Federal investigators concluded after 2.5 years that the Disney monorail collision that killed a 21-year-old resort employee was caused in part by a lack of adequate safety protocols.
In a 14-page report, the National Transportation Safety Board cited employee errors as the primary causes of the accident, but added that “Walt Disney World Resort’s lack of standard operating procedures leading to an unsafe practice when reversing trains” was also a factor in the accident.
The U.S. Occupational Safety and Health Administration had previously cited Disney with four safety violations in December 2009 upon concluding its investigation of the accident, and fined the resort $35,200.
The Orlando Sentinel reported that “an employee in the monorail’s maintenance shop, which controls the system’s track switches, failed to properly position the switch beam. It also found that the manager who was temporarily serving as the monorail system’s coordinator — relaying commands between the maintenance shop and the train drivers — was not in the system’s control tower during the track-switch procedure, where he could have seen that the track had not been properly aligned.”
Disney’s policies, however, did not require the central coordinator to be station in the control tower when directing monorail movements, nor that the employee in the monorail shop verify the beam realignment. Employees were also not required to follow an operating guide with regards to moving from the front cab of the train to the back cab before driving in reverse.