At the heart of the ROI are17 safety recommendationsthat aim to close regulatory loopholes, bolster oversight of vessels with novel designs, and bring commercial submersibles under the umbrella of maritime safety standards long applied to ships.
“This marine casualty and the loss of five lives was preventable,” said Jason Neubauer, chair of the Marine Board. “There is a need for stronger oversight and clear options for operators who are exploring new concepts outside of the existing regulatory framework.”
The board concluded thatOceanGate Inc. and its CEO Stockton Rushbore primary responsibility for the accident due to a string of engineering, operational, and cultural failures. OceanGate sidestepped traditional third-party classification, used intimidation to silence safety concerns, and exploited the U.S. Coast Guard’s vague “Oceanographic Research Vessel” (ORV) designation to avoid inspections and certifications required of commercial passenger vessels.
The Titan, which was not registered or classed, had suffered damage during previous dives. Despite warning signs in real-time hull monitoring data and acoustic emissions, the sub was sent down again without meaningful analysis or repair. When the carbon fiber hull finally gave way at 3,346 meters, the implosion was instantaneous and unsurvivable.
In response, the Coast Guard has issued14 safety and 3 administrative recommendationsthat represent a foundational shift in how submersibles are regulated:
While the Titan was lost in an instant, the MBI raised broader concerns aboutUSCG subsea SAR capabilities, particularly for entanglement or stranding scenarios. The board urged joint planning exercises with the U.S. Navy and commercial ROV operators to bolster subsea rescue readiness in remote and deepwater environments.
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).
Still, the report’s focus remains forward-looking: to protect lives and create a regulatory pathway for innovation. As deep-sea tourism, scientific exploration, and commercial activity push further offshore and underwater, the Coast Guard’s message is unequivocal—novel design cannot mean no oversight.
