Disney Gets Maximum Safety Fine

Disneyland’s misuse of equipment and its failure to train a key employee led to the Columbia Sailing Ship accident on Christmas Eve that killed a tourist 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.”

A Washington state man, Luan Phi Dawson, 33, was killed Christmas Eve while he waited to board the ship, a natural-gas-powered ride that cruises a park-created river on a submerged rail. Assistant Manager Christine Carpenter, 30, who Cal/OSHA said was untrained in operating the ride, slung a a dock-anchored mooring line around a cast-iron cleat on the still-moving boat, the state agency’s report said.

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 own 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 bow line is taut,” the report said. But that decision, the report said, is a judgment call based on the experience of the dockworker. And 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 own policy manual, which states that before an employee is qualified to operate the Columbia “it is essential that he/she completes a comprehensive 8-hour training program in the specific job responsibilities.”

But damage to the bolts on the cleat also show that this wasn’t the first time the wrong procedure had been used to stop the Columbia, the report said.

The history of improper docking--and Disneyland’s failure to pay attention to evidence that the cleat had previously been misused--along with Carpenter’s complete lack of training were the two major revelations in the report. The report also included taped interviews with Columbia workers who complained about lack of maintenance on the ride.

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

To have imposed higher fines, Carleson said, Cal/OSHA 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.

Disney officials denied in a press release Thursday that Carpenter was untrained in working the Columbia. Disney also said 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 stop, the press release said.

Dawson’s wife, who lives in a suburb of Seattle with the couple’s 6-year-old son, declined to comment Thursday, saying that she was not focusing on the Cal/OSHA investigation or its findings.

Wylie A. Aitken, a Santa Ana attorney representing Dawson’s family, said the report is “obviously a help to the family.”

“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. She had helped moor the Columbia before the December accident, it said, but never alone.

But in an interview Thursday, Disneyland spokesman Ray Gomez said that Carpenter had received hands-on training on the Columbia and had docked the boat alone before Christmas Eve. He said Disneyland had not decided whether to appeal the fines.

Shortly after the accident, Disneyland revamped its procedures for the Columbia and is in the midst of 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 dock worker 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. Gomez said the Columbia will be reopened for guest rides this summer.

Although the report does not say that Cal/OSHA’s investigation was affected, it notes that Disneyland workers had already 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.

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

The Bay Area lawmaker said information about the accident became available only because the worker 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, a Santa Ana Democrat whose district includes Disneyland, dropped his own weaker amusement park safety bill and signed on as a co-author to 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 was also contrary to Disneyland policy, the citation noted.

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 regulations under the California Labor Code.

Yet the report also said that bolts securing the cleat were bent prior to the accident, which meant “less serious violations of the docking speed policy occurred in the past.” And it said mooring ropes on the ride had snapped in the past, without injuring anyone.

In their investigation, Cal/OSHA officials interviewed a number of Disney workers, including one ride operator who told investigators he noticed the Columbia cleat was loose two weeks prior to 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. “The climate that we’re operating in here has changed dramatically in the last few years. . . . It’s carpentry; it’s maintenance; it’s management.”

Another employee, Mario Alberto Mora, told investigators 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.”

James Brown, manager of Cal/OSHA’s Anaheim district office, said one reason the violations were deemed serious was Disneyland’s apparent disregard of evidence of previous stress on the cleat.

Yet Carleson and Brown said they did not believe a ride-by-ride review of Disneyland operations was necessary.

“We did not go in there with the attitude of reviewing every ride” Brown said. “We’re not expert at operating rides.”

According to the report, the accident occurred as the ship’s captain, Matthew Childress, was distracted by sudden cries from a young boy who was pretending to drive the ship, as allowed under Disney operating procedures.

“The captain stated that by the time he was able to again focus on his visual landmarks, it was obvious that the ship was approaching the dock too fast for mooring safely, and he assumed that the bowline would not be secured,” the report said.

As Childress prepared to put the engine in reverse to back into position, “he heard a loud noise and saw an unknown object fly over the deck,” the report said.

“I remember somebody screaming, ‘Give me some scissors!”’ Childress said in a taped interview. “I couldn’t tell if there were two people down on the dock. . . . I saw a man laying down. There was blood all over the dock.”

One park guest approached him, extended a business card and said: “You’re one lousy captain.”

He felt overwhelmed “and I started to break down a little bit,” Childress said. Then a park manager led him away from the scene.

Times staff writers Jeff Gottlieb, Ray Herndon, Nancy Hill-Holtzman, Jack Leonard, Kim Murphy and Eleanor Yang contributed to this report.

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Deadly Accident

Cal/OSHA fined Disneyland $12,500 for violations that caused the death of a park visitor on Christmas Eve. The visitor’s wife and a park employee were seriously injured in the accident. How it happened:

1. As boat docks, employee hooks rope onto cleat.

2. Rope tears cleat off boat: employee’s foot injured.

3. Cleat snaps backward into crowd, striking two visitors’ faces.

Graphics reporting by BRADY MacDONALD / Los Angeles Times