Disneyland takes some responsibility for fatal coaster accident

Posted Wednesday, November 26, 2003 9:20 AM | Contributed by wahoo skipper

As the state prepares to release its report on the cause of September's fatal crash on Disneyland's Big Thunder Mountain Railroad, the attorney for the victim's family said his experts have determined that faulty maintenance was to blame. Disneyland officials acknowledged late Tuesday that required tasks on the ride were not completed, but they issued strong statements denying broader maintenance flaws.

Read more from The LA Times.

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Wednesday, November 26, 2003 10:31 AM
Some of those "bitter former employees" that had made public comments about the lax maintenance since the budget cuts may have been on to something.

The industry as a whole better come to grips with the scrutiny it is getting. You can't say that "safety is our number one priority" and that "we monitor better than anyone else can" and then not back it up.

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Wednesday, November 26, 2003 11:37 AM
I wonder...

Disney claims that required maintenance was not completed. In other words, they are saying that maintenance which had been scheduled, inspections that are on the inspection checklist, service that is on the service schedule, things that the park knew had to be done and had authorized to be done, were not done.

If that is true, then the griping by bitter former employees about a reduction in maintenance standards is just that: griping by bitter former employees. It isn't that there isn't a problem, it's that the problem might not be where they claim it is. This isn't about park management having declining standards...it's about park management's standards not being followed.

I hope that makes some kind of sense...

--Dave Althoff, Jr.

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Wednesday, November 26, 2003 1:13 PM
Dave,

I wouldn't automatically discount your theory but I think there is more to it than that. It is my understanding that there was a crew whose sole responsibility was BTMRR. With the change in maintenance philosophy, they now have various people rotating in and out of rides who are likely not as familiar with them as their predecessors were. If there has been a significant decrease in the numbers of people on the maintenance staff then fewer people have more responsibilities. Shortcuts then begin to take place.

I have not seen this at Disney but I have seen it at other parks well enough to know that it is something that shouldn't come as a great shock if it is now happening.

The wood rot in the cleat should have been caught with a good preventative maintenance program. The loose underwheel(s) on BTMRR should never have been missed.

Frankly Dave, I hope you are right. I hope it has nothing to do with the scaled down maintenance program. But, this is quite a coincidence.

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Wednesday, November 26, 2003 1:38 PM
It sounds to me like they are trying to find a scapegoat for a horrible accident that should have never happened. An accident that was a result in their "make money at all costs" business philosophy.<

They have cut maintenance costs by keeping rides not operating, reducing the number of cars that operate on a ride. Both result in lower quality park experiences. But their cuts in maintenance staffing has resulted in this, the worst thing imaginable. You can have all the procedures and checklists in the world, but you also have to have a paid, qualified staff that is not over extended to follow those procedures.
*** This post was edited by super7 11/26/2003 1:40:14 PM ***

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Wednesday, November 26, 2003 3:47 PM
DOSH (the Cal-OSHA department responsible for inspecting amusement rides) has released its report. A copy can be found here.

It is fascinating reading. It's also worth reading the report before deciding what, exactly, is to blame.*** This post was edited by Brian Noble 11/26/2003 3:48:38 PM ***

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Wednesday, November 26, 2003 3:52 PM
The short version of the report: the bolts on the upstop assembly were not tightened to specs, and the safety wire (read: cotter pin) was not installed to prevent backout. However, there was signed paperwork stating that "all maintenance was completed to spec", and the facilities staff that worked on the ride said that since the paperwork was signed, the work must have been done.

There are several other contributing issues (improper tagging, cross-signing of paperwork, etc.) that are to be fixed.

But, don't believe me: read it for yourself.

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Wednesday, November 26, 2003 10:08 PM
Actually, Brian, the way I read that report, "safety wire" is correct, and if you look at certain bolts on the wheel assemblies of Arrow looping coasters you can see that the bolts are tied together with a small (roughly #22, I'm guessing) wire, and that's probably what should have been used here. That might also explain why it was missing...it takes just a couple of seconds to install a cotter pin, but a bit more effort to install safety wire. But safety wire would be required in this application because it's apparently a capscrew into a blind hole. A cotter pin will keep a nut from backing out past the cotter pin, but safety wire will prevent the bolt from rotating.

The basic cause of the accident was a single preventive repair which was performed incorrectly. The paperwork that was filed incorrectly exists because the operations staff is not (and should not need to be) qualified to perform a complete mechanical inspection, and because the operations staff doesn't have the time to do a complete mechanical inspection. They have to rely on the paperwork to tell them that a qualified individual DID perform the necessary maintenance and inspection. The paperwork was in order. The ride wasn't.

It is worth noting that for all the yammering I have seen on discussion boards and in LA Times articles about Disney having lax maintenance procedures, cutting maintenance staff, and operating components beyond their useful life...those issues were addressed in the report. It was the published opinion of the investigator (the only individual in the report, I think, who is not identified by name...) that the maintenance procedures are "more than adequate" for the ride, and that even though one maintenance crew member was removed from the ride rotation, the staff was also adequate for the job...an opinion apparently shared by the maintenance staff.

--Dave Althoff, Jr.

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Thursday, November 27, 2003 3:44 AM
It also appeared, from his report, that much of the staff was unclear on the Green Tag vs. Yellow Tag procedures. It seems to me that there was a distinct lack of training for the staff that was maintaining the rides.

Nonetheless, I think the ultimate blame lies on however signed off on a procedure that wasn't actually performed. Knowing how I can be at my job (one that, thankfully, nobody's life depends on), eventually you get so tired of the same tedium that you skim over what you assume is a minute and unimportant detail. I know that's bitten me in the arse (when my webservers suddenly die for some reason I didn't see before), and in this case, it was about the most violent bite one would imagine.

That was definitely quite a report to read, and it was illuminating to read exactly what happened. Despite this, I still imagine that Disney procedures are followed more closely than other parks are, which makes me just the slightest bit nervous going to SFMM.

NOTE: This is my perception of Disney vs. Six Flags. This is not a reflection of any real knowledge about how completely either company maintains their rides.

That done, when I see how Revolution doesn't seem to have been painted in years, it makes me a little more nervous each time I go for a ride on one of the non-brand new rides at my local park. I know X gets constant attention, and I imagine that Goliath goes through pretty regular inspections, but what about Revolution, Colossus, Batman, etc? For those that have done those inspections time and time again...how often is an unimportant detail skimmed over?

Again....NOTE: I'm not accusing Six Flags of anything. It's just that that's my main park, so of course, that becomes the focus of my attention.

Finally....NOTE: I'm sorta sad that I actually feel like I need to add disclaimers to what I say. I *do* honestly feel more nervous after the BTMRR incident. I want reassurance that the rides that I ride are maintained well, and not even bothering to paint them decently makes me even more nervous. I continue to patrionise my home park, and I love riding the rides there...I just want my continued experience of "seemingly putting one's life in danger while not actually putting it in danger" to be exactly that.

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Thursday, November 27, 2003 3:46 AM
Whatever you want to call it...it's still a failure on the part of Disney and their management team. Like the Columbia incident (which you think they would have learned from) training, was once again, the issue. It's beyond me how something like the green tag/yellow tag procedures could be misunderstood or how others could sign off on things they did not handle. And ride ops not properly trained to deal with odd noises is a huge error on their part. It's appalling to me that they heard the noise and kept sending it around loaded with riders anyway.

It's even more troubling to me that the state basically seems to be serving an "after the fact/accident" type of role instead of a preventive one. I would have expected reviews of procedures and spot checks of equipment and employee knowledge (or lack thereof) to occur before someone dies, not after.

If prior training issues on the Columbia, and Roger Rabbit rides didn't motivate Disney enough to insure that Castmembers actually know what to do, what will? Will this be enough now? Or will it take even more problems? I have to wonder. This isn't a fly by night park...it's not a traveling carnival...these kinds of things should not be happening here. And it's very disturbing that they have.

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Thursday, November 27, 2003 11:05 PM
Upon further review...

I think I made a mistake in my earlier reading of the report, and I think I am not the only person who made this mistake.

On Page 18, Line 9 of the report, Conclusion #8 states, "As of the time of the accident, Disneyland Resort procedures allowed one outside machinist to sign for the work of another outside machinist to indicate completion." On Page 20, Line 19, Corrective Measure (H) addresses this stating, "The Owner/Operator shall require that only outside machinists who actually perform the work can indicate by their signature that work has been performed. (8 CCR Section 3195.3(a)(3)(b))".

Because that appeared twice in the report as outlined above, it is very easy to make the assumption that in fact the paperwork was cross-signed. This overlooks the investigator's comment on Page 11, Line 19ff, which states, "I concluded during this review that the Outside Machinist who had replaced the upstop/guide wheel on the left side of the floating axle on train #2 signed off on the paperwork stating that the assembly was tightened to specifications and that safety wire was applied." In other words, it appears that the investigator is pretty certain that while policies would allow for cross-signing of paperwork, in this case it did not happen.

It doesn't make a bit of difference, but I missed that until my third reading of the report, and I know I'm not the only one who could make that mistake!

--Dave Althoff, Jr.

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Friday, November 28, 2003 4:09 PM
I've just completed reading the DOSH report,which pretty much confirms what I have heard from former employees that I know. The ball was dropped in both in operational as well as maintenance proceures. I've NEVER heard of putting a additional train on a coaster without cycling it at least once empty, and once with employees on it.

As far as DOSH being reactive versus preventive, remember it's a new dept. At my last count the Anaheim office has four field inspectors to inspect every ride south of the San Francisco Bay area.(Half of the field staff was used on the DL case tying them up for a month.) They are also supposed to be self sustaining, with no operating funds coming from the legislature. That's why every time one of them steps foot on my property I get a bill for at least $125. (They bill at $125.00/hour total time spent both on site and writing the report.) We can have our annual inspection done by a Qualified Safety Inspector (QSI). These are firms licensed by the state to perform inspections as per the Permanent Amusement Ride Act. Besides the annual inspection, DOSH makes one announced and one unannouced inspection during the year.

In my dealings with them I have noticed an obsession with the paper chase, causing me to go to great lengths to prove to them that in some cases there were no owners or maintenance manuals ever issued. This got to be rather annoying when it came to a Looff carousel built in 1890 and rebuilt in 1914 by Wm. F. Mangels. I finally had to provide a letter from a nationally known researcher to validate this point.

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