An implosion that killed all five people aboard a small submersible during a June 2023 expedition to the Titanic wreckage site was the result of design flaws, lax oversight and a “toxic workplace culture” that put the company’s finances over safety, according to a U.S. Coast Guard report released Tuesday.
The implosion was triggered by a loss of structural integrity at a section of the carbon fiber hull, but it could have been prevented, according to the report, which held OceanGate CEO Stockton Rush responsible for ignoring safety warnings, design flaws and crucial oversight that, had he survived, could have resulted in criminal charges.
The Titan was owned by OceanGate, a company in Everett, Washington, that provided crewed submersibles for research, exploration and tourism. Rush, who co-founded the company, was among those aboard its final doomed mission.
“The two-year investigation has identified multiple contributing factors that led to this tragedy, providing valuable lessons learned to prevent a future occurrence,” said Jason Neubauer, chairman of the Coast Guard’s Marine Board of Investigations. “There is a need for stronger oversight and clear options for operators who are exploring new concepts outside the existing regulatory framework.”
The Coast Guard said the loss of the Titan could have been prevented had OceanGate followed basic safety protocols. The company’s “consistent pattern of neglect” underscored its prioritization of financial expediency over operational safety.
The safety culture at OceanGate was critically flawed, with “glaring disparities” between its written safety protocols and the company’s practice. Rush misrepresented Titan as indestructible, providing a false sense of safety for passengers, who paid $250,000 each for the trip to the Titanic, the Coast Guard said.
“OceanGate’s senior leaders fostered an organizational culture that allowed mounting financial shortfalls, customer expectations and operational demands to be prioritized over the mission director’s authorities and responsibilities for each Titanic dive,” the report said.
Investigators accused Rush of “intentional and systematic efforts” to misrepresent the company’s compliance with safety, engineering and regulatory standards.
“This intentional skirting of regulations, often achieved by masking the true intentions and operations of the vessels, was a key element incorporated by OceanGate during their strategic development of the Titan business model,” the report stated.
Company officials used firings and threats of firings as a tactic to dissuade employees from reporting their concerns about the safety conditions at OceanGate, the Coast Guard said.
The Marine Board concluded that Rush had an “escalating disregard for established safety protocols,” which contributed to the deaths of four people. If Rush were alive, the board would have passed the case to the Department of Justice, and he could have faced criminal charges, the board said.
OceanGate’s focus on cost-cutting included storing the submersible and its delicate equipment outdoors during a Canadian winter, according to the report.
“If the Titan had been properly stored in a controlled environment, shielded from inclement weather conditions, its structural integrity might have been better preserved,” the Coast Guard said.
The report said the exposure of the Titan to significant temperature fluctuations and precipitation during its prolonged storage in an outdoor parking lot likely accelerated material degradation, including potentially weakening the hull and other critical components. The dire consequences could have been avoided with more responsible decision-making, the Coast Guard said.
The carbon fiber hull design and construction of the Titan introduced flaws that weakened the structural integrity, and they likely worsened over time. OceanGate failed to conduct a detailed investigation of the potentially damaging forces exerted on the submersible’s carbon hull and critical components while diving. The Coast Guard said there may have been several incidents of damage on the Titan during previous dives.
OceanGate also failed to properly investigate and address known hull anomalies after its 2022 Titan expedition. The sub’s real-time monitoring system generated data that should have been analyzed and acted on, the Coast Guard said.
“However, OceanGate did not take any action related to the data, conduct any preventative maintenance, or properly store the Titan during the extended offseason before its 2023 Titanic expedition,” according to the damning report.
The Coast Guard report noted a lack of “meaningful analysis” from OceanGate to gauge the expected life cycle of the Titan hull. Prior material testing was not conducted, and the analysis of the vessel’s integrity was based on assumed material properties with “minimal manufacturing defects.”
The paying passengers aboard the Titan submersible were Hamish Harding, a British businessman; Shahzada Dawood, a Pakistani-British businessman; his son Suleman Dawood; and Paul-Henri Nargeolet, a French diver and Titanic expert. After the implosion, all five were exposed to almost 5,000 pounds per square inch of water pressure, resulting in their instantaneous death, the Coast Guard said.
The design and testing processes for the Titan didn’t address many of the engineering principles crucial for constructing a vessel capable of operating in a hazardous environment. OceanGate didn’t ensure an analysis was conducted to understand the expected life cycle of the submersible’s hull, the report found.
The Coast Guard also cited the company’s continued use of the Titan after incidents that compromised critical components of the submersible without a proper assessment and inspection.
The constant need to raise additional capital to sustain operations was paramount to OceanGate’s survival. Rush was forced to make “significant” personal loans to the company to keep the lights on in 2022 and 2023.
“The pressing need to have Titan appear fully operational in order to continue securing investor capital directly impacted multiple decisions related to Titan’s 2023 operations,” according to the report.
The Coast Guard also criticized the lack of effective regulations for the oversight and operation of manned submersibles and vessels of novel design that operate in U.S. waters. The accident board called for expanding federal and international requirements for all submersibles conducting scientific or commercial dives and requiring Coast Guard documentation for all U.S. nonmilitary submersibles.
Mr. Neubauer also recommended “adding personnel capacity at Coast Guard headquarters to support new construction oversight and field inspections involving submersibles and vessels of novel design.”
OceanGate suspended operations in July 2023. A spokesperson for OceanGate, Christian Hammond, said the company has been wound down and was fully cooperating with the investigation, and offered condolences to the families of those who died and everyone affected.
• This article is based in part on wire service reports.
• Mike Glenn can be reached at mglenn@washingtontimes.com.
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