Titan implosion that killed all five on board was preventable, says report

The US Coast Guard has determined the implosion of OceanGates Titan submersible that killed all five people on board was "preventable", citing the companys "critically flawed" safety practices.

A damning 335-page report from Coast Guard investigators states that OceanGate, the company that owned and operated the Titan, failed to follow maintenance and inspection protocols for the deep-sea vessel.

"There is a need for stronger oversight and clear options for operators who are exploring new concepts outside of the existing regulatory framework," Jason Neubauer, the chair of the Coast Guard Marine Board, said in a statement.

The Titan submersible disappeared in the Atlantic Ocean while descending to the wreckage of the Titanic on 18 June 2023.

OceanGate has extended its condolences to the families of the victims and stated that it "directed its resources fully toward cooperating with the Coast Guards inquiry".

Here are five key takeaways from the two-year investigation.

The report condemns OceanGates safety practices as fundamentally inadequate. It says the primary causal factor for the implosion was the firms failure to follow "established engineering protocols" for safety and testing.

There were "glaring disparities between their written safety protocols and their actual practices", the report states.

"This marine casualty and the loss of five lives was preventable," said Jason Neubauer, the chairman of the Coast Guard Marine Board of Investigation that was charged with investigating the Titan disaster.

The company continued to use the Titan sub despite a series of previous incidents that compromised the craft without properly assessing its suitability, the investigation found.

The sub imploded 90 minutes into the dive after its carbon-fibre hull suffered a catastrophic loss of structural integrity, the investigation found.

The report says the crew died instantly, subjected to nearly 5,000 pounds per square inch of water pressure.

Carbon fibre has not been used for a deep diving sub before.

It is known to be unreliable under pressure, and its layers are known to come apart in a process called delamination.

The submersible did complete 13 dives to the Titanic in the two years preceding the tragedy. But the coastguard criticised the companys continued use of the submersible without checking its hull, after a number of safety issues were picked up its monitoring.

Rob McCallum, from EYOS expeditions, a specialist in deep water operations, who advised Oceangate between 2009 and 2016, told the BBC that carbon fibre is an unpredictable material.

"When you listen to the sounds of that hull under stress, and the cracking and the popping, thats the sign of damage in the hull, that means the hull is getting weaker," Mr McCallum said.

"So you cant expect to take a vehicle to the same depth every time knowing that its weaker than the dive before, and expect it not to fail at some stage, It is a mathematical certainty that it will fail," he said. "The tragedy is, you dont know when its going to fail."

The report accuses OceanGate of intentionally avoiding regulatory scrutiny through intimidation and strategic manipulation.

In the years leading up to the incident, the company "leveraged intimidation tactics, allowances for scientific operations, and the companys favorable reputation to evade regulatory scrutiny", the report said.

"By strategically creating and exploiting regulatory confusion and oversight challenges, OceanGate was ultimately able to operate Titan completely outside of the established deep-sea protocols," it added.

The report also blames Stockton Rush, OceanGates founder and the pilot of the Titan sub during its fatal voyage, for contributing to the disaster.

Rush "exhibited negligence that contributed to the deaths of four individuals" (apart from his own), investigators said.

Had he survived, investigators said they would have recommended referring him to the US Department of Justice for potential "criminal offences".

Coast Guard Marine Board of Investigation Chair Jason Neubauer told the BBC that the structure of the organisation was "deeply flawed".

"One of the biggest standouts that I think that any company could take away is, if your CEO, was also filling the role of safety officer, and lead engineer at the end, its just too many," he said. "Its a consolidation of power that leads to no checks and balances."

To prevent similar disasters in future, the Marine Board issued 14 safety recommendations to the US Coast Guard and the wider submersible industry.

Key among them:

In a statement, Oceangate offered condolences to the families of those who died in the deadly disaster, and to all "those impacted by the tragedy".

"After the tragedy occurred, the company permanently wound down operations and directed its resources fully towards cooperating with the Coast Guards inquiry through its completion," it said.