Multiple contributing factors — including OceanGate’s toxic workplace environment and intimidation tactics — led to the entirely “preventable” implosion of a submersible that killed five people off the coast of Newfoundland two years ago, Coast Guard investigators said Tuesday.
The findings were made in a 327-page report that outlined a series of critical flaws and recommendations aimed at heading off future potential tragedies.
“This marine casualty and the loss of five lives was preventable,” said Jason Neubauer, the chairman of the U.S. Coast Guard Marine Board of Investigation that was charged with probing the Titan disaster.
The planned dive to the historic wreck of the Titanic on June 18, 2023, ended in disaster after the Titan lost communication with its OceanGate handlers, setting off a frantic search.
Days later, it was determined that the submersible imploded and instantly killed all five people on board, including a 19-year-old, officials said.
The Titan’s hull experienced a “critical event that compromised the structural integrity of its pressure vessel, resulting in an instantaneous and catastrophic implosion” at 10:47 a.m. that day, according to the report.
“The two-year investigation has identified multiple contributing factors that led to this tragedy, providing valuable lessons learned to prevent a future occurrence,” Neubauer said. “There is a need for stronger oversight and clear options for operators who are exploring new concepts outside of the existing regulatory framework.”
Investigators said many factors contributed to the tragedy, including OceanGate’s continued use of the Titan after a series of incidents that compromised the integrity of the hull, and the company’s failure to conduct detailed investigations after mishaps.
OceanGate leaders fired senior staff members and threatened other terminations to “dissuade employees and contractors from expressing safety concerns,” investigators also said.
During the Coast Guard’s investigatory hearing last year, OceanGate’s former engineering director, Tony Nissen, testified that he was fired because he refused to sign off on a planned expedition after the submersible was struck by lightning, compromising its experimental carbon fiber hull.
Nissen also testified that OceanGate had no designated safety officer and that “most people would eventually just back down” to OceanGate CEO Stockton Rush.
Nissen said he turned down a request by Rush to be the Titan’s pilot on missions to tour the Titanic because he didn’t trust the operations crew or Rush.
Investigators found that OceanGate “leveraged intimidation tactics” to “evade regulatory scrutiny” and ultimately operate the Titan “completely outside of the established deep-sea protocols.”
The report said the lack of oversight and experienced OceanGate employees allowed Rush to “completely ignore vital inspections, data analyses, and preventative maintenance procedures, culminating in a catastrophic event.”
OceanGate bypassed “rigorous testing” which led to “significant” failures in the Titan’s design, investigators said. The company didn’t do enough research to determine if the Titan’s materials would hold up under high pressure, according to the Coast Guard.
“OceanGate failed to dedicate the requisite time and resources to these crucial processes, which likely contributed to undetected vulnerabilities in the submersible’s hull,” investigators found.
“Without detailed research and testing on the bonding capabilities, there was a high risk that structural failure would occur at the interface under the extreme conditions experienced by a submersible.”
Days before the implosion, during a test dive, the Titan crew encountered several challenges, with mission specialists expressing concern that Rush was rushing, the report states.
They “felt Mr. Rush was beginning to get ‘antsy’ and ‘clearly frustrated’ and that Mr. Rush made the statement, ‘I’m going to get a dive in, even if it kills me,’” according to the report.
Rush, 61, French diver and Titanic expert Paul-Henri Nargeolet, 77, British billionaire Hamish Harding, 58, Pakistani businessman Shahzada Dawood, 48, and his 19-year-old son, Suleman, all perished in the implosion.
Support personnel lost all communications and tracking with the Titan around the time of the implosion at 10:47 a.m.
When the Titan did not surface as expected at 3 p.m., OceanGate’s protocol directed support personnel to first search the surface for three hours before seeking outside emergency help.
The report said the team notified the Canadian Coast Guard of the Titan’s distress at 7:10 p.m.
The Canadian Coast Guard directed the team to contact the U.S. Coast Guard Rescue Coordination Center in Boston, which initiated the distress phase and prompted a multinational search and rescue operation.
The fatal implosion was confirmed days later on June 22, 2023, when a remotely operated vehicle found a piece of the Titan and other debris from the submersible on the seafloor, according to the report.
OceanGate has since “permanently wound down operations,” an OceanGate spokesperson said in a statement Tuesday.
“We again offer our deepest condolences to the families of those who died on June 18, 2023, and to all those impacted by the tragedy,” the statement said.
Investigators conceded, despite all the missteps chronicled in their report, that the biggest problem of all could be the lack of clear domestic and international standards for submersibles.
There’s a lack of “regulatory frameworks for submersible operations” that can “address the complexities of modern submersible technologies and practices,” the report said.
Without clear standards, virtually all key operational practices were dictated by Rush with no one seriously questioning him.
“Compounding these issues, the company’s leadership structure concentrated virtually all decision-making power in the hands of its CEO, Mr. Rush,” the report said. “Although OceanGate had a Board of Directors, Mr. Rush’s dominant behavior rendered it largely ineffective.”
For years, Rush ran the operation with an iron fist without regard for opposing viewpoints, investigators said.
During a Jan. 19, 2018, meeting with OceanGate’s director of operations, who acted as one the company’s top safety officers, Rush complained that “we’ve gotten to the point where his experience and his estimation of the correct way” is “fundamentally opposite of the approach that I want to take,” the report said.
That director of operations was fired a short time later, and “the messages were clear to OceanGate’s remaining senior staff that opposing views needed to be completely stifled,” according to the Coast Guard.
Financial hardships might have also played a role in the disaster, with the company under pressure to turn a profit.
By 2023, “OceanGate resorted to asking employees to temporarily forgo their salaries in exchange for future repayment,” the report said.
A former director of engineering, who was not named and left the company in early 2023, told investigators that “these economic pressures severely undermined the already low safety standards at OceanGate,” the report said.
“The safety was being compromised way too much,” the former engineering director said.
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