NTSB Press Release

National Transportation Safety Board
Office of Public Affairs


NTSB releases final report on 2009 monorail collision at Walt Disney World

October 31, 2011

The National Transportation Safety Board (NTSB) issued a report today citing a shop panel operator's failure to properly position a switch-beam and the central coordinator's failure to verify the position of that switch-beam before authorizing a monorail train to move in a reverse direction as the probable cause of a 2009 fatal accident on the monorail system.

On Sunday, July 5, 2009, two monorails, which move passengers to and from locations within its resorts, collided on a fixed guideway system within the Walt Disney World Resort in Lake Buena Vista, Florida. The accident occurred when a Pink monorail backed through an improperly aligned switch-beam and struck a Purple monorail which was on the same line. At the time of the accident, there was an operator and six passengers on board the Purple monorail and one operator on board the Pink monorail. The operator on the Purple monorail was fatally injured; the six passengers were uninjured. The operator of the Pink monorail was treated at a hospital and was released.

The NTSB also determined that contributing to the accident was Walt Disney World Resort's lack of standard operating procedures which led to an unsafe practice when reversing trains on the monorail system.

Since the accident, Walt Disney World Resort has taken numerous steps to address the operational and performance deficiencies identified by the NTSB during its investigation. These actions have included revising operating procedures for monorail drivers and guidelines for monorail central coordinators; providing additional training for monorail employees; updating monitoring system software; installing additional direct-feed video cameras; and planned reconfiguring of the monorail braking system.

The accident report is available online.

Contact: NTSB Public Affairs
Peter Knudson
Keith Holloway
(202) 314-6100

 

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The National Transportation Safety Board (NTSB) is an independent federal agency charged with determining the probable cause
of transportation accidents, promoting transportation safety, and assisting victims of transportation accidents and their families.