WASHINGTON — The U.S. Coast Guard has released a 335-page report detailing what went wrong when the Titan submersible imploded in 2023, killing five people and leading to a days-long search in deep Atlantic waters for the sub’s wreckage. 

The report, put together by the Coast Guard Marine Board of Investigation, found that OceanGate, the company that designed and operated Titan, played an outsized role in the tragedy. 

According to the board, the primary contributing factors included that the company’s design for the vessel, which was made from carbon fiber instead of the traditional steel and titanium, was “inadequate” and that OceanGate had a flawed maintenance and inspection process for Titan. 

The report also criticized the company’s toxic workplace culture, an ineffective whistleblower process and lax international regulations that allowed the vessel to conduct dives with little oversight. 

On June 18, 2023, the submersible began a dive to the wreckage of the Titanic, piloted by OceanGate’s founder, Stockton Rush. On board were tourists Hamish Harding, Shahzada Dawood and Dawood’s son Suleman. Titanic expert Paul-Henri Nargeolet was also on board as an OceanGate crew member. 

Crew members on the surface lost contact with Titan during its dive. Authorities were contacted later in the day, kicking off a search across a remote stretch of the Atlantic Ocean in the slim hope that the people in the vessel were still alive. 

Despite the drama playing out for days on international television, with some even including a countdown to when the sub’s oxygen supply would run out if it was still intact, no survivors were found. 

On June 22, debris from the Titan submersible was found on the ocean floor, about 500 meters from the bow of the Titanic – for which it was named. 

Although the Coast Guard was unable to definitively determine a reason the Titan imploded, investigators say they have an almost certain guess. 

“The facts and evidence collected and analyzed strongly suggest that the most likely initiating event to the tragedy was a loss of structural integrity of the carbon fiber or glue joint within the TITAN’s cylindrical pressure hull,” investigators noted in the report. 

In layman’s terms, the carbon fiber hull of the vessel couldn’t withstand the pressure and collapsed inward, instantly killing all five people on board. 

“This marine casualty and the loss of five lives was preventable,” said Jason Neubauer, the chair of the board assigned to investigate the disaster. “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.”