After a two-year investigation, the US Coast Guard Marine Board of Investigation (MBI) has released a 335-page report on the loss of the Titan, a submersible designed, built, and operated by the American underwater-tourism company OceanGate. The submersible imploded during a June 2023 dive to the Titanic, killing five people. The report concluded that the loss of the commercial submersible was a preventable tragedy.

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.

Much of the blame goes to the Chief Executive Stockton Rush, the US Coast Guard said. He was on board and also died in the disaster. The report found he “exhibited negligence that contributed to the deaths of four individuals”.

The Titan first began taking people to the Titanic in 2021.  The price per passenger on an OceanGate expedition to the Titanic shipwreck was $250,000.

The 22-foot long (6.7-meter long), 23,000-pound submersible was touted for a roomier cylinder-shaped cabin made of carbon-fiber — a departure from the sphere-shaped cabins made of titanium used by most submersibles.

Unlike a spherical passenger compartment, however, where the immense water pressure is equally distributed across the hull’s surface, the Titan’s 5-inch-thick cylindrical-shaped hull was exposed to unequally distributed loads along the carbon fiber hull.

Also, unlike a titanium passenger compartment, the Titan‘s carbon fiber hull was subject to fatigue and delamination over multiple dives. Each trip to the Titanic exposed the Titan submersible to water pressure of 4,930 pounds per square inch, which could result in tiny cracks forming in the carbon fiber structure.

A Tragedy Preventable and Forseen

If the tragic implosion of the Titan was preventable, it was also forseen,

OceanGate’s former operations director David Lochridge had warned of potential safety problems years before the tragecy. He was fired and sued by the company for revealing confidential information. He countersued for wrongful dismissal.

Lochridge said in a 2018 lawsuit that the company’s testing and certification was insufficient and would “subject passengers to potential extreme danger in an experimental submersible.”

He advocated for “nondestructive testing,” such as ultrasonic scans, but the company refused.

Ultrasonic testing can help spot areas inside the structure where the composites are coming apart, said Neal Couture, executive director of a professional organization called the American Society for Nondestructive Testing.

“Once this thing is going down and going under stress, it’ll affect those materials, it’ll affect those composites,” Couture said. “Nondestructive testing is how you would then assess those structures and say, ‘OK, they’re still viable,’ or, ‘they’re still susceptible.’”

The Marine Technology Society, an organization of ocean engineers, technologists, policymakers and educators, also expressed concern to OceanGate about the size of the Titan, the construction material and the fact that the prototype wasn’t being examined by a third party.

“We were very afraid that without that certification process, they might be missing something,” Will Kohnen, the organization’s chairman, told PBS. He sent a letter to the company in 2018 warning that its “current experimental approach … could result in negative outcomes (from minor to catastrophic) that would have serious consequences for everyone in the industry.”

In a 2019 company blog post, OceanGate criticized the third-party certification process as one that is time-consuming and stifles innovation.

“Bringing an outside entity up to speed on every innovation before it is put into real-world testing is anathema to rapid innovation,” the post said.

Famed undersea explorer Robert Ballard, who first located the Titanic wreckage in 1985, called the lack of outside certification and classification a “smoking gun” in the vessel’s failure.

Likewise, James Cameron, the movie director who made 33 dives to the Titanic shipwreck himself, along with many others in the deep submergence community, had long been concerned about the vessel’s safety and OceanGate’s experimental approach.

“I’m struck by the similarity of the Titanic disaster itself, where the captain was repeatedly warned about ice ahead of his ship, and yet, he steamed up full speed into an ice field on a moonless night, and many people died as a result,” Cameron said to NPR. “And for a very similar tragedy, where warnings went unheeded, to take place at the same exact site, with all the diving that’s going on all around the world, I think it’s just astonishing, it’s really quite surreal.”

Thanks to Alaric Bond for contributing to this post.