, being assigned an elite role such as Monorail Driver usually required high seniority. Monorail managers were themselves all former “railies.” Today, the ranks are filled with new hires, less experienced part-timers, College Program participants, and other seasonal workers. And the person in charge may never have driven a train for himself.
As recently as 10 years ago, prospective monorail workers were required to go through three interviews: A prescreen telephone interview with Casting, an in-person interview at Casting, and finally, an interview with a manager in Monorails. The first and the last have been eliminated, and the remaining interview reduced to a “And what would you like to do?” meeting.
“Casting doesn’t seem to understand what is required of a monorail operator any more,” bemoaned a second former trainer. “Driving the train is only a small part of the job, at least back then. You spent most of your shift standing on the platform in extremes of weather, packed in with hundreds of guests. You had to speak and understand English clearly on the radio and understand somewhat complex instructions. Back at Shop, you have to climb a ladder to gain access to the train. But Casting keeps sending over retirees and some whose English skills are less than stellar.”
“I don’t know whether it’s that Transportation is simply getting fewer qualified people, or whether they’re being forced to take people that aren’t up to the task, or what the situation is,” added Trainer 1. “I do know that when I was there, there was increasing pressure to make do with the people that we were given, and I’d never heard of an applicant for a transfer into the department being turned away.
“It also used to be that all the monorail managers had actually worked in the department as drivers, and were promoted from within, and thus had a keen understanding of how things worked and what kinds of problems could crop up. That started changing when I was there, and there were a few occasions where inexperienced managers threw a monkey wrench into our operations, and on at least one occasion, delayed literally thousands of guests for half-an-hour because they misunderstood the meaning of a couple of radio calls.”
Training
Instruction has become what some current cast members refer to as “No Trainee Left Behind.” Said Trainer 2: “The on-the-job instruction focuses on driving the train in optimum conditions, instead of failure modes, and they depend fully upon the MAPO system instead of teaching new folks to drive visually. MAPO (the monorails’ computerized moving blocklight safety system) is meant only as a back-up to the driver’s attention in the cab.
“Instead of a verbal exam, you now spend one of your training days doing computer-based training. It’s a PowerPoint-like presentation with a test at the end. The trainee can keep repeating the questions until he gets them all right.
“No Trainee Left Behind also means that nobody fails checkout. If you’re a trainer and you refuse to sign off on your trainee’s program, then you lose your trainer status and they find someone else to sign off. Big things that used to terminate a checkout instantly now are glossed over and the trainee passes. I guess they figure the MAPO system will sort them out.”
Trainer 1 agreed: “I would often be assigned the ‘problem children’—trainees who had failed their first checkout for whatever reason. Sometimes there was a mismatch/personality conflict between the trainee and his initial trainer, and the trainee was fundamentally able to learn and do the job properly. Often, I was given trainees who frankly had no business in the cab of a monorail though, and had either a lack of ability (couldn’t multitask well, or remember their hold-points, or whatever), or had a lack of motivation to learn and just didn’t care. When given trainees like that, I did my best to try to get them to internalize what they needed to know, just like I would anyone else. But when it became obvious they couldn’t/wouldn’t learn what they needed, I’d have no hesitation about recommending them for transfer out of the department. To my knowledge, my recommendations were never acted on.”
The frustration caused many good trainers and training managers to quit or drop their trainer status, disgusted that they were being forced to pass unqualified drivers. Trainer 1 remembers one new hire in particular. “She had failed a checkout before, and was assigned to me for remedial training. I spent two full days with her, mostly going back over the basics, and during that time it became painfully obvious that she didn’t know her hold-points, couldn’t keep track of Central’s instructions, and couldn’t remember essential procedures that we’d gone over again and again. In my personal and professional opinion, she was a liability and dangerous in the cab of a train, and as such in my written evaluation I strongly recommended a transfer for her. No dice. She passed her checkout with a lot of coaching being given during the test (which is not supposed to be done at all).”
Not long after, she brought the entire Express line to a standstill for about 15 minutes when she couldn’t respond to a door alert. Central attempted to walk her through the procedure via radio, but she was unable to confirm that all her doors and hatches were secure. A few weeks later, she received a mandatory transfer upon reaching the magic “three overrun” limit, meaning she managed to get her train dangerously close to another train on three separate occasions within two years.
“Training now is a joke compared to when I started,” confirmed a current, longtime driver. “When I started, drive-training had a 50% failure rate. Now everyone passes. Management treats us as an attraction. They figure a monkey can do our jobs, and that we had been ‘overly proactive’ in failing marginal drivers in training. That doesn’t work with 40-ton monorails.”
Technology
Technological advances don’t always make things safer. Improvements over the years have allowed Shop and Central to no longer be on site to make a track switch—removing two pairs of eyes that had acted as safety back-ups.
Trainer 2 explained, “The old radio system had a limited range, but the whole property is using Sprint Direct-Connect now. The Central coordinator and management can be anywhere within Sprint’s system and still be effective. The way the SOG was written up until this incident, Central was a person, not the tower. It didn’t really matter where he was. Yes, during the switch it is better if he’s in the tower, but not exactly necessary. The switches and their position are Shop’s responsibility. Central’s console is a back-up. It wasn’t uncommon for Central to be working a long shift and literally get caught with his pants down in the men’s room with a train or station calling him on the radio.”
Other new labor-saving systems, such as automatically closing doors, have resulted in fewer operators being needed to load and unload trains. Before that, a former manager recalled, you might see up to 20 cast members at the Ticket & Transportation Center and Magic Kingdom station and a half-dozen each at the Polynesian and Contemporary stops. “It gave you a lot of eyes and lots of people to react when problems arose,” he noted.
Safeguards in the MAPO system, too, allow drivers to lower their guards. They let MAPO do their thinking for them and they don’t pay as close attention to their surroundings as they should. The driver of Pink missed numerous visual and computer indications that the track hadn’t switched. He should have noticed his green MAPO light didn’t turn red. As he reversed across the switch, out his left-side window he would have seen the spur—the beam he should have been on. Had he looked in his right-side mirror, he would have seen darkness, instead of the station. And he could have noticed the pylons were numbered differently.
Cast members also perform tasks in less safe, though SOG-allowable ways. For instance, years ago, a driver taking a monorail offline was required to change ends, so he wouldn’t have to back into the station. “A driver backing a train into a station is a bad idea while there are guests around,” the ex-manager said. “What would happen if a guest decided to hop on the beam? The driver would never see them. I have had that happen. The general thought is you always want a driver to see where he was going—especially when you’re bypassing the safety system.”
Maintenance
One current monorail driver views Facilities as “a department that had its budget squeezed, while having its operating hours expanded. It’s led to Maintenance cutting corners when they could to save money and get the job done. If there is a problem with Space Mountain, it affects a couple hundred guests total. They serve 1,800 guests per hour, and a 30-minute downtime at most affects 900 people who couldn’t get on if they wanted to. If we go down, it affects 12,000 people that we move per hour. That does not take long to back up and further complicate issues. And on top of that, they can’t just go ride Pirates of the Caribbean until we come back up again. There is a lot of pressure to be fast and reliable.”
Rushing duct-taped equipment back into service taught cast members that sloppiness was acceptable. The driver continued, “The pressure allowed the corners to continue to be cut to the point where it became standard practice to do things as quickly as possible, regardless of what the SOG stated, and I believe it was a fault of management and the workers themselves that let this mentality continue.”
As well, the more overworked a monorail fleet, the more the trains break down, creating more opportunities for people to get hurt. The attraction’s next most recent serious injury—a maintenance man crushed between Monorail Yellow and a tow tractor in November 2005—occurred after Yellow broke down for the third time in three days. A month before, management—too impatient to tow Monorail Lime to the Shop or to wait for maintenance to arrive with new parts—gave the okay to run Lime without air pressure (hence, no brakes) three times around the Magic Kingdom loop. Another time, management directed operators to tow a train without brakes around the resort line, making its regular stops, with guests aboard.
Trainer 2 blames the maintenance issues on money. “From what I understand, they’ve all but eliminated whole shifts at Monorail Shop. Some of the practices they’ve adopted—because of Blue [after it blew a tire] and issues on Coral, where a side tire fell off during operation—require them to spend more time doing detailed inspections of every train every 24 hours. Since Shop has limited time and bodies on which to work on the trains, the required inspections prevent them from doing preventive maintenance. The Company depends on at least 11 trains being ready on most days, all 12 on busy days. With events like Not-So-Scary [Mickey’s Not-So-Scary Halloweeen after-hours event in October] or the Marathon [WDW Marathon and Half-Marathon, held in January], all of the trains are effectively being cycled 24 hours a day. They really need 14 trains, so Shop can have a couple to work on while the rest are in service.”
Eerily, a driver sent me this note three years ago:
“Since Yellow (colliding with the tractor), as best as I can tell, and based on several other maintenance issues that I’ve seen, nothing fundamental has changed. I’m just hoping it doesn’t take someone dying to do it.”
The Aftermath
Immediately following the latest fatal crash, WDW added several mechanical and operational safeguards to prevent a similar accident.
But the changes must be deeper.
“The department needs to be tightened up, with stricter standards, and more accountability for everyone,” advised Trainer 1. “As it is, there’s precious little to be lost when people don’t follow the SOGs, or otherwise do their job properly, and that needs to change. There needs to be a big hammer waiting for people who can’t or won’t do their job properly, because peoples’ lives can be at stake otherwise.”
It will take more than new signals and sensors. “The monorail tragedy is just that: a tragedy. It’s an accident,” said a retired Manager from the first days of WDW. “Could it have been prevented? Maybe. You can educate and invest in safety systems, but they will not stop all accidents. Isn’t this same criticism that we all have heard through the years about the airline and auto industries?”
Disney will be fighting against human nature. A fellow former executive points to “a general malaise” and “selfishness,” evidenced by rude driving, butting into line, showing up late for work because there’s no loyalty and it’s only about the money. “So, WDW is no different than other organizations with respect to entry-level-pay cast member work,” he said. “Thus, there’s a chance that what happened with the monorail operations was slow in coming. Sloppy attitudes by sloppy folks. An attitude that I don’t have to work my full shift. I can have someone cover for me. I’m tired and want to go offsite. Nobody will notice.
“Sure, the recent procedures save time compared to what we old-timers did. But their procedures have a potential fatal hole. A chain of human actions is required for safety. Aw, heck, I’m tired… let’s go to Denny’s… no one will notice. Except the trapped, doomed soul watching his death approach.”
Talk Monorails & More This Weekend
Meet author David Koenig (that’d be me) and pick up a copy of my latest book, Realityland: True-Life Adventures at Walt Disney World, at the NFFC’s All Disneyana Show & Sale this Sunday July 19 from 11 a.m. to 5 p.m. at the Crowne Plaza Resort, a mile south of Disneyland in Garden Grove, Ca. Details at www.nffc.org.
