Monorail collision triggered by worker’s failure to activate track switch

From the Orlando Sentinel:

The chain of events leading to a fatal crash on Walt Disney World‘s monorail system was triggered by an employee who mistakenly radioed others that he had activated a track switch, according to multiple people familiar with details of the accident’s investigation.

The employee was working in the monorail’s maintenance bay on July 5 when a central coordinator overseeing all of Disney’s trains radioed him to activate a switch on Disney’s Epcot loop for a train that was waiting to transfer off the track and onto a spur so it could go out of service for the night.

The employee has told investigators that he thought he had activated the switch before radioing back to the coordinator that it had been done. But the switch never moved from the main line to the spur, and investigators have found no evidence of a mechanical malfunction.

Because the track did not realign with the spur, when the coordinator instructed the waiting train to reverse direction and cross the switch, it wound up backing down the Epcot line instead and colliding with another train, killing 21-year-old monorail pilot Austin Wuennenberg.

Investigators piecing together details of the 2 a.m. crash still have much work to do. They continue to interview employees and review reams of data and documents from Disney. The group, led by the National Transportation Safety Board, includes the U.S. Occupational Safety and Health Administration, the Orange County Sheriff’s Office and the Transportation Communications Union.

The investigators have already determined that the maintenance worker’s mistake was not the only contributing factor to the first fatal accident in the 38-year history of Disney World’s monorail.

They have found, for instance, that the crash occurred with responsibility for the central coordinator’s job in flux, according to the people familiar with the investigation’s details. All spoke to the Orlando Sentinel only on the condition that they not be identified because only the NTSB has been authorized to speak publicly about the probe.

An employee who had been working as central coordinator that night became ill and radioed an on-duty manager for permission to go home, these people said. The manager, who was in the midst of his dinner break at a Perkins restaurant just off Disney World property, granted the request and contacted another employee to replace the ill worker as coordinator.

The accident happened before the second employee had taken over. It occurred while the manager was coordinating the trains temporarily via radio — off-site and away from a central console that would have shown the track switch had not been activated.

The manager, whose primary responsibility is dealing with guest complaints, was permitted to be off property at the time, people familiar with the investigation’s details said. He was taking a typical dinner break during a shift that was supposed to run until about 5 a.m.

What’s more, at the time of the crash, Disney did not require the system’s central coordinators to be stationed by the console at all times, one person said. The resort changed that policy in the aftermath of the accident to ensure the coordinator is always at the console when trains are switching tracks.

NTSB spokesman Peter Knudson said he could not confirm specific details of the investigation. He said the agency may issue a public update next week.

“We’re working on developing more factual information,” Knudson said.

Representatives for Disney, OSHA and the Transportation Communications Union all declined to discuss the investigation. A representative of the Sheriff’s Office could not be reached for comment.

Investigators are looking into the roles others may have played in the events that led to the accident. For example, they staged a re-enactment of the accident using two other trains, in part to determine whether pilot Alan Rubino, who was driving the train that backed into Wuennenberg’s vehicle, should have realized his train was moving in reverse down the wrong track and stopped his train.

It’s unclear, however, how much blame investigators are likely to assign to Rubino.

They have also examined whether a worker in the Transportation and Ticket Center, near where the collision occurred, could have prevented the accident with a “kill pack,” a portable device that can be used to shut down track power around the station in an emergency.

But workers with kill packs are typically walking the station platform and are trained to be on the lookout for passenger-related situations, such as someone dropping something onto the track, rather than monitoring trains.

Jason Garcia can be reached at jrgarcia@orlandosentinel.com or 407-420-5414.

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