In a report issued today, the U.S. Coast Guard panel investigating the loss of OceanGate’s Titan submersible and its occupants in 2023 blamed the disaster on a series of safety lapses — and issued recommendations that were aimed at heading off future tragedies.
“This marine casualty and the loss of five lives was preventable,” Jason Neubauer, the chair of the Coast Guard’s Marine Board of Investigation, said in a news release.
The 335-page report said the Coast Guard would have referred the CEO and founder of Everett, Wash.-based OceanGate, Stockton Rush, to the Justice Department for criminal investigation if he had survived Titan’s catastrophic implosion on June 18, 2023. Rush, who piloted the sub, died instantly during a dive to the wreck of the Titanic, along with four passengers: Titanic expert P.H. Nargeolet, British billionaire adventurer Hamish Harding, and Pakistani-born business executive Shahzada Dawood and his 19-year-old son, Suleman Dawood.
After the report’s release, the Dawood family said the report confirmed that the deaths were due to “unregulated behavior, a lack of accountability, and a fundamentally flawed design.”
“No report can alter the heartbreaking outcome, nor fill the immeasurable void left by two cherished members of our family,” the Dawood family said in a statement reported by the BBC. “We believe that accountability and regulatory change must follow such a catastrophic failure.”
In a statement emailed to GeekWire, an OceanGate spokesperson said the company offered its “deepest condolences to the families of those who died … and to all those impacted by the tragedy.”
“After the tragedy occurred, the company permanently wound down operations and directed its resources fully towards cooperating with the Coast Guard’s inquiry through its completion,” the spokesperson said.
Bad design, toxic workplace
The report faulted OceanGate’s initial decision to use a carbon-composite hull that was vulnerable to degradation and sudden collapse. It said that mistake was compounded by inadequate measures to certify, maintain and inspect the sub. The investigators cited other factors as well, including a “toxic workplace culture at OceanGate,” an inadequate regulatory framework — and an ineffective procedure for dealing with a complaint that a whistleblower filed with the Occupational Safety and Health Administration in 2018.
“It was a long journey, and OSHA were handed everything,” whistleblower David Lochridge, who was fired from his post OceanGate’s director of marine operations five years before the fatal dive, told GeekWire via email in June. “They let us down.”
OceanGate’s lapses, and Rush’s behind-the-scenes attempts to downplay such lapses, came under the spotlight in a series of hearings conducted by the investigative board last summer — and in follow-up documentaries that were released this year.
Publicly, Rush contended that OceanGate’s submersible technology was too innovative to fit the mold for the standard certification process, and structured the company to avoid being subject to U.S. regulations. Privately, Rush tried to explain away evidence that Titan’s hull might crack under the extreme pressures of the deep ocean, and used legal threats to squelch criticism.
OceanGate executed several rounds of dives to the Titanic shipwreck in 2021 and 2022, carrying “mission specialists” who paid as much as $250,000 to participate in the adventure. During one of the dives in 2022, known as Dive 80, a loud bang was heard as the sub was ascending. At the time, OceanGate’s team brushed off concerns, saying the noise was merely due to the sub settling into its carrier platform. But after analyzing the acoustic readings, investigators suspect that the noise was actually an early indication of the hull’s delamination and failure.
The investigators said that Titan’s acoustic monitoring system — which Rush had held up as an innovative early warning system — didn’t work as advertised. Nevertheless, 2023’s catastrophe might have been avoided if OceanGate had paid closer heed to the acoustic readings and conducted a complete hull inspection back at its Everett headquarters. Instead, OceanGate left the sub open to the elements in a parking lot at its Canadian port.
“The pre-existing delamination caused during Dive 80 was likely exacerbated by cyclic thermal changes on the hull throughout its outdoor fall and winter storage in Newfoundland following the 2022 expedition, combined with continual impact damage from towing the submersible thousands of miles across the North Atlantic in moderate sea conditions,” the report said.
Still more damage might have been done during a dive that took place just days before the disaster, when a platform malfunction tilted the sub at a 45-degree angle and upended the passengers.
The report said that investigators were unable to pinpoint the exact point of failure for Titan’s last dive, but added that the facts strongly suggest the most likely initiating point was “a loss of structural integrity of the carbon fiber or glue joint within the Titan’s cylindrical pressure hull.”
Next steps in the Titan saga
Investigators made more than a dozen safety recommendations, including restricting the research designations for submersibles, expanding regulatory requirements for all submersibles that are conducting scientific or commercial dives, and requiring Coast Guard documentation for all U.S. submersibles.
The report recommends establishing an industry working group to review and update the standards for submersibles, with an eye toward allowing new passenger operations under U.S. regulations while reducing the incentive for operators like OceanGate to “conduct non-compliant operations.” And it calls for a new agreement between OSHA and the Coast Guard to improve interagency coordination and clarify the protocols for following up on whistleblower reports.
It will be up to the Coast Guard, other U.S. government agencies and groups such as the International Maritime Organization to follow through on the recommendations. OceanGate is already facing a lawsuit filed by the family of P.H. Nargeolet, seeking $50 million in damages — and now that the investigative report has come out, more legal action may follow.
