NTSB releases preliminary report about monorail accident

The National Transportation Safety Board (NTSB) yesterday released their preliminary investigation into Sunday's monorail that resulted in the death of 21-year old monorail pilot Austin Wuennenberg, reports the Orlando Sentinel.

According to the NTSB, Wuennenberg actually was attempting to put his monorail into reverse when the accident happened. The report also confirms that the accident was caused when monorail pink failed to switch to a spur line connecting the Epcot and Magic Kingdom express loops. Instead of reversing onto the spur, monorail pink reversed back onto the Epcot loop and into the path of monorail purple, piloted by Wuennenberg.

The preliminary report said investigators found no problems with any equipment or other systems, inferring the accident was a result of human error.

The Sentinel article also cites a report from a unnamed Disney employee. The employee, who apparently was familiar with the situation surrounding Sunday's accident, says the cast member who was supposed to be coordinating monorail central had gone home sick earlier in the day. A manager assumed responsibility for those duties but was not on-site and was communicating by radio when the accident happened. Even if a cast member was not physically in monorail central, say other pilots, the monorail maintenance shop, located behind the Magic Kingdom, also has monitoring capability and can execute an emergency stop. Further, cast members at the TTC are supposed to have what is called a "kill pack," which can shut down power if cast members see a monorail heading the wrong way.

The NTSB report has yet to say what errors may have caused the accident. It appears clear that human error caused this accident, and possibly several errors.

A Disney spokesperson told the Orlando Sentinel that the company will "continue to work closely with the NTSB and other agencies investigating the incident." OSHA, the Orange County Sheriff's Office and the Transportation Communications Union (union for monorail workers) are still conducting their own investigations.

Below is the complete preliminary report from NTSB:

The National Transportation Safety Board has developed the following factual information from its investigation of the collision of two trains on the monorail system at Walt Disney World in Lake Buena Vista, Florida, that occurred early Sunday morning:

At about 2 a.m. on July 5th, a Walt Disney World monorail train, designated the Pink train, backed into another monorail train, designated the Purple train, near the Ticket and Transportation Center (TTC) monorail station. The operator of the Purple train was fatally injured; the six passengers on that train were treated at the scene. The operator of the Pink train, who was transported to the hospital, treated and released, was the only one aboard that train at the time of the collision.

Prior to the accident, the Pink train had been instructed to detrain all passengers at the TTC station and then to operate without passengers past the station and a switch to a point where the train could be backed through the track switch from the Epcot loop over to the Magic Kingdom loop. The operator of the Pink train moved the train past the track switch and stopped.

The Pink train was then instructed to back through the track switch, towards the Magic Kingdom loop. At about the same time, the Purple train, which was inbound to the TTC station, was instructed to stop at the station to detrain passengers. For undetermined reasons that are currently under investigaton, the switch had not changed position needed to allow the Pink train to be routed to the Magic Kingdom loop, which resulted in the Pink train backing down the same track it had just come from, putting it on a collision course with the Purple train. The Pink train passed through the TTC station and struck the Purple train while it was outside the station.
There are indications that the operator of the Purple train had brought the train to a stop and had attempted to put the train in reverse prior to the collision. To this point in the investigation, no anomalies or malfunctions have been found with the automatic train stop system or with any mechanical components of the switch or with either of the trains.

The on-scene phase of the investigation is expected to continue for several days. The parties to the investigation are Walt Disney World, the Occupational Safety and Health Administration, the Orange County Sherriff's Office, and the Transportation and Communications International Union.