Titan Submersible Implosion Was Caused By ‘Inadequate Design,’ Deaths Were Preventable, Final Investigation Finds

The implosion of the Titan submersible was “preventable” and caused by the owner’s failure to follow established protocols for engineering, safety, testing, and maintenance, a final report on the incident released on Tuesday by the United States Coast Guard has found.

The June 18, 2023 implosion of the Titan—a tourist submersible that brought passengers to the wreck of the Titanic in the North Atlantic Ocean for the hefty price tag of up to $250,000—led to the instantaneous loss of five lives, including that of Oceangate’s CEO, Stockton Rush.

The report accused the company of harboring a “toxic work place environment,” citing the firings of some staff members and the threat of firings against others to dissuade employees from “expressing safety concerns.”

The report pointed to gaps between the company’s written safety protocols and actual practices. Financial concerns at the company, the report said, were prioritized over the safety standards that had to be observed during each Titanic dive. The company also engaged in intimidation tactics to “evade regulatory scrutiny,” according to the report.

Read more: The Titan Sub and the Dangers of Unregulated Deep-Sea Tourism

The USCG criticized OceanGate’s use of the Titan despite numerous incidents that compromised the “integrity of the hull,” which already had flawed design issues in terms of thickness, winding, and curing standards. It noted that the carbon fiber used to make the submersible is strong, but it is not reliable under pressure.

“There are currently no recognized national or international standards that approve of the use of carbon fiber pressure hulls for submersibles,” Tuesday’s report said.

There were also flaws in terms of the submersible crew's reliance on a real-time monitoring system that would assess the health of the hull during their dives. No dives were ever aborted due to the real-time monitoring system, the report found.

The 22-foot Titan was “not registered, certified, inspected, or classed by any international flag administration or recognized organization.” 

The company’s failure to investigate mishaps in the Titan during dives before the June 2023 incident led to the submersible’s tragic implosion, during which passengers were subject to nearly 5,000 pounds per square inch of water pressure. 

But the onus was not solely on OceanGate. The USCG report also pointed to a “missed opportunity” by government agencies to investigate the Titan submersible. In 2018, OceanGate’s former director of marine operations filed a report with the Occupational Safety and Health Administration (OSHA) after he was fired for citing safety concerns about the submersible. “Early intervention may have resulted in OceanGate pursuing regulatory compliance or abandoning their plans for TITANIC expeditions,” the report said. 

Still, the report did not find any acts of misconduct or incompetence by USCG employees or other personnel that “contributed to this casualty.” Instead, investigators found that Rush, as a corporate executive and subpilot of the submersible, had displayed negligence that factored into the deaths of the other passengers aboard. He could have been subject to “criminal liability,” though a full investigation into the matter did not occur due to his passing.  

Fourteen recommendations were outlined in Tuesday’s report, including calls for enhanced communication for underwater operations in the case of an emergency, and new regulations mandating U.S. submersibles to be built under specific standards. 

The tragic incident, which generated international interest, led to a two-year investigation by the USCG. The report is the culmination of nine days of public hearings from at least twenty-six former OceanGate employees, experts, and maritime investigators. 

OceanGate ceased operations after the incident.