The United States Coast Guard’s Marine Board of Investigation released a 335-page final report on the 2023 loss of the Titan submersible, calling the event an avoidable tragedy caused by design flaws, weak oversight, and a toxic safety culture at OceanGate Expeditions.
“This marine casualty and the loss of five lives was preventable,” said retired Captain Jason Neubauer, who chaired the board. Neubauer added, “There needs to be firmer oversight and clear options for operators exploring new concepts outside the current regulatory framework”.
Investigators identified eight primary causal factors and noted failures in design, certification, maintenance, and inspection. They reported that Titan repeatedly descended to about 3,800 meters even though its acrylic window was rated for 650 meters and that the vessel never underwent an independent safety review. Among 17 recommendations, the board urged mandatory dive and emergency plans, expanded standards for passenger submersibles, and a review of underwater search-and-rescue capabilities.
The carbon-fiber hull wrapped around titanium rings and fitted with an acrylic window introduced structural weaknesses that engineers never resolved. Specialists had warned OceanGate that carbon fiber in compression was unproven at extreme depths, and investigators concluded that the hull’s durability was not properly tested. A real-time monitoring system meant to detect impending failure was deemed severely defective, with all alert thresholds set by OceanGate chief executive and pilot Stockton Rush. The report noted there was no audible alarm because Rush was completely opposed to installing one.
“I knew that hull would fail. It’s an absolute mess,” said former director of marine operations David Lochridge during the hearing. He testified that he was fired after raising concerns and that Rush liked to do things on the cheap. The board documented repeated instances of employees being dismissed or threatened for questioning safety, creating a hostile work environment.
On 18 June 2023 Titan began its descent toward the wreck of RMS Titanic, nearly 4,000 meters below the North Atlantic. Communications with the support vessel Polar Prince stopped about ninety minutes into the dive. Military acoustic sensors later detected a sound consistent with a catastrophic implosion. Investigators calculated that the submersible collapsed under roughly 4,930 pounds per square inch, killing everyone on board instantaneously.
The dead were Rush, French Titanic expert Paul-Henri Nargeolet, British adventurer Hamish Harding, Pakistani businessman Shahzada Dawood, and his 19-year-old son Suleman. Each had paid $250,000 for an eight-hour expedition. The Dawood family said no report can fill the void left by their loved ones and that such a catastrophic failure must have consequences.
Search teams from the United States and Canada used ships, aircraft, and remotely operated vehicles to comb an area about 435 miles south of St. John’s, Newfoundland, for four days. On 22 June wreckage was found roughly 330 yards off the Titanic’s bow, scattered across the seabed. Investigators later confirmed that the main compartment had disintegrated.
The report recounts how OceanGate continued operating Titan despite anomalies on earlier dives, including a 2022 thruster malfunction at depth and a separate dive during which a loud bang was heard as the vessel ascended. The company never aborted a dive because of monitoring alerts and did not perform preventive maintenance before the fatal mission. It also stored the submersible outdoors through a Canadian winter, exposing the hull to temperature swings that compromised its integrity.
OceanGate suspended operations in July 2023 amid civil lawsuits. The Coast Guard found evidence of potential criminal offenses; the report stated that if Rush had survived, a criminal referral would have been recommended. The National Transportation Safety Board is conducting a separate inquiry.
The board concluded that Titan’s implosion resulted from failure to comply with established engineering safety, testing, and maintenance protocols and called for mandatory independent certification, periodic inspections, non-destructive testing, and stronger protections for whistle-blowers. “I am optimistic the findings and recommendations will help improve awareness of the risks and the importance of proper oversight while still providing a pathway for innovation,” said Neubauer.