2009 WDW Monorail Crash - WTF?

(I wasn't able to find an original thread talking about the accident, sorry for the new topic.)

I went down a bit of a rabbit hole yesterday reading about the 2009 WDW Monorail crash after a bit of an argument with my father-in-law about the stupid state regulation of "monorails in special districts that cross county lines" thing.

Anyhow, I somehow missed that the NTSB report was ever published so I read it yesterday and holy crap is there some interesting stuff in there.

I know we've discussed before how the manager wasn't in the tower so couldn't have visual on the trains when giving the OK to reverse, but I don't recall anyone ever talking about this (from the report):

When the monorail manager issued these instructions, he was not in the Concourse Tower, but was instead at a local restaurant. He was not in the tower and could not use the display screens to monitor or confirm any of the movements. Walt Disney World Resort’s procedures for the central coordinator did not specify that the central coordinator should observe the display at the Concourse Tower when directing the monorail movements. Procedures also did not require that the central coordinator be in the Concourse Tower when directing monorail movements.

The monorail manager was not even on-site. He was "at a local restaurant." Yes, that's right. He was out to eat at 2am yet still responsible for monorail movements. Maybe my newly-forty-years-old memory is faulty but I don't remember hearing this at all.

This detail is absolutely shocking to me, but I found the report fascinating. It's a great write-up so if you've got any interest in knowing more about the incident give it a read!

I don't remember a lot of discussion about it here, but I definitely remember reading the report and some of the summaries. There were a lot of procedures that went wrong with this accident.

I was a Cast Member at the time and still remember waking up to the news this had happened. I had been at Epcot that Saturday night and had an afternoon shift at AK on the Sunday after it happened. There was a very uneasy feeling in the Cast Member areas even at AK.