The catastrophic deep-sea implosion of OceanGate’s Titan submersible was “a preventable tragedy” that resulted from repeated failures by the company and its late CEO to follow established safety, testing and maintenance protocols, the U.S. Coast Guard concluded in a damning report released Tuesday.
The 335-page final report by the Coast Guard’s Marine Board of Investigation (MBI) cites multiple instances of intentional disregard for human safety by the company amid efforts to promote “a false sense of safety and security” by OceanGate CEO Richard Stockton Rush III, who was piloting the vessel during a planned 2023 tour of the Titanic’s wreckage.
French submariner Paul-Henri Nargeolet, 77, and passengers Hamish Harding, 58, Shahzada Dawood, 48, and his son Suleman Dawood, 19, were among those killed when the submersible’s carbon fiber hull imploded under approximately 4,930 pounds per square inch of water pressure.
“This marine casualty and the loss of five lives was preventable,” Jason Neubauer, Titan MBI chair, said with the report’s release. “The two-year investigation has identified multiple contributing factors that led to this tragedy, providing valuable lessons learned to prevent a future occurrence.“
The primary causal factor for the implosion was determined to be the Titan’s “inadequate design, certification, maintenance and inspection process.” The report also cites a toxic workplace culture, an ineffective whistleblower process, and Rush repeatedly undermining authority and safety practices in order to make business deadlines.
“For several years preceding the incident, OceanGate leveraged intimidation tactics, allowances for scientific operations, and the company’s favorable reputation to evade regulatory scrutiny,” the report states. “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 cites testimony from former OceanGate staff and employees who detailed “frequent disagreements” between Rush and his engineering team. One employee described Rush having a “meltdown” after a submersible he was operating became stuck.
All three of OceanGate’s directors of engineering stated that Rush took full control and “made all engineering decisions independently, despite having a Director of Engineering in place.” One director said Rush “prioritized more cost-effective approaches and solutions” over project execution and safety.
After the company’s director of marine operations argued in early 2018 that the submersible’s hull needed additional testing, citing safety concerns that he had outlined in a report, he was fired, the report states.
His recommendations were received with “strong resistance and disdain from OceanGate’s CEO and other senior company officials,” the report states.
The fired employee went on to file a retaliatory complaint with the U.S. Occupational Safety and Health Administration, alleging that his dismissal was in retaliation for him raising safety concerns.
OceanGate responded by filing a lawsuit against him. The former director ultimately withdrew his complaint before a federal investigation began. He cited “the emotional toll of the ensuing legal battle” as his reason for retracting his complaint, according to the report.
The Coast Guard lists a number of recommendations following its investigation, including requiring operators to submit dive and emergency response plans to the local Coast Guard officer in charge. It also recommends new restrictions on submersibles that identify as Oceanographic Research Vessels, which is a designation that OceanGate sought for its submersibles due to its “less stringent” requirements, the report states.
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