OceanGate's safety culture criticized for fatal submarine incident: Final report highlights critical faults
The U.S. Coast Guard has released a damning report on the 2023 implosion of OceanGate's Titan submersible during a deep-sea expedition. The report identifies several issues with the carbon fiber hull design and a critically flawed safety culture at OceanGate as the primary causes of the disaster.
Faulty Carbon Fiber Hull Design
The report highlights several flaws in the design and manufacturing of the Titan's carbon fiber hull. These include problems with the winding, curing, gluing, and thickness of the hull material, which weakened its structural integrity under deep-sea pressure. The design and testing processes also failed to adequately address fundamental engineering principles required for hazardous underwater operations.
Moreover, no meaningful analysis was performed to verify the suitability and reliability of the carbon fiber material for the extreme pressures encountered during Titanic wreck expeditions. Manufacturing flaws in the carbon fiber hull introduced vulnerabilities that compromised overall strength, and the vessel was exposed to harsh environmental conditions, such as outdoor storage through a Canadian winter, which further compromised hull integrity.
Deficient Safety Culture and Operational Practices
The report describes OceanGate's safety culture as critically flawed, with glaring disparities between written safety protocols and actual operational practices. The company sidestepped regulatory oversight by exploiting loopholes and using tactics such as calling passengers “mission specialists” to evade classification and regulatory scrutiny.
Despite a series of incidents that compromised the submersible’s hull and other critical components, the company continued to use the Titan without proper assessment or inspection of its safety. CEO Stockton Rush ignored or concealed serious structural and safety concerns throughout the development and operational history of the Titan.
OceanGate’s maintenance and inspection processes were inadequate, lacking independent review or certification that is standard in this field. The report also notes fraudulent documentation submitted by Rush to obtain credentials and intimidation tactics used by OceanGate to evade regulatory oversight.
The Disaster and its Aftermath
The report concludes that the loss of structural integrity of the carbon fiber pressure vessel directly caused the implosion, killing all five people onboard during a Titanic wreck expedition. It recommends the creation of regulatory oversight frameworks nationally and internationally for innovative submersible designs to prevent similar tragedies.
While the Coast Guard’s report did not hold lack of government oversight as a direct cause, it highlights the challenges in monitoring novel underwater vessels when companies eschew safety norms.
Implications for OceanGate and Beyond
The report states that OceanGate used firings of senior staff members and the threat of being fired to dissuade employees and contractors from expressing safety concerns. The disaster occurred in June 2023 during an underwater expedition in the North Atlantic.
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. The U.S. Coast Guard report states that OceanGate's carbon fibre hull design had flaws in winding, curing, gluing, thickness of hull, and manufacturing standards.
OceanGate failed to conduct preventative maintenance on the Titan's hull or protect it from the elements during the extended offseason layup period ahead of the 2023 TITANIC Expedition. The submersible was operated by OceanGate Expeditions and had passengers including a billionaire adventurer, a wealthy businessman and his son, and the CEO of OceanGate.
Global News has reached out to DFO for comment regarding the report's findings. Carbon fibre, the building material used for the Titan submersible, is considered unreliable in deep water. 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, but the DFO member was not on the dive logs for that particular expedition.
- The report indicates that OceanGate's use of carbon fiber in the construction of the Titan submersible was questionable, as the material showed flaws in winding, curing, gluing, thickness, and adherence to manufacturing standards, making it unreliable in deep-sea conditions.
- The Coast Guard's report reveals a deficient safety culture and operational practices at OceanGate, where regulatory loopholes were exploited, safety protocols were not adhered to, and maintenance and inspection processes were inadequate, leading to the critical flaws that contributed to the Titan's implosion in 2023.
