Today, the Cal/OSHA released their findings on the Big Thunder Mountain accident. After reading an initial report from the Orange County Register (free registration required), I had assumed that Disney's maintenance procedures were being blamed for this tragedy.

I just spent a few minutes reading the entirety of the report, which was posted and later removed from the Cal/OSHA website. Isn't that odd? I found a copy, and have placed it here for your purusal.

When learning to fly, managing risks is often a topic that receives considerable attention. Most aviation related accidents occur because of several events, chained together, ultimately ending in an accident. The goal of managing risks while flying is to break that chain somewhere along the line. This seems to be the case in this accident. The chain of events regarding Big Thunder Mountain were:

1. Two bolts were not properly tightened to tolerances.
2. Safety wire was not installed where these bolts resided, as required.
3. No procedure existed for ride operators to act upon the train exhibiting an unusual sound.

Had any one of these problems been corrected, then there would not have been an accident. There's also a great deal of rumbling in the report about how green and yellow tag procedures were not followed, which apparently didn't have a result on the accident.

After reading the report, what is very clear to me is that Disney is not at fault at all. Disney had proper procedures in place and the operators and maintenance people failed to follow those procedures. What's frightening is that Disney will escape this unscathed except for a large under the table payment to the deceased's family.

If you've been to Disneyland in the last 5 years, it's obvious that it is not maintained as it used to be. Here's hoping against hope that the new President of the Disneyland Resort, Matt Ouimet, will actually reverse his predecessors objective of maximizing revenue. He obviously has a very rough road ahead of him, and with someone like Eisner leading the company, I don't think he's going to be able to get things back to how they used to be run. My two cents.