NTSB says lack of procedure led to Disney monorail crash

Walt Disney World's "lack of standard operation procedures" led to the unsafe practices behind the 2009 monorail crash that killed a Disney cast member, according to a report from the National Transportation Safety Board.

The report, released Monday, breaks down the entire sequence of events that led to one monorail train backing up onto the wrong beam and killing 21-year-old Austin Wuennenberg, who was piloting another monorail train.

• READ the full NTSB report now!

The report also faulted two Disney employees, including a monorail manager, for not making sure the beams were properly positioned, so that the trains would not have crashed into each other.

The Occupational Safety and Health Administration fined Disney an undisclosed amount of money for the July 2009 incident, which caused $24 million in damages.

Walt Disney World has since released a list of the safety improvements it has made since the crash.

The new procedures require monorail managers to actively watch every second of a beam change and monorail train's change in direction.

Disney has also given employees additional training to address condensation on the monorail windshields, something the NTSB report stated also played a role in the moments leading up to the crash.

Managers are also now required to remain on the premises when the monorail system is under their supervision.

The NTSB encouraged Disney to make improvements in the safety of passengers as well.