The company OceanGate, whose submersible Titan imploded during an expedition to the Titanic wreck in 2023, had “critically deficient” safety practices and a “toxic work culture,” according to the official report by the United States (U.S.) Coast Guard released after a two-year investigation.
The final report on OceanGate was published by the U.S. Coast Guard and its Marine Board of Investigation (MBI). The company (OceanGate) was responsible for the Titan submersible that imploded during a dive to the Titanic wreck two years ago, killing all five people on board.
The 335-page report, released on Tuesday, states that OceanGate did not follow engineering protocols for the safety, testing, and maintenance of the vessel. The document highlights serious issues in the company’s operations, its work culture, and warns of the need for stricter regulatory oversight over “crewed submersibles and new design vessels.”
Avoiding oversight and exploiting reputation
“For several years prior to the incident, OceanGate used intimidation tactics, permits for scientific operations, and the company’s favorable reputation to avoid regulatory oversight,” the report states.
It further notes that the company, by “strategically creating and exploiting regulatory confusion,” was able to operate Titan entirely outside of established deep-sea protocols, which have historically contributed to the safety of commercial submersibles.
The June 2023 tragedy triggered an international search and rescue operation. Titan lost contact with its support vessel, the Polar Prince, on June 18th, after which it was determined that the submersible’s hull had lost structural integrity and imploded. The accident claimed the lives of OceanGate CEO Stockton Rush, United Kingdom (UK) billionaire and explorer Hamish Harding, father and son Shahzada and Suleman Dawood, and renowned Titanic expert Paul-Henri Nargeolet.
“The tragedy was preventable”
“This marine casualty and the loss of five lives were preventable. The two-year investigation identified multiple factors that led to the tragedy, providing valuable lessons for preventing future accidents. Stronger oversight and clear options are needed for operators exploring new concepts outside the existing regulatory framework,” said Jason Neubauer, chairman of the Titan MBI.
Critically flawed safety culture
The report states that the “primary causal factors” of the tragedy were the inadequate handling of engineering problems and the lack of understanding of how the hull would react in an “inherently hazardous environment.”
OceanGate, despite incidents that compromised the integrity of the hull, continued to use Titan. The MBI also points to a “critically flawed” safety culture and operational practices of the company.
“At the center of these failures were clear discrepancies between written safety protocols and actual practice,” the report states.
It also highlights how the OceanGate CEO’s efforts to present Titan as “indestructible” due to unverified safety margins and alleged compliance with advanced engineering principles created a “false sense of security” among passengers and regulators.
Government failures and a 2018 whistleblower
The U.S. Coast Guard also pointed to failures of government institutions, emphasizing that there was a “missed opportunity” for intervention. It highlighted a 2018 whistleblower from OceanGate, as well as weaknesses in communication between the Occupational Safety and Health Administration (OSHA) and the U.S. Coast Guard regarding protocols of the Seaman’s Protection Act.
“Early intervention could have led OceanGate to seek regulatory compliance or abandon plans for Titanic expeditions,” the report emphasized.
17 recommendations for the future
The report outlines 17 recommendations, including the establishment of an industry working group to revise the submersible safety framework and align its standards more closely with those for surface vessels.
It also recommends the introduction of federal requirements for “appropriate regulatory oversight” of submersibles involved in exploratory operations.
Among the recommendations are: mandatory communication for all submersibles conducting commercial or scientific operations; introduction of requirements for sub owners to notify local U.S. Coast Guard offices, including a dive plan and emergency response plan.
