After two years of investigating, the United States Coast Guard has released its final report on the deadly implosion of the Titan submersible. In the more than 300-page report, investigators laid out multiple reasons why the incident, which left all five people on board dead, was completely “preventable.”
“The two-year investigation has identified multiple contributing factors that led to this tragedy, providing valuable lessons learned to prevent a future occurrence,” TItan Marine Board of Investigation Chair Jason Neubauer said in the report. “There is a need for stronger oversight and clear options for operators who are exploring new concepts outside of the existing regulatory framework.”
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What sparked the investigation?
On June 18, 2023, during a planned expedition to the Titanic wreckage, OceanGate’s Titan lost communication with its handlers above the surface of the Atlantic Ocean. It was later discovered that the submersible had imploded, killing everyone on board.
That included OceanGate founder and CEO Stockton Rush, British billionaire Hamish Harding, French underwater explorer Paul-Henri Nargeolet (known as “Mr. Titanic”), and Pakistani businessman Shahzada Dawood and his 19-year-old son, Suleman.
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The Titan submersible imploded on June 18, 2023, less than two hours after it began its expedition to the wreckage of the Titanic, killing all five people on board.
What did the Coast Guard find?
During its journey, the Titan’s hull experienced a “critical event that compromised the structural integrity of its pressure vessel, resulting in an instantaneous and catastrophic implosion,” according to the Coast Guard’s report.
Investigators noted many factors contributed to the tragedy, including “inadequate design, certification, maintenance and inspection process for the Titan.” They said OceanGate also failed to properly investigate and address known issues with the submersible’s hull.
“Investigators determined the Titan’s real-time monitoring system generated data that should have been analyzed and acted on during the 2022 Titanic expedition,” the report read. “However, OceanGate did not take any action related to the data, conduct any preventative maintenance or properly store the Titan during the extended off season before its 2023 Titanic expedition.”
But the Titan itself wasn’t the only problem.
Other factors included “a toxic workplace culture at OceanGate, an inadequate domestic and international regulatory framework for submersible operations and vessels of novel design, and an ineffective whistleblower process under the Seaman’s Protection Act.”
The Coast Guard identified eight primary causes for the deadly implosion:
- OceanGate’s design and testing process didn’t adequately address the fundamental engineering principles needed for a journey to an inherently hazardous environment.
- OceanGate didn’t conduct an analysis to understand the expected cycle-life of the hull.
- OceanGate’s “excessive” reliance on its real-time monitoring system to assess the condition of the hull and its failure to conduct a meaningful analysis of the data provided.
- The company continued to use the Titan even after a series of incidents compromised the integrity of the hull and other critical components without properly assessing or inspecting it.
- The Titan’s carbon fiber hull design and construction led to flaws that weakened its structural integrity.
- OceanGate did not conduct detailed investigations after the Titan experienced mishaps.
- OceanGate had a “toxic workplace environment” that dissuaded employees and contractors from expressing safety concerns.
- The company didn’t do any preventative maintenance on the Titan or protect it from the elements during the offseason ahead of the June 2023 expedition.
The report also listed four other contributing factors:
- OceanGate’s safety culture and operational practices were “critically flawed,” and there were “glaring” disparities between the company’s written safety protocols and its actual practices.
- Rush, the company’s CEO, misrepresented the Titan as “indestructible,” creating what the Coast Guard says was a “false sense of safety” for passengers and regulators.
- OceanGate’s top leaders prioritized money and customer expectations over the company’s responsibilities.
- In general, there is a “lack of comprehensive and effective regulations for the oversight and operation of manned submersibles and vessels of novel design.”
What happens next?
In its report, the Coast Guard laid out a series of recommendations to avoid tragedies like this in the future.
They include improving interactions between organizations and groups in the submersible industry, and that existing submersibles have their Oceanographic Research Vessel (ORV) designation revoked until they are certified under federal passenger vessel inspection requirements.
The Coast Guard’s investigators also gave the agency its own set of specific recommendations, like pursuing “proper regulatory oversight” of submersibles and dedicating resources to “providing field support for vessels of novel design.”
It also suggested the Coast Guard start requiring sub owners to notify them before they conduct operations, including a dive plan and emergency response plan.
