State Blames Ride Death on Lax Work

State investigators Wednesday blamed a series of human errors for September’s fatal crash on Disneyland’s Big Thunder Mountain Railroad, underscoring concerns by some workers that efforts to make ride maintenance more efficient have undermined the park’s once-unassailable reputation for safety.

A report by the California Division of Occupational Safety and Health found that workers who maintained Big Thunder Mountain didn’t understand Disneyland’s safety procedures and hastily approved paperwork to show that the train-style roller coaster was ready for public use. The crew made the same mistakes on other unspecified rides elsewhere in the park, inspectors said.

When employees were questioned, “Their ... response was that the work must have been completed because the paperwork had been completed and signed,” state inspectors wrote.

The Sept. 5 crash occurred when two bolts on the locomotive’s left guide wheel assembly fell off, causing an axle to jam into the railroad ties. The locomotive nose-dived, and its rear hit the top of a tunnel. The force snapped a tow bar connecting the locomotive to the lead passenger car, which slammed into the locomotive’s undercarriage. Ten riders were hurt, and 22-year-old Marcelo Torres of Gardena was killed.

State inspectors faulted a mechanic who didn’t tighten bolts and attach a safety wire on the wheel assembly that fell off. They also blamed a manager who they said declared the ride safe without inspecting it, and they chastised Disneyland’s maintenance guidelines for allowing workers to sign for procedures done by others. And they said ride operators who heard a clanking sound at least 30 minutes before the accident and kept the coaster running weren’t trained how to respond.

The state ordered Disneyland to retrain ride maintenance workers, managers and ride operators; to require a test run of all cars on Big Thunder Mountain before passengers are loaded; and to require that those who perform the maintenance be the ones who sign that the work was completed.

The state report did note that staffing on the roller coaster was adequate. It also found no problems with its design and said Disneyland’s emergency response was proper, as was its effort to secure and preserve the accident site for state investigators.

A spokeswoman for Disneyland said the park was addressing all of the state’s concerns and had already begun to retrain ride maintenance workers, but she declined to say whether any employees were disciplined. The ride remains closed, and no date has been set for it to reopen.

“The safety of our guests and cast has been and continues to be our top priority, and we strive to make sure that accidents do not occur,” Leslie Goodman, senior vice president of strategic communications for Walt Disney Parks and Resorts, said in a prepared statement. “Unfortunately, in this case, a failure to follow procedures resulted in grave consequences, which we deeply regret.”

Though the state concluded that Disneyland’s maintenance procedures for Big Thunder Mountain -- if followed -- were adequate, the picture of sloppy oversight is in keeping with complaints by current and former park workers who say a push for efficiency and cost savings that began in 1997 gutted morale and employees’ sense of ownership of the rides.

“We didn’t have problems like this in the past. We didn’t have people signing off on jobs that weren’t done,” said Mike Goodwin, a ride maintenance supervisor who went to work at Knott’s Berry Farm after his job at Disneyland was eliminated as part of the shakeup. “That wasn’t part of the old Disney culture.”

An attorney representing the Torres family was also critical.

“I don’t know how safety can be paramount if you’re not following the very procedures that produce the safety,” said Wylie Aitken. “The problem with procedures is that it’s not just the written word, it’s the training. It’s not the nice, pretty book you put on the shelf.... This is a symptom of the greater disease.”

The Big Thunder Mountain crash is the third major accident at Disneyland in the last six years in which ride maintenance has arisen as an issue. A patron was killed in 1998 when he was hit by an iron cleat that a taut rope tore from the Columbia sailing ship. Two years later, nine passengers were injured on Space Mountain when a bolt broke on a wheel assembly.

In 1997, Disneyland moved to a system of “reliability-centered maintenance,” which relies on repair histories and failure rates -- rather than the intuition of experienced workers -- to determine how often a safety procedure needs to be performed.

A consultant hired by the park to plan the changeover estimated that Disneyland would save millions in maintenance costs. But longtime workers complained that staffing and maintenance procedures were pared back and that redundancies that provided an extra margin of safety were eliminated. Numerous veteran ride mechanics and supervisors were laid off, were fired or took retirement.

“The system that they have in place is not working,” said Ken Martin, an amusement ride safety consultant who has worked for parks and state regulators. “If nothing else, it should serve as a wake-up call that things need to be changed.”

Disney executive Goodman didn’t directly address the 1997 overhaul of maintenance procedures in her statement. But she did say: “While we may from time to time make process and organizational changes, our long-standing commitment to safety remains the same.”

Though state investigators found that the team assigned to Big Thunder Mountain also failed to follow safety procedures on other high-speed rides, the occupational safety agency didn’t examine whether there were problems in maintenance throughout the park.

“We did not take the scope of the investigation that far,” agency spokesman Dean Fryer said. “That’s outside the realm of what our investigation is looking at. Hopefully, they will review the procedures in other rides also.”

Neither did the state fine Disneyland, because regulations outlining penalties in the 4-year-old law giving the agency oversight of amusement parks haven’t been completed. As one of his first acts in office, Gov. Arnold Schwarzenegger signed an executive order putting off all such state agency rule-making for six months.

But given the findings in this investigation, Fryer added, state occupational safety inspectors may decide to more closely monitor procedures and record-keeping at Disneyland.

The state’s report ignited debate on Web sites for Disney fans and roller-coaster enthusiasts. Many were surprised that Disneyland officials acknowledged that they were at fault. Many more expressed disappointment over the shoddy maintenance detailed by inspectors.

“The industry as a whole better come to grips with the scrutiny it is getting,” one person wrote on Coasterbuzz.com. “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.”