Coast Guard report reveals who was to blame for Titan submersible implosion

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The implosion of the Titanic-bound submersible in June 2023 that killed five people in a tragedy that captured the world's attention was "preventable," fueled by its inadequate design and a toxic workplace culture, a newly released Coast Guard report found.

The 335-page report released Aug. 5 said Titan, a 22-foot-long submersible made of carbon fiber, imploded on June 18, 2023, because of factors largely in the hands of the company that operated it, OceanGate. They include "OceanGate’s inadequate design, certification, maintenance and inspection process for the Titan," the report said.

All five on board were killed in the implosion. They were OceanGate's founder and CEO Stockton Rush, British billionaire Hamish Harding, French maritime expert Paul-Henri Nargeolet, Pakistani businessman Shahzada Dawood and his 19-year-old son, Suleman Dawood. 

More: Audio of Titan submersible's final moments before implosion released by Coast Guard

“This marine casualty and the loss of five lives was preventable,” said Jason Neubauer, chair of the U.S. Coast Guard Marine Board of Investigation for Titan. “The two-year investigation has identified multiple contributing factors that led to this tragedy, providing valuable lessons learned to prevent a future occurrence."

Report issues scathing critique of OceanGate and its CEO

The Coast Guard report laid blame for the catastrophic implosion squarely on OceanGate, which it said failed to follow protocols for safety, testing and maintenance. For years before the implosion, OceanGate "leveraged intimidation tactics, allowances for scientific operations, and the company’s favorable reputation to evade regulatory scrutiny," the report said.

Titan was not registered, certified or inspected by any recognized organization, it said.

Had Rush, the CEO, survived, he could have faced criminal charges, the report said. Investigators concluded he "exhibited negligence that contributed to the deaths of four individuals."

"It is important to note that the determination of whether any crime was committed would be made by the (Department of Justice) following its own investigation and analysis, which will not occur in this instance due to the death of Mr. Rush," the report said.

Timeline of Titan's final moments

The report documents the precise times Titan lost communication with the Polar Prince, the support ship that held the rest of the expedition's crew, and ultimately imploded. The expedition began June 16, as the Polar Prince set sail from Newfoundland and Labrador, Canada. Two days later, the Polar Prince arrived at the vicinity of the Titanic wreckage in the North Atlantic, and the submersible was launched.

• 8:30 a.m.: The five crew members board the submersible and are sealed into the vessel.
• 9:14 a.m.: Titan begins its free fall to Titanic. Usually, during dives, Titan would maneuver near the ocean's surface for a "communications check," but it failed to do so on its final descent, the report said.
• 9:28 a.m.: Using abbreviated text messages to communicate, the Titan crew confirms the vessel is descending at a rate of 33 meters (more than 100 feet) a minute.
• 9:53 a.m.: Communication between Titan and the Polar Prince is lost for about 15 minutes, prompting the research ship to send this message repeatedly: “Do you see Polar Prince on your display?”
• 10:08 a.m.: Titan sends the message "k" back to the Polar Prince, reestablishing communication. The vessel continues sending messages about its position.
• 10:47:02 a.m.: Titan sends a message that it "dropped two wts," indicating it dropped ballast weights to slow its descent.
• 10:47:08 a.m.: Titan sends an automated transmission recording its final location at a depth of 3,346.28 meters (just under 11,000 feet).
• 10:47:09 a.m.: Titan implodes, and all on board arevkilled immediately. "Two seconds later, the TITAN Communications and Tracking Team on the POLAR PRINCE heard a 'bang' emanating from the ocean’s surface, which the investigation later correlated to the TITAN’s implosion," the report said. "After that, all communications and tracking with the TITAN were lost."
• 7:10 p.m.: After conducting mission protocols to try to regain communication with the Titan unsuccessfully, the Polar Prince alerts the Canadian Coast Guard that Titan is in distress. The Canadian Coast Guard directs the crew to alert the U.S. Coast Guard, launching a multinational search operation that lasts until a debris field is found June 22.

What factors contributed to the Titan implosion? Lackluster design, toxic workplace

The report identified eight key factors and a few contributing factors in the catastrophe:

• OceanGate's design and testing procedures were not adequate for the engineering precision needed for a vessel like Titan, which had to navigate inherently dangerous conditions.
• OceanGate didn't conduct analyses to determine the expected lifespan of Titan's hull.
• OceanGate overly relied on a real-time monitoring system for the carbon fiber hull but didn't conduct a "meaningful analysis" on the data provided by the system.
• The company continued using Titan after a series of incidents that "compromised the integrity of the hull" and other components of the sub without assessing or inspecting it.
• The design and construction of Titan's hull itself "introduced flaws that weakened the overall structural integrity."
• OceanGate didn't properly investigate previous mishaps.
• The company suffered from a "toxic workplace environment" that included firing of staff members or threats of firings to dissuade employees and contractors from speaking out about safety concerns.
• OceanGate didn't properly store or maintain Titan during the offseason.

Other contributing factors identified in the report include that OceanGate didn't follow its own written protocols for safety; Rush's boasting that the Titan's hull was "indestructible," providing a false sense of safety for passengers and regulators; and the prioritization of financial considerations over safety. Also partly to blame were a lack of regulations for submersibles in U.S. waters and a missed opportunity to intervene when the U.S. Occupational Safety and Health Administration took too long to investigate a 2018 whistleblower complaint, the report said.

Research ship heard a 'bang' when Titan imploded

Crew members on board the Polar Prince told investigators they heard a "bang" at the time they lost communications with the Titan but didn't think much of it at first.

The noise was heard at about 10:47:11 a.m., two seconds after the implosion, according to the report. The leader of communications and tracking for OceanGate was in the chart room at the time and turned to another OceanGate employee and said, “What was that bang?”

Later, the master of the Polar Prince told investigators in a written statement, “With the benefit of hindsight, I now believe I felt the POLAR PRINCE shudder at around the time communications were reportedly lost, but at the time we thought nothing of it … it was slight.”

Footage of that moment on the Polar Prince was released earlier this year, with Wendy Rush, who was the wife of the OceanGate CEO, and Gary Foss, part of the submersible's tracking and communications team, identified as the people in the room. In the footage, the sound is a muffled thump, and neither Rush nor Foss seemed alarmed as they worked to maintain communication with Titan.

The Coast Guard has said the thump was believed to be the sound of the implosion reaching the ocean's surface moments later.

What was the final straw that broke the Titan?

The report said investigators were unable to definitively identify the exact cause of the failure of Titan's hull, but pointed to a loss of structural integrity of either the carbon fiber that made up the hull or the glue joint within the vessel's cylindrical pressure hull.

A Boeing feasibility study indicated in 2013 that the adhesive joints' performance was uncertain and recommended further research into how the intense pressure at the ocean's depths would impact them, which OceanGate did not do, the report said. The study also highlighted that carbon fiber was unproven in submersibles at such depths.

Investigators who examined the hull's debris saw that the adhesive used to bond the carbon fiber hull to the titanium elements had "disbonded from the entire forward segment."

"Any crack or separation at either of the adhesive joints would have triggered the TITAN’s implosion due to the extreme pressures involved at its final depth," the report said.

When the sub imploded, investigators believe its viewport, or window, was ejected outward; it was never found in the debris field, but its retaining ring was found bent outward with its 16 bolts sheared off, the report said.

Titan passengers died instantly upon implosion

The implosion of Titan's hull exposed its occupants to 4,930 pounds per square inch of water pressure, causing their instant deaths, the report found.

When the Titan was first reported to authorities as being in distress, a multi-national search was launched for signs that they sub may have surfaced with its occupants still alive inside, but possibly running out of oxygen. It wasn't until the discovery of the debris field at the bottom of the ocean on June 22 that investigators conclusively determined the vessel imploded, killing all on board.