During a sightseeing trip to the wreck of the Titanic on June 18, 2023, the submersible Titan imploded. All five people on board died instantly. The submersible was not registered anywhere. The escort ship was Canadian and left the port of St. John’s in Newfoundland, which is why the Canadian Transportation Safety Board (TSB) investigated the fatal voyage. On Wednesday it published its report M23A0169. In it she describes numerous deficiencies and makes six recommendations.
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The Titan’s design was unique and untested. It was built and operated by a small US company called Oceangate. However, she did not check whether the assumptions she made about materials and construction were actually correct. It was therefore completely unclear how many dives the carbon fiber shell would withstand.
Schematic of Titan
(Image: TSB/Daniel AJ Sokolov)
Although a system was installed that recorded material stress, its data was not regularly evaluated. There were also two warning systems that were supposed to sound the alarm in the event of problems. One didn’t work. Oceangate has never verified whether the other would have warned so early that Titan could have carried out the diving operation, which lasted more than three hours.
Safety was secondary
In addition, the company used defective carbon fiber material: cheap rejects that had failed the aircraft assembler Boeing. This known bad material was then installed, stored and transported improperly. The fact that the Titan did not have a hatch that could be opened from the inside was irrelevant to the specific accident, but exemplary of the safety culture. Outsiders had to remove screws to let the occupants get out.
In addition, the emergency plan was completely inadequate. The escort ship had no way of locating Titan underwater. Theoretically, the use of diving robots was planned if Titan could not surface independently. But there were no contracts with operators of suitable diving robots. Life support for Titan inmates was limited to just 96 hours. Finding suitable diving robots and bringing them to site took significantly longer.
Social factors
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The Canadian report diplomatically summarizes the conditions at Oceangate that contributed to the fatal accident: “Oceangate’s risk management was hampered by the structure and composition of the company and influenced by power relations and social and psychological factors.” As is already known from a US investigation report into the fatal Titanic diving voyage, company boss Stockton Rush only placed moderate importance on safety.
Rush relied on trial and error and responded spontaneously to problems. Several people who had flagged security risks internally left or were fired. One filed a complaint with the US Occupational Safety and Health Administration (OSHA), but was silenced by a lawsuit from Oceangate. At the time of the accident, Oceangate no longer had a development manager.
Company boss Rush can no longer be held responsible. He is one of the five fatalities.
No supervision
Watercraft must be registered in a single country, which then has jurisdiction. But Oceangate has not registered its Titan anywhere. The company canceled an attempt to register in the Bahamas after its authorities explained the necessary requirements, the Canadian report states.
But registration does not mean that the watercraft has to be certified. Specifically in Canada, only around a quarter of the registered fleet is subject to the certification requirement (depending on size and maximum number of passengers carried). The rest must also comply with operating and safety regulations. Whether they do this is not continually checked by the authorities. The Canadian Ministry of Transport relies on “risk-based” inspections.
Foreign ships entering Canadian ports must report in advance and can then be examined in port. However, this only applies from 500 gross tons and not to watercraft that are imported as cargo by other vessels, as was the case with the Titan.
No rules
Above all, there are no mandatory standards for the design, manufacture and operation of submersibles. The International Maritime Organization (IMO) has drawn up guidelines (Maritime Safety Committee Circular 981), but compliance with them is voluntary. Therefore, the Canadian Transportation Safety Board recommends that the Department of Transportation lobby the IMO to incorporate these guidelines into international treaties or standards.
Additionally, the monarchy should require compliance with the guidelines for all submersibles registered in Canada, having a Canadian escort vessel, or operating in the exclusive economic zone off the country’s coasts. (The Titanic is outside this zone, note.)
Three further recommendations aim at better communication between authorities and a concrete definition of risk factors that trigger official inspections. The sixth advice concerns better cooperation between the crew of a submersible and the crew of its support vessel.
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