November 14, 2011 | Mark Paradies

Monday Accident & Lessons Learned: NTSB Investigation of the Disney Monorail Accident

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Here a quote from a report by WESH Orlando:

The National Transportation Safety Board says the death of a monorail driver in July 2009 was the fault of a fellow Walt Disney World Resort employee.”

Here’s is what the NTSB report said the “Probable Cause” was:

The National Transportation Safety Board determines that the probable cause of the July 5, 2009, collision between two monorails at Walt Disney World Resort in Lake Buena Vista, Florida, was the shop panel operator’s failure to properly position switch-beam 9 and the failure of the monorail manager acting as the central coordinator to verify the position of switch- beam 9 before authorizing the reverse movement of the Pink monorail. Contributing to the accident was Walt Disney World Resort’s lack of standard operating procedures leading to an unsafe practice when reversing trains on its monorail system.

Here’s a link to a video on the Orlando Sentinel site that shows the new way that Disney controls the monorail:,0,4139169.story

Here’s what the Orlando Sentinel had to say about the cause of the accident:

A lack of adequate safety protocols at Walt Disney World contributed to a 2009 collision between two monorail trains that killed a 21-year-old resort employee, federal investigators said Monday, concluding an investigation that took nearly two-and-a-half years.

Here’s a You Tube video recreation of the accident:

What do you think?

Did the NTSB find the root causes of the accident?

What can you learn from the report and the accident that would impact operations at your company?

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