A damning new report on the Titan submersible disaster that killed five people has revealed that the tragedy was preventable, and the result of a flawed experimental design and ignored safety warnings — with particular culpability placed on OceanGate CEO Stockton Rush.

The 335-page report by the U.S. Coast Guard (USCG) is the first full government post-mortem on the tragedy to date and the first official document to clearly assign blame to OceanGate, the now-defunct operators of the ill-fated vessel, and Rush.

The report paints Rush as the architect of the submersible’s failure who overruled engineers’ warnings about the vessel’s flawed design, which ultimately led to the vessel imploding near the Titanic wreck in the North Atlantic Ocean in 2023, resulting in the instantaneous death of all five occupants. 

“Titan’s carbon fiber hull design and construction, in terms of winding, curing, gluing, thickness of hull and manufacturing standards, introduced flaws that weakened the overall structural integrity of the Titan hull,” the report reads. “The carbon fiber pressure hull suffered a full material collapse due to buckling on its final dive.”

Several red flags were raised in previous dives, but Rush continued operating Titan, dismissed internal warnings and concealed critical damage from crew and clients, the report found. 

For instance, more than 150 loud hull-cracking noises were heard in a 2019 dive, indicating progressive degradation. A four-foot crack was later found in the original hull, which was de-rated after pressure testing — prompting OceanGate to build a new one. However, throughout the development of both hulls, four one-third scale models were tested and all of them imploded under pressure, reinforcing that the carbon fiber design was unstable.

Additionally, the forward dome of the Titan — a 3,500-pound pressure-bearing component — was designed to be secured with 18 bolts, but Rush only used four bolts, according to testimony from OceanGate’s director of engineering at the time.

During a 2021 Titanic dive, Titan’s four securing bolts sheared off while being hoisted aboard the Horizon Arctic, causing the forward dome to detach and fall onto the Launch and Recovery System platform in a catastrophic mechanical failure that narrowly avoided injuring the crew.

The report found OceanGate bypassed industry-standard certification, ignored its own Health, Safety, and Environmental (HSE) manual and fostered a culture that suppressed safety concerns.

Stockton Rush poses at Times Square in New York City on April 12, 2017. (REUTERS/Shannon Stapleton)

“Had OceanGate adhered to the safety standards outlined in its own HSE Manual and fostered a culture of transparency and accountability, this tragedy would likely have been averted with the final Titan hull removed from service well ahead of its implosion,” the report states.

“Encouraging employees to voice concerns without fear of retaliation and prioritizing safety over expediency could have prevented the sequence of events that led to the disaster. Instead, the company’s systemic failures created an environment where risks were ignored, and consequences were inevitable.”

Along with Rush, U.K. billionaire Hamish Harding, French mariner Paul-Henri Nargeolet and father-son pair Shahzada Dawood and Suleman Dawood also perished in the disaster.

While the passengers signed waivers, they were not fully informed of the degree of experimental engineering involved or prior red flags, according to the report. 

The Titan submersible in the Bahamas in May 2018. The Titan imploded during a mission to view the Titanic on Monday, June 19, 2023. (Becky Kagan Schott)

Neubauer said stronger oversight and clear options for operators who are exploring new concepts in deep-sea exploration.

U.S. regulatory authorities like the USCG and NTSB lacked jurisdiction because the Titan operated in international waters and was registered in the Bahamas. The report called for new legislation to expand U.S. oversight authority over deep-sea commercial submersibles carrying American citizens.

The MBI called for new international safety standards, a ban on unclassed passenger vessels at extreme depths, a national submersible registry and referred potential legal violations to the Justice Department.