USCG Report on Titan Cites Glaring Failures Calling Incident "Preventable"

Two years after the implosion of the submersible Titan that killed five people on their way to explore the wreck of the Titanic, the U.S. Coast Guard’s Marine Board of Investigation issued its final report calling the incident a “preventable tragedy.” The report is highly critical of the management of the vessel’s operator, Ocean Gate, as well as the design and processes for the handling of the submersible, while also identifying critical changes to the oversight and management of the industry.

The investigation found that OceanGate’s failure to follow established engineering protocols for safety, testing, and maintenance of its submersible was the primary factor in the casualty. However, they further identified the need for proper corporate governance, a professional workplace culture, and improved regulatory oversight.

They found that the groundwork for the disaster was laid years earlier, saying that OceanGate “leveraged intimidation tactics” as part of its efforts to evade regulatory scrutiny. Further, they charge that the company created and exploited regulatory confusion and oversight challenges, which permitted it to operate the Titan “completely outside of the established deep-sea protocols.” Further, it finds that CEO Stockton Rush, who died as the pilot of the vessel, “completely ignored vital inspections, data analysis, and preventative maintenance procedures, all of which the USCG says culminated in the catastrophic event on June 18, 2023.

Titan, built in 2021, was a 22-foot submersible. It had an 8-foot-long carbon fiber pressure hull glued to titanium end caps. The USCG points out that the vessel was not registered, certified, inspected, or classed by any international flag administrator or recognized organization. The report concludes that the probable failure point was either the adhesive joint at the forward dome or the carbon fiber hull near the forward end of the Titan.

“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, Titan MBI chair. “There is a need for stronger oversight and clear options for operators who are exploring new concepts outside of the existing regulatory framework. I am optimistic the ROI’s findings and recommendations will help improve awareness of the risks and the importance of proper oversight while still providing a pathway for innovation.”

The final 335-page report details many previously revealed factors while also piecing together a long list of issues that it says combined to result in the catastrophic failure of the Titan. It starts with the design and testing of the Titan, which it found did not adequately address many of the fundamental engineering principles. The design and construction process they also report “introduced flaws that weakened the overall structural integrity of Titan.” They report OceanGate did not conduct a proper analysis to understand the expected life cycle of the hull.

Once in operation, it finds that OceanGate was excessively reliant on a real-time monitoring system to assess the condition of the hull. The company failed to conduct additional analysis and to conduct analysis after mishaps that negatively impacted the hull and its components. Also, they found there was a lack of preventative maintenance.

The report has strongly worded criticisms of Rush, saying that OceanGate had a “toxic workplace environment” and used firings or the threat of firing to dissuade employees from expressing safety concerns. It says the company’s safety culture and operational practices were “critically flawed,” with glaring dispraises between written safety protocols and actual practices. It says Rush sustained efforts to misrepresent Titan as indestructible.

It, however, also reports that the Occupational Safety and Health Administration failed to properly follow up on a 2018 whistleblower complaint about safety concerns. Among the recommendations from the investigation are improvements in the communication between OSHA and USCG, saying that if that had been properly followed, it might have led OceanGate to regulatory compliance or abandoning the plans for Titanic expeditions.

In addition to reporting that communications were improved with OSHA, the investigation recommends a broad set of steps to improve the submersible industry. There is a recommendation for an industry working group that, among other things, would review USCG limitations and regulations, as well as calling for an expansion of federal requirements to ensure proper regulatory oversight.

The Coast Guard, the report recommends, should review policies and guidance for Oceanographic Research Vessels (ORVs), including the surface support vessels, and any existing submersible ORV should have its letter of designation revoked and should be reinspected for certification under passenger vessel requirements. It is part of a long list of steps they found that are necessary to enhance the regulation and oversight of submersibles in the wake of this catastrophe.