The Report of Investigation (ROI), which is over 300 pages long, details the key findings and contributing factors that led to the incident. It also includes 17 safety recommendations. These recommendations are designed to improve oversight of submersible operations, enhance coordination among federal agencies, and address differences in international maritime policy.
Based on the U.S. Coast Guard report, OceanGate’s director of marine operations, who was responsible for crew and client safety, testified that the company ignored his safety concerns. He stated that the company prioritized “image and marketing” over building a safe and reliable operation.
The director, who had over 25 years of experience in subsea operations and was hired in early 2016, described a “toxic” work environment. He claimed that CEO Stockton Rush and the engineering department “would brush off any concerns he raised regarding serious failure points.” The report also noted a lack of clear communication between the operations and engineering teams, as well as the withholding of information. This “culture of secrecy,” he said, contributed to the ongoing dysfunction within the company.
“This marine casualty and the loss of five lives was preventable,” said Jason Neubauer, Titan Marine Board of Investigation (MBI) chair. “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 board determined that the primary factors contributing to the incident were deficiencies in OceanGate’s design, certification processes, maintenance practices, and inspection procedures for the Titan. Other factors included a harmful work environment at OceanGate, a lack of effective regulations for submersibles and innovative vessel designs, and an insufficient whistleblower protection system under the Seaman’s Protection Act.
Investigators also found that OceanGate did not thoroughly investigate or fix known hull problems that were discovered after the 2022 Titanic trip. The Titan’s real-time monitoring system had collected data during that expedition that should have been studied and acted upon. However, OceanGate did not take any action on this data, perform any preventative maintenance, or correctly store the Titan during the long off-season before its 2023 expedition.
The U.S. Coast Guard’s MBI report listed 17 safety recommendations intended to help prevent similar incidents. These recommendations are organized into several categories:
Regulatory and Oversight Changes
- Restrict Vessel Designations: The MBI wants to restrict the use of the “Oceanographic Research Vessel” designation for submersibles, as OceanGate exploited this to avoid strict safety regulations.
- Expand Federal and International Regulations: The report recommends extending federal and international safety requirements to all submersibles used for scientific or commercial dives.
- Mandatory Documentation: All U.S. submersibles would be required to obtain a Certificate of Documentation from the Coast Guard.
- Update Regulations for Novel Designs: The MBI suggests modernizing the existing Navigation and Vessel Inspection Circular to create a clearer path for certifying new and unique submersible designs.
Operator and Crew Safety
- Submitting Dive Plans: Operators would be required to submit detailed dive and emergency response plans to the local U.S. Coast Guard officer in charge of marine inspections before every operation.
- Maintaining Communication: The report recommends that all commercial and scientific submersibles have the ability to maintain voice communication at their maximum operating depth.
- Increased Inspections: The MBI calls for more U.S. Coast Guard personnel with expertise in submersibles to support inspections and certifications.
Whistleblower Protections and Interagency Coordination
- Clarify Whistleblower Protocols: The report recommends a new agreement between the U.S. Coast Guard and the Occupational Safety and Health Administration (OSHA) to clarify how whistleblower complaints are investigated.
- Improve Interagency Coordination: This new agreement would also work to improve coordination between the two agencies to ensure a timely response to safety concerns.
Search and Rescue Capabilities
- Evaluate Capabilities: The MBI urges the U.S. Coast Guard to evaluate its subsea search and rescue capabilities, particularly for situations where a vessel is entangled or stranded.
- Joint Training Exercises: To improve readiness, the board recommends holding joint training exercises with the U.S. Navy and commercial remotely operated vehicle (ROV) operators.
The remaining recommendations address technical and administrative updates to improve overall safety, covering international policy and submersible operation procedures.
The ROI provides information to guide policy decisions and improve oversight of submersible operations under U.S. and international regulations. By addressing the critical failures in oversight, regulation, and corporate culture, these measures seek to protect not only future passengers but also the crewmembers and whistleblowers who are essential to a safe maritime industry. Human safety must be the priority, and exploration must not jeopardize the well-being of the individuals involved.
Learn more about this tragic accident at Titan Loss: Marine Board of Investigation Assembled. The full Report of the MBI is available at The Implosion of the Submersible TITAN.