USCG: Deadly loss of Titan submersible was preventable

Coast Guard marine safety engineers, working for the Marine Board of Investigation for the Titan submersible case, conduct a survey of the aft titanium endcap from Titan in the North Atlantic Ocean. [Photo courtesy of the U.S. National Transportation Safety Board]

The June 2023 loss of the Titan submersible, which cost five lives, was preventable according to Jason Neubauer, chair of the U.S. Coast Guard Marine Board of Investigation (MBI) into the incident. The MBI yesterday released its 300-page Report of Investigation (ROI) on the Titan’s ill fated attempted dive to the Titanic.

The more than 300-page ROI outlines key findings and contributing factors in the casualty and includes 17 safety recommendations aimed at strengthening oversight of submersible operations, improving coordination among federal agencies and closing gaps in international maritime policy.

“This marine casualty and the loss of five lives was preventable,” said Neubauer. “The two-year investigation has identified multiple contributing factors that led to this tragedy, providing valuable lessons learned to prevent a future occurrence. 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 submersible’s operator, OceanGate, and its CEO, Stockton Rush, who died in the incident, do not emerge well from the report.

“Five people died when the commercial submersible Titan imploded on June 18, 2023, in what is considered to be a preventable tragedy,” the report says. “The U.S. Coast Guard’s Marine Board of Investigation into the fatal incident found that OceanGate’s failure to follow established engineering protocols for safety, testing, and maintenance of their submersible, was the primary causal factor.

“The investigation further identified the need for proper corporate governance, a professional workplace culture, and improved regulatory oversight, in particular for novel vessel designs and operations. For several years preceding the incident, OceanGate leveraged intimidation tactics, allowances for scientific operations, and the company’s favorable reputation to evade regulatory scrutiny. By strategically creating and exploiting regulatory confusion and oversight challenges, OceanGate was ultimately able to operate Titan completely outside of the established deep-sea protocols, which had historically contributed to a strong safety record for commercial submersibles. The lack of both third-party oversight and experienced OceanGate employees on staff during their 2023 Titan operations allowed OceanGate’s Chief Executive Officer [Stockton Rush] to completely ignore vital inspections, data analyses, and preventative maintenance procedures, culminating in a catastrophic event.”

The board determined the primary contributing factors were OceanGate’s inadequate design, certification, maintenance and inspection process for the Titan. Other factors cited in the report include a toxic workplace culture at OceanGate, an inadequate domestic and international regulatory framework for submersible operations and vessels of novel design, and an ineffective whistleblower process under the Seaman’s Protection Act.

The board also found OceanGate failed to properly investigate and address known hull anomalies following its 2022 Titanic expedition. Investigators determined the Titan’s real-time monitoring system generated data that should have been analyzed and acted on during the 2022 Titanic expedition. However, OceanGate did not take any action related to the data, conduct any preventative maintenance or properly store the Titan during the extended off season before its 2023 Titanic expedition.

MBI recommendations include restricting the Oceanographic Research Vessel designations for submersibles, expanding federal and international requirements to all submersibles conducting scientific or commercial dives and requiring Coast Guard documentation for all U.S. submersibles. The board also recommended adding Coast Guard personnel capacity at Coast Guard Headquarters to support new construction oversight and field inspections involving submersibles and vessels of novel design.

Further recommendations include requiring operators to submit dive and emergency response plans to the local Coast Guard officer in charge, marine inspection; evaluating the Coast Guard’s subsea search and rescue capabilities; and working with the International Maritime Organization to define passenger submersibles and expand international safety requirements for submersibles operating on the high seas. The board also called for a new Occupational Safety and Health Administration and Coast Guard agreement to clarify whistleblower investigative protocols and improve interagency coordination.

The Marine Board’s report is now under review by the Commandant of the Coast Guard. Upon completion of the review, the Commandant will issue a Final Action Memorandum confirming the U.S. Coast Guard’s position on the recommendations and any actions to be pursued.

• The Marine Board’s report is available HERE