- The OceanGate submersible implosion was caused by lack of adherence to safety and engineering standards, Tuesday's report said.
- The investigation identified numerous factors, including not following maintenance and inspection protocols.
- Several safety and regulatory recommendations came from the report, including uniform standards for all submersibles.
The U.S. Coast Guard’s Marine Board of Investigation released a report on Tuesday outlining what it found out about the 2023 OceanGate Titan submarine implosion that killed five people.
The report determined the disaster was preventable and was ultimately caused by OceanGate Expeditions cutting corners due to financial issues and its inability to meet safety and engineering standards, according to The Wall Street Journal.
“This marine casualty and the loss of five lives was preventable,” Titan Marine Board Investigation Chair Jason Neubauer said in a statement, according to NPR. “The two-year investigation has identified multiple contributing factors that led to this tragedy.”
The Coast Guard’s 335-page report detailed the findings of a two-year investigation, including that the company failed to follow maintenance and inspection protocols, operated without third-party oversight, and disregarded analyses and assessments for the Titan submersible.
On June 18, 2023, five people aboard the Titan submersible were killed when it imploded on a trip to view the wreckage of the Titanic.
One of the people who died in the implosion, Stockton Rush, the co-founder and CEO of OceanGate, was found to have shown negligence and, if he were alive, could have faced criminal investigation, per The Wall Street Journal.
The other people aboard the submersible were British adventurer Hamish Harding, French explorer Paul-Henri Nargeolet, and two members of a prominent Pakistani family, Shahzada Dawood and his son, Suleman Dawood, according to NPR.
Key takeaways from the report
According to The Wall Street Journal, the report showed that the company avoided regulatory review and managed the Titan submersible outside of standard protocols.
This was done “by strategically creating and exploiting regulatory confusion and oversight challenges.”
There was also a “toxic culture” within the company, especially around the idea of safety.
Last year, when former staffers testified in a hearing for the investigation, they said that the company would cut corners and did not give priority to safety. They added that Rush didn’t like to be pushed on concerns about safety and that he made most of the major engineering decisions for the company.
The report from the Coast Guard also cites the submersible’s inadequate design as an issue that contributed to the implosion. According to NPR, the hull was made of cheaper carbon fiber instead of a stronger steel alloy that is more commonly used.
Investigators also reported finding a lack of maintenance, inspections and certifications for Titan.
Evidence found in the investigation showed the tragedy was most likely due to “a loss of structural integrity of the carbon fiber or glue joint,” according to The Wall Street Journal.
Other issues with OceanGate listed in the report
The report included testimony that Rush had all the decision-making power and would fire people when they spoke out.
Due to people being fired for speaking out and others leaving the company by choice, OceanGate was forced to rely on contractors. With fewer full-time employees, the company was less able to address safety risks, according to CNN.
After the engineering director left the company due to safety concerns, Rush did not fill the position.
Financial pressure within the company also led to the submersible using text-based communications instead of “the industry-standard for submersibles which enables voice communication,” the report said, per CNN.
The report also said that the Titan submersible and other equipment were stored outdoors through the winter in Canada, where they were potentially compromised. The investigators cited this as an example of a “consistent pattern of sacrificing safety and operational integrity for financial gain.”
Recommendations given by the board of investigations
According to CNN, the report included multiple recommendations from the Coast Guard’s Marine Board of Investigation on how similar disasters can be avoided in the future.
It was recommended that enhanced communications capabilities be mandated for all submersibles.
The board also called on the Coast Guard to seek a new regulation that would require all submersibles built in the U.S. to be built and maintained with uniform standards, per CNN.