State Report Blames Disney for Fatal Accident at Park

Disneyland’s misuse of equipment and its failure to train a key employee led to the Columbia sailing ship accident Christmas Eve that killed a man and seriously injured his wife and the employee, the state reported Thursday.

After a three-month investigation, Cal/OSHA fined California’s largest amusement park $12,500--the maximum allowed--for what it categorized as two serious violations that park officials “knew or should have known” carried the potential for “serious physical harm.”

Disney officials also were ordered to sign affidavits by April 12 that they have corrected the conditions. The Columbia ride also could be the focus of unannounced follow-up inspections, said Mark Carleson, Cal/OSHA deputy chief.

A Washington state man, Luan Phi Dawson, 33, was killed Dec. 24 as he waited to board the ship, a natural gas-powered ride that cruises a man-made river on a submerged rail. Assistant manager Christine Carpenter, 30, who Cal/OSHA said was untrained in operating the ride, slung a dock-anchored mooring line around a cast-iron cleat on the still-moving boat.

The bolts securing the cleat sheared off, hurtling the 9-pound piece of metal into the waiting crowd, where it struck Dawson and his wife, Lieu Thuy Vuong, on the head and Carpenter on the foot.

Under Disney’s operating procedures, the mooring line was to be attached to the cleat “only if the Columbia is making an approach slow enough to be able to stop before the bowline is taut,” the report said. But that decision, the report said, is a judgment call based on the experience of the dockworker. On that morning, Carpenter had appointed herself, despite her lack of training, to work the dock alone until another employee arrived for a scheduled 11 a.m. shift.

According to the report, this violated Disneyland’s policy manual, which states that before an employee is qualified to operate the Columbia, “it is essential that he/she completes a comprehensive eight-hour training program in the specific job responsibilities.”

Disney officials denied in a news release Thursday that Carpenter was untrained in working the Columbia. Disney also said that it had improved training for employees and had made mechanical modifications to the ride, including adding instruments measuring speed and improving communications among the three-person crew.

Disneyland also has directed employees to not affix mooring lines until the ship has come to a complete stop, the news release said.

According to the report, damage to the bolts shows that the Dec. 24 incident was not the first time the wrong procedure had been used to stop the Columbia. The report also includes taped interviews with Columbia workers who complained about lack of maintenance on the ride.

Still, Cal/OSHA’s Carleson said that to have imposed higher fines, the agency would have had to determine that the violations were “willful,” which it did not.

“I think the term ‘slipped through the cracks’ is a very good characterization,” Carleson said.

Dawson’s widow, who lives in a Seattle suburb with the couple’s 6-year-old, said she is not focusing on the Cal/OSHA investigation or its findings.

Wylie Aitken, a Santa Ana attorney representing the family, said the report is “obviously a help.”

“It clearly assesses the responsibility for this tragedy against the Disneyland corporation,” Aitken said, adding that the family is very private and hopes to settle without a lawsuit. “Unfortunately, it also shows that this was clearly an avoidable tragedy and certainly could have been prevented. Hopefully, this report will help protect some other family that may visit the park.”

Carpenter also declined comment Thursday.

Her mother, Susan Carpenter, said the family felt vindicated by Cal/OSHA’s placing of blame on Disney for failing to provide adequate training.

“We knew it all along,” she said. “It didn’t always come out that way in the papers, but we knew it.”

Carpenter had hands-on training in docking the Mark Twain, a paddle steamer ride operating from the same dock, but not the Columbia, the report said, adding that she had helped moor the Columbia before the December accident but never alone.

Shortly after the accident, Disneyland revamped its procedures for the Columbia and is reviewing ride procedures throughout the park, Disneyland director of operations Michael T. Berry said in January.

A Disney source said Thursday that in addition to a better control panel, new safety measures on the Columbia and the Mark Twain riverboat include a system using bells to signal the boats’ positions and whether they have stopped. Instead of the dockworker deciding when to put on the bowline, a “lookout” worker on the ship will drop the bowline over the side, the source said.

After an overhaul, the Columbia is now sailing when the park is closed for rehearsals of Fantasmic, a special effects and live action show that uses the ship. Fantasmic opens April 2. Disney spokesman Ray Gomez said the Columbia will be reopened as a ride this summer.

Although the report does not say that Cal/OSHA’s investigation was affected, it notes that Disneyland workers removed “the broken parts of the cleat and the rope” before a state inspector arrived.

Disney was widely criticized for cleaning the accident scene before investigators for Anaheim police--themselves criticized for slow response--could inspect the area. The criticisms led to policy changes at Disneyland and within the Anaheim Police Department, and to the stationing of an Anaheim police officer at the park.

Theme Park Inspections Sought

The incident also has led to renewed calls for outside inspections of theme parks. At a Sacramento news conference Thursday, Assemblyman Tom Torlakson (D-Antioch), sponsor of a bill to regulate amusement parks, said the Cal/OSHA report proved that state inspections are needed to protect the public.

The Bay Area lawmaker said information about the accident became available only because the worker’s injury triggered the Cal/OSHA probe. He wants patrons to have the same protections.

“It shows we can go a long way further to improve the safety of amusement parks,” Torlakson said.

Assemblyman Lou Correa (D-Anaheim), whose district includes Disneyland, dropped his own weaker amusement park safety bill and signed on as a co-author of Torlakson’s bill after concluding it was a better approach.

“The Cal/OSHA report was quite shocking,” Correa said. “It indicates we do need to focus on training and have some inspections.”

Torlakson said he also plans to try to get the Legislature to increase the amounts of fines that Cal/OSHA can impose.

One violation, for which Cal/OSHA fined Disneyland $6,250, was for allowing a supervisor to be “inadequately trained in the hazards to which the [employees] under her supervision were potentially exposed.” This violation also was contrary to Disneyland policy, the citation said.

The second violation, which drew an identical fine, was for operating “machinery and equipment . . . under conditions of speeds, stress or loads which endangered employees” in violation of the California Labor Code.

In their investigation, Cal/OSHA officials interviewed a number of Disney workers, including one ride operator who told them that he noticed the Columbia cleat was loose two weeks before the accident but didn’t report it because “normally they aren’t repaired.”

“We’ve been having increasing carpentry problems on both of the boats for the last two years,” Tom Bugler, a 14-year Disneyland employee, said in a taped interview with investigators.

Another employee, Mario Alberto Mora, told investigators that he had noticed weaknesses in the wood around the cleat in late November, the last time he worked on the ride before the accident.

“‘I remember noticing that the wood around [the cleat] was rotten,” Mora said. “There was a big hole coming in next to the cleat. The wood was really rotten, like termites had gotten in.”

In the accident, however, the failure was in the metal, which sheared off.

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Times staff writers Jeff Gottlieb, Ray Herndon, Nancy Hill-Holtzman, Jack Leonard and Eleanor Yang reported from Orange County, and Kim Murphy reported from Duvall, Wash.