Titan sub: Final report blames OceanGate’s ‘critically flawed’ safety culture

The Titan submersible’s implosion was the result of a “critically flawed” safety culture at OceanGate, the final U.S. Coast Guard report on the disaster said on Tuesday.

OceanGate’s design and testing process was named as a key factor in the disaster, which caused the deaths of all five passengers in June 2023.

The final report of the of the Marine Board of Investigation into the implosion of the submersible in the North Atlantic was released Tuesday, outlining the causes behind the disaster.

The U.S. Coast Guard report said OceanGate’s design and testing processes for the Titan submersible “did not adequately address many of the fundamental engineering principles that would be crucial for constructing a hull to the precision necessary for the intended operations in an inherently hazardous environment.”

It added that OceanGate’s safety culture and operational practices were “critically flawed and at the core of these failures were glaring disparities between their written safety protocols and their actual practices.”

The report said the company continued to use the submersible, even after “a series of incidents that compromised the integrity of the hull and other critical components of the submersible without properly assessing or inspecting the hull.”

1:08 Haunting ‘knocking’ sound from Titan sub heard in trailer for ‘Minute by Minute: The Titan Sub Disaster’

On June 18, 2023, the submersible went missing in the northern Atlantic Ocean during an underwater expedition to view the site of the Titanic shipwreck.

The expedition off the coast of Newfoundland, operated by U.S. company OceanGate Expeditions, was reported overdue shortly after 9 p.m. local time Sunday evening and above-water crews had not been able to contact the vessel.

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Those on board include a billionaire adventurer, a wealthy businessman and his son, and the CEO of OceanGate.

 Carbon fibre is considered to be unreliable in deep water and was a highly unconventional building material. The U.S. hearing into the disaster heard that each dive taken by the Titan likely compressed and damaged the vessel, making it weaker over time.

The U.S. Coast Guard report said OceanGate’s carbon fibre hull design was flawed in terms of winding, curing, gluing, thickness of hull and manufacturing standards. OceanGate’s design “introduced flaws that weakened the overall structural integrity” of the hull, the report said.

Tuesday’s report said OceanGate “did not ensure an analysis was conducted to understand the expected cycle-life” of the Titan’s hull. It added that OceanGate’s “continued use of the TITAN after a series of incidents that compromised the integrity of the hull” was one of the causes behind the disaster.

It also pointed to OceanGate’s failure to conduct preventative maintenance on the the Titan’s hull “or protect it from the elements during the extended offseason layup period ahead of the 2023 TITANIC Expedition.”

0:37 U.S. Coast Guard releases audio believed to have captured moment OceanGate’s Titan sub imploded

The U.S. Coast Guard in its findings pointed to a “toxic” workplace culture within OceanGate, which fostered an atmosphere of fear and silence.

It said “OceanGate’s toxic workplace environment which used firings of senior staff members and the looming threat of being fired to dissuade employees and contractors from expressing safety concerns” was one of the primary causes of the implosion.

The Coast Guard said the company’s leadership fostered an organizational culture that allowed mounting financial shortfalls, customer expectations, and operational demands to be prioritized over the responsibilities and authority of the mission director of the Titanic dive.

“The lack of comprehensive and effective regulations for the oversight and operation of manned submersibles” contributed to the disaster, the report said.

 The Canadian government appears to have considered collaborating with OceanGate to further maritime research, the report also suggested.

The authors cited a May 19, 2021, letter to OceanGate’s CEO Stockton Rush, Canada’s Department of Fisheries and Oceans (DFO) expressed its support for OceanGate’s conservation efforts.

The report said DFO intended to “to assess the potential of its manned submersibles for scientific research, noting that OceanGate’s systems offered a unique opportunity for Canadian scientists to explore deep-water ecosystems, a capability that was not available at the time with Canadian equipment.”

According to the report, DFO intended to assess the capabilities of the Titan submersible by sending one of its researchers on a Titan dive in 2021. While the DFO member was listed as a passenger on the 2021 dive, they were not on the dive logs for that particular expedition.

The DFO letter outlined plans for “further discussions in the fall” and mentioned that the collaboration could lead to “financial contributions for future missions, with an initial contribution of $25,000, plus in-kind support, planned for 2022 to help cover ship time costs.”

However, the report did not find evidence of any further collaborations beyond the 2021 Titan expedition between DFO and OceanGate or evidence of any actual contributions from DFO to OceanGate.

Global News has reached out to DFO for comment.

— With files from Global’s Michelle Butterfield