Disneyland’s Most Preventable Tragedy

This is the Big Thunder Mountain

Railroad,

a mine train roller coaster rattling

down the tracks at 45 kmh.

One guest will not make it through this

next ride alive.

Disneyland calls itself the happiest

place on earth.

>> This kingdom of fantasy and imagination

is the happiest place on earth.

>> Life-sized movie characters, blissful

kids, and carefree parents. Safety on

the rides is supposed to be the park's

top priority. But something has changed

over the past few years. During the Big

Thunder Mountain Railroad crash, riders

suffer broken ribs, facial cuts, and

painful chest injuries. One person dies.

And this is not the only fatal accident

in the park.

How did this happen? How did the

happiest place on earth turn into a

nightmare? At the turn of the

millennium, we talked to journalists,

engineers, and writers to piece the

story together. It seemed like every

couple of weeks there was some new

headline of some horrible thing that

happened at Disneyland. He warned them

in writing several times and they

ignored him. They ignored him because it

didn't fit into their proposal.

>> As it turns out, these accidents were no

unfortunate coincidence. They appear to

have been the result of calculated

corporate cost cutting and disastrous

negligence by the staff. And at the

center of it all sits one of the world's

most powerful consulting firms,

McKenzie.

Confirm.

My first time I visited Disneyland was

in the summer of 1969.

Uh I was uh 6 years old. I just remember

the feeling of being someplace unlike

any place I'd visited ever before in my

life. It was it was truly a magical

feeling. For many, a trip to Disneyland,

California is a lifelong dream,

something they travel from all over the

world to experience. Walt Disney, the

legendary founder of the Entertainment

Empire, once said, "I don't want the

public to see the world they live in

while they're in Disneyland. I want them

to feel they're in another world."

Disneyland is just able to tap into

something that no place else has.

combination of joy, nostalgia,

innocence,

color, light, music, all with a a story

personalized for each person uh playing

in the background that sews it all

together through familiar images and

characters. This is David Koik. He's

written several books about Disneyland,

and over the years, he has interviewed

around a thousand Disney employees.

Disneyland California opened in 1955,

and for decades, it was considered one

of the safest theme parks in the world.

In 1991, an expert magazine even

recognized the park's facilities

division as the world's best maintenance

organization. But at some point, others

start calling the shots.

This is Paul Pressler. He's been

Disneyland California's top executive

for 3 years now. On paper, the numbers

don't look bad. The parks division is

turning a healthy profit. But Presler is

determined to squeeze out more because

Disney stocks aren't doing so well.

>> He wanted to impress the board and the

way you do that is by cutting expenses.

It's the quickest way and the way to do

that was by cutting maintenance.

>> That's Walt Bogdanic, a New York Times

journalist. We interviewed him and his

colleague Mike Foresight for this video.

They co-authored this book, a key source

for our research. You'll find the link

in the description.

Presler is a former toy industry

executive and known as a hard-nosed cost

cutter. And for that, he brought in help

from McKenzie. McKenzie is one of the

most prestigious consulting firms in the

world. The company hires only the best

of the best. Clients pay up to $1,200

per hour for their expertise. Now, a few

of those consultants have drawn up a

plan to make Disneyland even more

profitable. And today, they're pitching

their ideas to Prestler.

They spent over a year studying every

facet of Disneyland looking for ways to

cut costs.

>> Initially, uh, McKenzie and company came

in and targeted the maintenance division

that was known as one of the most

respected facilities divisions of any

company anywhere. And yet, the

consultants aimed to slash the

division's budget by 25%. Mainly by

cutting staff.

To do that, they borrowed a concept from

the aviation industry called reliability

centered maintenance or RCM. The idea is

that maintenance decisions should not be

based on the intuition of experienced

employees, but on the analysis of repair

histories and breakdown rates. According

to McKenzie, the resulting increase in

efficiency would allow the park to let

go or transfer about half of its

maintenance staff, and that would save

Disney up to $16.9 million per year.

Presler goes on to put many of those

recommendations into practice.

In the past, maintenance workers were

each assigned to one specific ride,

which they ended up knowing inside out.

Now, they're floated between several

attractions to maximize efficiency.

Also, most maintenance workers are

transferred to the night shift. Only a

small emergency response team remains to

handle mechanical breakdowns during the

day. That way, the mechanics can work

undisturbed after the park closes its

gates. Moving more folks to third shift

probably made some sense, but not moving

almost everyone because there are many

things that can't be done in the middle

of the night when it's dark and cold and

wet. You're not going to effectively

painting a building in the middle of the

night. Many employees complain it's a

harsh change for people who've worked

days almost their entire lives. Many of

them were devastated by these changes.

To suddenly have your working conditions

worsened by tenfold. You know, if you're

working suddenly graveyard shift and

never able to see your family, being

exhausted on your job, being rushed

through what you had to do. McKenzie

responds by granting all overnight

workers a free annual subscription to

the Working Knights newsletter. It

features leading experts sharing shift

work wisdom on nutrition, sleep, and a

healthy family work balance. To no

avail, according to David Koig, more and

more employees are soon being treated

for high blood pressure and other stress

related symptoms. Night work

significantly increases the risk of

chronic health issues and is simply not

very healthy. So, management brings in

psychological counselors. They advise

insightful suggestions such as to use

caffeine to stay alert and have their

loved ones videotape daytime family

activities so the workers can stay

connected to them.

Robert Clrike is part of Disneyland's

maintenance crew. One day he's

interviewed by a McKenzie consultant to

review his routine on the Big Thunder

Mountain Railroad. The consultant asks

him, "Why do you inspect the lap bars

every single day? Those are the

restraints that hold passengers in their

seats." And according to Mackenzie's

data, they have never failed.

>> And the maintenance workers said, "Well,

the reason there's no accidents is

because we check the lap bars every

day." And it was almost as if, you know,

we're not going to do if we were an

airline, we're not going to do

pre-flight checks because we haven't had

accidents in a while. In 1997, Close

Strike sent an internal memo to warn his

supervisors. the ongoing staff shortage

and labor distribution could no longer

guarantee effective daily preventative

management.

>> He warned them in writing several times

and they ignored him. Um they ignored

him because it didn't fit into their

proposal which was look cost cutting if

we do it in a rational way is a good

thing.

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in 1997, Cluster Strike is concerned

that the new system can no longer

guarantee proper maintenance. And

unfortunately, time will prove him

right.

But who exactly are these consultants

and how do they work?

This is Eric Edstrom. He holds an MBA

and a master's degree in environmental

science from Oxford. Edstrom has served

as a soldier in Afghanistan. He returned

disillusioned and is now determined to

make a difference. He wants to help

fight climate change. McKenzie promises

him exactly that. Dream with me for a

second. What if we could be the largest

private sector catalyst for

decarbonization in the world?

>> To change the world, make the world just

a little bit better place.

>> To bring a new future to life, doing

something that's meaningful to our

clients and ultimately the societies

they act on and being an enabler for

that kind of change. That is change that

matters.

In 2018, after working for another

consulting group, Edstrom joins

McKenzie, he's full of energy and

optimism. If there's one thing McKenzie

does very, very well, it's recruit the

best and brightest

from elite universities uh in Europe and

the United States and in Asia as well.

They appeal to young people, really

bright people, you know, with a very

attractive package that you'll be able

to learn about uh business in the world,

and you might also make a positive

difference in the world. It's about

money.

>> McKenzie is one of the most coveted

employers on the planet. Each year,

nearly a million people apply for just a

few thousand spots. Only about 1% make

it in. The firm claims to serve 90 of

the top 100 corporations worldwide.

McKenzie also advises governments around

the world from ICE in the US and the

German Defense Ministry to past stints

with Saudi Arabia and Russia.

>> They're doctors for companies. They're

corporate doctors. That's how they like

to view themselves. In the most simple

terms, they have knowledge that for many

reasons companies pay for and they pass

on that knowledge for good or ill uh to

their clients.

Hiring McKenzie means getting support

from a small army of exceptionally smart

and highly trained advisers. These

consultants help managers with some of

their most challenging tasks acquire

other companies, drive innovation, or

cut costs. Or at least they try to help.

One of the problems is that when you

hire McKenzie, you're hiring young

people who don't have experience. You're

hiring people who don't know your

industry and you're paying them a lot of

money because supposedly they have this

genius because they're McKenzie. They

know what to do, but often they don't

know what to do and frankly they're just

doing what management tells them to do

because management doesn't want to take

responsibility for layoffs or for cost

cutting. So, it's easier to say, "Hey,

well, McKenzie told us to do it."

>> Disneyland chairman Paul Presler and

McKenzie go on to form a highly

profitable alliance. The consultants

deliver good numbers which appear to

legitimize the layoffs and budget cuts.

Meanwhile, Presley continues to climb

the ranks inside Disney.

The effects of the rigid cost cutting

slowly start to show throughout the

park. Paint is peeling here and there.

Rides break down more often. And when

the lights on Main Street go dark, no

one replaces the bulbs anymore.

>> Most of that preventive maintenance was

gone. And it was just sort of emergency

lastm minute slap dash get this thing

working in the middle of the night

maintenance. Uh things were breaking

down constantly. The late '9s you would

walk through Disneyland and it would be

a third of the attractions could be

closed. Unfortunately um there were

consequences for these many decisions of

moving to people in charge who didn't

necessarily have a familiarity with how

to operate the attractions.

Christmas Eve 1998. Lann Dawson is 33

and works as a software engineer at

Microsoft. He and his wife and son are

standing in line for a ride called

Rivers of America. The Colombia, an

old-fashioned river boat, is approaching

the dock.

According to David Koig, management

significantly reduced the number of crew

members to the bare minimum of three.

Today, one of them is running late.

Another colleague agrees to fill in at

the last minute. She's standing at the

dock holding a nylon rope and ready to

dock the ship. Disneyland's safety

protocol says she should wait until the

Columbia has fully stopped and reversed,

but she's new to the section of the

park. 2 months ago, she completed a

10-day crash course covering seven

different attractions. She has never

docked the Columbia before and has not

been trained to operate the ride. The 4

kg iron cleat on the ship's hole is

loose. The wood around it is rotten. She

throws the rope too early. The ship is

still moving

and the cleat is torn from the ship.

It shoots back towards the dock and hits

the employees foot and ankle.

Then it ricochets upwards, crushing

Luendos's school and striking his wife

across the face.

The dock is almost immediately cleaned

by Disneyland personnel. According to

Koig, they also brief witnesses on what

to say to the police, but officers don't

arrive for 5 hours. Apparently, they

only heard about the accident from the

paramedics. 48 hours later, Luan Dawson

is declared brain dead at the hospital

and taken off his respirator.

An investigation by the competent

authority blames the accident on

inadequate staff training. Several

employees will later remember having

noticed the loose cleat and the rotting

wood around it, but it was obviously

never repaired. The weak wood is never

formally identified as a cause of the

accident. The new regime and the

McKenzie recommendations had made so

many cutbacks. Everything sort of

accumulated into this perfect storm of

terror. It was horrible. The Dawson

family sues the park for damages. Disney

settles out of court and pays an

estimated 20 to $25 million. The exact

terms of the settlement are sealed. At

first, Disneyland reacts by updating

ride procedures and bringing back

experienced ride operators across the

park. But according to David Koig, many

of these safety measures are quietly

rolled back soon after. some new

procedures were instituted immediately

um as far as uh extra precautions in how

to operate the ship. But unfortunately,

many of the most important reasons that

allowed this accident to happen related

to the cutbacks, those were allowed to

continue. It was forgotten because it

was believed that McKenzie was doing the

right thing and Disney was doing the

right thing by listening to them. And

accidents do happen. I mean that is a

fact. There's no way that you know a

company can avoid all all problems. What

they really tried to do at least try to

interpret their actions from the outside

appear to be doing was to protect their

own bad decisions and cutbacks as to

sort of cover their backsides.

>> 2 months after the Columbia tragedy,

maintenance worker Robert Clustrike

resends his warning. This time he

submits it directly to one of the park's

senior managers. He writes, "I'm

concerned that the attractions are

deteriorating even more." Shortly after,

Clustrike is fired. Disney claims he was

let go because he refused to work night

shifts. Claustri himself believes he was

dismissed for blowing the whistle. The

cost cutting doesn't seem to slow down

Paul Presler's own ascent. By the time

of the Columbia accident, he had just

been promoted to president of the entire

Disney theme park division. But this is

only the beginning.

In 2000, a 4-year-old boy named Brandon

Zucker falls out of a spinning car on

the Roger Rabbit cartoon spin. He's

trapped under the following car and

stuck there for 10 minutes before first

responders can get him out. Brandon

suffers severe brain damage and can

never walk or talk again. He dies at

just 13 years old.

There's no evidence that ties the

accident directly to the cost cutting

measures, but an official investigation

once again cites grave mistakes

committed by the staff. Brandon Zucker

should never have been seated closest to

the cutout entryway of the car. Also,

ride operators probably failed to

properly lower his lap bar. It stands to

reason that better training might have

prevented the tragedy from happening. To

my knowledge, the experts from McKenzie

Company that were brought in, none of

them had any theme park experience. They

were all folks who were trained in doing

business better in general. In a sense,

that's what Disney really wanted. Their

company had been run by theme park

experts since its founding 40 years

before. McKenzie is hired to solve

problems and make companies better. But

better in what way? Better for whom?

McKenzie has made a lot of money working

for the tobacco industry. It has advised

authoritarian governments and has helped

the ICE department in the US quote

unquote optimize its detention and

deportation processes. But perhaps the

most haunting example is this one. Since

the mid90s, US pharmaceutical company

Purdue has been selling a drug called

Oxycottton. The company said it had a

low risk of addiction, but that claim

turned out to be false. As of 2004,

McKenzie was deeply involved in helping

produce turbocharged sales of the highly

addictive opioid. One strategy involved

identifying which doctors were most

likely to generate the biggest increases

in oxycottton prescriptions if actively

targeted by Purdue's sales force. We

know all this because McKenzie admitted

to it in court. McKenzie also helped

Purdue avoid problems with the US Food

and Drug Administration. The FDA also

happened to be one of Mackenzie's

clients.

You know, not only was McKenzie working

with the regulator and then the

industries, but also sometimes it was

the same consultants doing that work.

The same consultants would be advising

the Food and Drug Administration in the

United States, and they would also be on

a project with an opioid maker.

>> Since 1999, more than 850,000 people in

the US have died from opioid related

overdoses. Purdue isn't the only

culprit, but the company played a major

role in fueling America's opioid crisis.

Eventually, thousands of opioid lawsuits

were filed against Purdue Pharma and its

owners, the Sackler family. They agreed

to a $7.4 billion settlement after

previously paying $5.5 billion in fines.

The company is now bankrupt. McKenzie

spent years shaping Purdue strategy.

Walkbanage says they've always used the

same exact excuse to dodge any sort of

responsibility. They can always say and

have said that we just gave advice, we

didn't give orders. They can always slip

out of responsibility by saying that

well we recommended it but we didn't

carry out the orders. And that worked

for a long time until the opioid crisis.

We were able to look at thousands and

thousands of documents about that case

and it really did present a picture of

these McKenzie consultants that were

working extremely close with the

management. They were part of the team

and the result was that they did have to

pay a price.

>> In 2024, McKenzie paid over $600 million

to settle investigations into its role

in the opioid crisis. The Firm since

apologized for its involvement. The

statement can still be found on its

official website. It reads, "This

terrible public health crisis and our

past work for opioid manufacturers will

always be a source of profound regret

for our firm." The statement also

emphasizes that the company introduced

comprehensive compliance reforms. And

yet, McKenzie even advised Purdue Pharma

on how to counter emotional messages

from families who lost members to opioid

overdoses. The firm also admitted to

this in court.

We don't know if Mackenzie offered a

similar service to Disney after. Well,

by now more and more Disneyland

employees are speaking up against

McKenzie.

But hey, doesn't every business try to

optimize?

And what's the big deal with making the

park more efficient?

Sure,

you can't please everyone during a

transition like this,

and McKenzie only ever gives advice. The

final shots are always called by the

park's management.

Marcelo Torres dies at only 22 years

old. His best friend was seated next to

him and survives severely injured. Nine

other passengers are hurt in the

accident.

That morning, staff at Big Thunder

Mountain Railroad had noticed a strange

noise coming from the train, but they

didn't know how to respond and ended up

hesitating too long.

Taurus's family sues Disney and

investigators step in. They conclude the

accident was the result of poor

maintenance and insufficient staff

training. But the family's lawyer goes

further. This was not just one mechanic

making a mistake. This was really

systemic to how they were running the

park.

There's still a lot we simply don't know

about the Disneyland case, like which

consultants were involved, which of

their recommendations were actually

implemented. Neither Disney nor Paul

Presler responded to our questions.

McKenzie denies any responsibility for

the accidents.

One of the biggest mysteries is the

maintenance system known as RCM, the

method the consultants borrowed from

other industries. RCM is considered a

gold standard in aviation, nuclear

industries, and railroad infrastructure.

So why didn't it work at Disneyland?

>> Sometimes that might be done as we would

say you know in English in cookie cutter

fashion and you know the same solution

for for different industries. Uh and so

you know perhaps what went wrong is they

tried this cookie cutter approach uh to

Disneyland that might have worked for

another industry but it it it didn't

work uh there.

>> Disney is not a normal factory. It's not

an assembly line where you can just take

things from other industries and say,

"Oh, well, what worked there in this

produce factory is going to work in

operating the Indiana Jones Adventure."

We reached out to Marius Bassin, one of

the leading experts on reliability

centered maintenance. His company,

Aladdon, owns the trademarks for two

major RCM protocols. Basson doesn't know

all the technical details of what

happened at Disneyland, but he strongly

doubts that RCM was applied correctly.

He thinks that in theory RCM could work

in a theme park environment. But he also

writes if RCM is used to reduce costs,

it is probably applied incorrectly. RCM

or reliability centered maintenance is

not cost- centered maintenance. The

problem with most RCM program

implementations is that senior

management and stockholders want to see

immediate benefits and cost reduction.

We don't know if RCM was applied

incorrectly at Disneyland or it's just

used as a pretext for cutting costs or

whether it was the wrong approach to

begin with. What we do know is that many

people believe the cost cutting measures

recommended by McKenzie have played a

role in the accidents. But was the firm

ever held accountable?

Eric Edstrom joined Mackenzie full of

hope and idealism, but he soon realizes

that the company was not living up to

its promises. I joined McKenzie in 2018

and while I was there I found that the

projects that were available were not

anything like what were advertised and

rather than what you might see on a

McKenzie website which talks about

vaccine cold storage or renewable energy

that in practice is far and few in

between. He grows increasingly

disillusioned. He can only watch as

McKenzie helps fossil fuel companies

become even more efficient at extracting

coal and oil from the ground. Even

though the firm had originally recruited

him with the prospect of fighting

climate change, eventually he's had

enough. He sends out a farewell

statement that ricochets around

Mackenzie offices across the globe. We

know it from the book when McKenzie

comes to town. As an organization,

McKenzie seems to talk a lot about

values and principles without taking a

valued or principled stand for much of

anything. In my mind, McKenzie is an

amoral institution, an organization that

regularly takes on clients who bring

harm to others.

We would have loved to hear Disney and

Paul Presler's take on the allegations

made against them. Unfortunately,

neither responded. We also sent a

laundry list of questions to McKenzie.

For example, we were curious about what

the consultants themselves thought about

their work at Disneyland. But instead of

giving concrete answers, McKenzie

pointed us to a general statement of

theirs from 2022. There it says that the

book by Walt Buckdanic and Mike

Foresight fundamentally misrepresents

the firm and its work. The statement

also claims that Mackenzie's clients

contributed to 80% of global CO2

reductions in recent years. We can't

independently verify that number, nor

whether Mackenzie's work for those

clients has anything to do with climate

mitigation. The allegation that

Mackenzie's work has directly

contributed to mass layoffs is rejected

as a stereotype about consultants. The

statement says that McKenzie is

typically hired to help clients grow

their business and expand their

workforce. The company has supposedly

learned from its mistakes and invested

around $1 billion in a new risk

management and compliance system. The

firm claims it now has the industry's

most rigorous client selection policy.

The statement further denies any form of

responsibility for the incidents at

Disneyland. So, we decided to follow up

again, asking what McKenzie had to say

about the many reports, suggesting the

firm's recommendations did play a role.

A spokesman replied, "We aren't

commenting on whether or not we served a

particular client, but rather we reject

the author's attempt to connect our work

to events and issues that we simply had

nothing to do with."

The firm was never sued over its

connection to Disneyland tragedies. Paul

Presley left Disney in 2002 and became

CEO of the Gap clothing chain. He is

currently the chairman of the board of

directors of eBay.

The family of Marcela Torres has reached

an outofc court settlement with Disney

for an undisclosed sum. The company

accepts responsibility for the Big

Thunder Mountain accident. Torres's

parents have given $500,000 from the

settlement to provide scholarships to

aspiring talents at their son's former

college.

Marcela Torres was a graphic artist.

So, there was just all this bad

publicity and we were about less than 2

years away from the 50th anniversary of

Disneyland. This is 2003

and the 50th anniversary of Disneyland

was planned to be the biggest

celebration the Disney company in any

facet has has ever had. They knew that

all cameras that not all attention,

everything would be on Disneyland.

Accidents were still relatively

infrequent, just much more frequent than

they they had been before. But when the

Big Thunder Mountain accident happened,

they realized, "Oh my gosh, what are we

doing? This has this has got to stop.

>> Oh my god, Chloe, we're going to

Disneyland.

Oh my god."

>> Disneyland eventually recovered. Since

2003, no visitors have died due to poor

maintenance or errors committed by the

staff. Apparently, with Mackenzie and

Presler gone, a shift in mentality

followed. the park returned to its one

stellar and globally renowned safety

standards.

>> And so that come 2005 for that 50th

anniversary, Disneyland was truly the

happiest place on earth once again.

>> In 2022, Disney once again hired

McKenzie. This time, the consultants

were asked to identify redundancies and

cost-saving opportunities across

Disney's operations. According to the

Wall Street Journal, McKenzie proposed

stripping top creative executives of

control over how their work is marketed.

And once again, Disney employees started

to protest against Mackenzie's

recommendations.