“This marine casualty and the loss of five lives was preventable,” said Jason Neubauer, Titan MBI chair. “The two-year investigation has identified multiple contributing factors that led to this tragedy, providing valuable lessons learned to prevent a future occurrence. There is a need for stronger oversight and clear options for operators who are exploring new concepts outside of the existing regulatory framework. I am optimistic the ROI’s findings and recommendations will help improve awareness of the risks and the importance of proper oversight while still providing a pathway for innovation.”
The investigation determined that the primary cause of the incident was the loss of structural integrity of the Titan’s carbon fiber hull, with the probable failure point being either the adhesive joint between the forward dome and titanium segment, or the carbon fiber hull near the forward end of the submersible. The catastrophic implosion occurred at approximately 10:47:09 a.m. on June 18, 2023, at a depth of 3,346.28 meters, resulting in the immediate death of all five occupants who were exposed to approximately 4,930 pounds per square inch of water pressure.
The board identified OceanGate’s inadequate design, certification, maintenance, and inspection processes as the primary contributing factors to the tragedy. Additionally, the investigation cited a toxic workplace culture at OceanGate, inadequate regulatory frameworks for novel vessel designs, and an ineffective whistleblower process under the Seaman’s Protection Act as significant contributing elements.
According to the investigation, OceanGate strategically exploited regulatory gaps and confusion to operate the Titan completely outside established deep-sea protocols that have historically contributed to a strong safety record for commercial submersibles. The report states: “For several years preceding the incident, OceanGate leveraged intimidation tactics, allowances for scientific operations, and the company’s favorable reputation to evade regulatory scrutiny.”
One of the most alarming findings was OceanGate’s continued use of the TITAN despite warning signs from previous dives. The report details how the Titan’s real-time monitoring system generated data during a July 2022 dive—known as ‘Dive 80’—that should have been analyzed and acted upon, but OceanGate took no action related to the data.
During Dive 80 on July 15, 2022, the Titan’s monitoring systems recorded a “major acoustic emission event” with significant strain gauge readings that indicated potential structural issues. Following this event, subsequent dives showed non-linear behavior in the hull’s strain response at shallower depths – a clear warning sign that was ignored. Particularly concerning was evidence that the hull’s acoustic emissions had significantly increased between the 2021 and 2022 expeditions, after a period when the hull had been “quiet” — a change that OceanGate CEO Stockton Rush, who ultimately perished in the implosion, had previously described as a potential warning sign.
Following what investigators described as a “delamination event” during Dive 80, OceanGate “lacked the expertise in carbon fiber structures and the necessary knowledge to properly interpret what the shift in strain data indicated.” Despite possessing data showing that “the TITAN hull’s behavior had changed significantly after Dive 80,” the company’s analysis methods failed to reveal this critical shift.
“Despite the significant inspection limitations, Mr. Rush concluded that the loud bang heard when the submersible surfaced was likely due to a shift in the submersible’s position within its frame and directed that no further investigation or assessments were necessary ahead of the next scheduled 2022 dive or during the TITAN’s extended layup period ahead of the 2023 TITANIC Expedition,” the report stated.
“The failure to properly analyze post-surfacing data—particularly the acoustic and strain anomalies indicative of delamination after Dive 80—represents a grave oversight, due to negligence,” it added.
The MBI also highlighted OceanGate’s “toxic workplace environment which used firings of senior staff members and the looming threat of being fired to dissuade employees and contractors from expressing safety concerns.” For years preceding the incident, the company “leveraged intimidation tactics, allowances for scientific operations, and the company’s favorable reputation to evade regulatory scrutiny.” This approach allowed OceanGate to “operate TITAN completely outside of the established deep-sea protocols, which had historically contributed to a strong safety record for commercial submersibles.”
The investigation provides a detailed timeline of the final dive. Mission 5 of the 2023 Titanic Expedition began on June 16, 2023, when the support vessel Polar Prince departed from St. John’s, Newfoundland with 42 persons on board. On June 18, at approximately 9:14 a.m., the Titan began its descent toward the Titanic wreck site.
The submersible’s final communications came at 10:47:02 a.m. when it reported “dropped two wts” at a depth of 3,341 meters. Six seconds later, at 10:47:08 a.m., the Titan sent its final automated transmission recording its location. Approximately one second after that, the vessel suffered catastrophic implosion. The Polar Prince’s communications team heard a “bang” emanating from the ocean’s surface two seconds later.
After notification of the distress, a massive international search and rescue operation was launched, involving 11 vessels and four aircraft that searched 12,145 square nautical miles of ocean. On June 22, debris from the Titan was discovered on the seafloor, confirming the catastrophic loss of the submersible and all five persons aboard.
Notably, the report stops short of recommending criminal prosecution only because the sub’s operator, Stockton Rush, died in the accident. However, the board made clear that had he survived, it would have recommended revoking his mariner credentials and referring the case to the Department of Justice under the Seaman’s Manslaughter statute (18 USC § 1115).
The report includes 17 safety recommendations aimed at strengthening oversight of submersible operations. These include restricting Oceanographic Research Vessel designations for submersibles, expanding federal and international requirements to all submersibles conducting scientific or commercial dives, and requiring Coast Guard documentation for all U.S. submersibles.
Additional recommendations call for requiring operators to submit dive and emergency response plans to local Coast Guard officers, evaluating the Coast Guard’s subsea search and rescue capabilities, and working with the International Maritime Organization to expand international safety requirements for submersibles operating on the high seas.
The investigation also identified missed opportunities for intervention, noting that a 2018 OceanGate whistleblower complaint was not investigated in a timely manner by the Occupational Safety and Health Administration. The report calls for a new agreement between OSHA and the Coast Guard to clarify whistleblower investigative protocols and improve interagency coordination.
This detailed investigation reveals how regulatory gaps, corporate negligence, and a toxic workplace culture combined to create conditions that led to this tragedy. The Coast Guard’s recommendations, if implemented, could significantly improve the safety framework for novel vessel designs and experimental submersibles, potentially preventing similar incidents in the future while still allowing for maritime innovation.
