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The U.S. Coast Guard Marine Board of Investigation (MBI, Washington, D.C., U.S.) has released its Report of Investigation (ROI) on the loss of the Titan submersible, which imploded during a June 2023 dive to the Titanic, killing five people. The Titan was a 22-foot manned submersible with an 8-foot long carbon fiber composite pressure hull glued to titanium end sections.

The more than  outlines key findings and contributing factors in the casualty and includes 17 safety recommendations aimed at strengthening oversight of submersible operations, improving coordination among federal agencies and closing gaps in international maritime policy. 

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“This marine casualty and the loss of five lives was preventable,” says Jason Neubauer, Titan MBI chair. “The 2-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 board determined the primary contributing factors were OceanGate’s inadequate design, certification, maintenance and inspection process for the Titan. Other factors cited in the report include a toxic workplace culture at OceanGate, an inadequate domestic and international regulatory framework for submersible operations and vessels of novel design, and an ineffective whistleblower process under the Seaman’s Protection Act. 

The board also found OceanGate failed to properly investigate and address known hull anomalies following its 2022 Titanic expedition. Investigators determined the Titan’s real-time monitoring system generated data that should have been analyzed and acted on during the 2022 Titanic expedition. However, OceanGate did not take any action related to the data, conduct any preventative maintenance or properly store the Titan during the extended off season before its 2023 Titanic expedition. 

MBI recommendations include restricting the 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. The board also recommended adding Coast Guard personnel capacity at Coast Guard headquarters to support new construction oversight and field inspections involving submersibles and vessels of novel design. 

Further recommendations include requiring operators to submit dive and emergency response plans to the local Coast Guard officer in charge, marine inspection; evaluating the Coast Guard’s subsea search and rescue capabilities; and working with the International Maritime Organization (IMO) to define passenger submersibles and expand international safety requirements for submersibles operating on the high seas. The board also called for a new Occupational Safety and Health Administration and Coast Guard agreement to clarify whistleblower investigative protocols and improve interagency coordination. 

The Marine Board’s report is now under review by the Commandant of the Coast Guard. Upon completion of the review, the Commandant will issue a Final Action Memorandum confirming the U.S. Coast Guard’s position on the recommendations and any actions to be pursued.  

The complete Marine Board report can be .