The report shines a light on OceanGate's "inconsistent" and "insufficient" training program for its pilots.

At one point, the firm aimed to qualify pilots in a single day, even if they had never operated a submersible before, a former OceanGate operations director told investigators.

He described this approach as a "huge red flag".

The report finds the company's approach to training was "inadequate and lacked the rigor necessary for ensuring safe operations".

The report is damning about Stockton Rush's role at OceanGate. It finds that he "essentially" held several roles - CEO, safety officers and pilot - which "enabled him to set operational safety parameters and then make all final decisions for Titan operations without adequate input or checks and balance".

The report finds Rush was so concerned with managing the expectations of his guests that it came at the expense of keeping everyone safe.

Each guest paid hundreds of thousands of dollars for a chance to see the Titanic wreck, and "the pressures created by the presence of VIP guests on the excursion created a 'get it done' mentality that undermined standard safety protocols".

Shortly after the implosion in June 2023, a remotely operated vehicle was sent to the seabed to recover the Titan's wreckage.

Footage from the vehicle shows its robotic arms clawing at the remains of the submersible so it could be taken back to the surface for analysis.

The video was released by the US Coast Guard during its investigation in September 2024.

Rebecca Morelle
Science editor

OceanGate’s CEO Stockton Rush openly described his sub as experimental.

The hull - the part of the sub where the passengers were - was made from layers of carbon fibre mixed with resin.

No deep diving sub had been made of this material before - most use a hull made from titanium or steel.

Carbon fibre is considered unreliable under pressure. A known problem is that its layers can come apart. There were also concerns about other components.

The manufacturer of the viewport on Titan told the US Coast Guard’s public hearings that it was only rated to a depth of 650m underwater - far shallower than the 3,800m the sub was diving to.

The Titan was also fitted with titanium domes at both ends of the hull. Issues had been raised about how they were attached, as well as the fact that using a mix of metal and carbon fibre meant the sub was made of materials that responded to compression in different ways.

We can now bring you more on the specific cause of the Titan's implosion during its descent.

The report says the "initiating event" of the incident was the "loss of structural integrity of the Titan pressure vessel".

The "probable failure point" of the hull was one of these two vulnerabilities:

• the adhesive joint between the Titan's forward dome and the titanium segment
• or, the carbon fibre hull near the forward end of the sub

Since the sub's implosion, experts have pointed out that the sub's "experimental" design left it with several key weaknesses.

Rebecca Morelle
Science editor

The submersible was made from layer upon layer of carbon fibre, which can separate over time.

There were known problems with it before the implosion.

In 2022, during its 80th dive, there was a loud bang, which the US Coastguard say they think was the sound of the carbon fibre starting to delaminate - coming apart, in other words.

Instead of stopping for the submersible to be checked, the dive continued.

That's why the experts I've spoken to believe the Titan was always going to implode.

Thomas Mackintosh
Live reporter

Image source, Us Coast Guard/Handout/Anadolu Agency via Getty Ima

We have been sifting through the detailed report from the US Coast Guard’s Marine Board of Investigation two-year probe into OceanGate's fatal incident.

Here are 10 key takeaways from the lengthy 335-page report:

• OceanGate failed to follow established engineering protocols for safety, testing, and maintenance of their submersible, which the US Coast Guard says was the primary causal factor
• The sub's sudden implosion was caused by the loss of "structural integrity" - everyone on board was exposed to approximately 4,930 pounds per square inch of water pressure, resulting in the "instantaneous death" of all five
• CEO Stockton Rush, who died onboard the Titan submersible in June 2023, was able to ignore vital inspections, data analyses and preventive maintenance procedures

• Investigators analysed the technical aspect of the Titan submersible and described its carbon fibre-made design as "flawed" adding that the company did not follow up on signs of problems within the vehicle which had surfaced in previous months
• Part of the problem was OceanGate's "toxic work place environment which used firings of senior staff members and the looming threat of being fired to dissuade employees and contractors from expressing safety concerns"
• Mounting financial pressures on the company in 2023 resulted in an increased risk to Titan's hull and its operations
• OceanGate employees were asked to temporarily forgo salaries with the promise of back pay
• One ex-staff member told investigators: "The company was economically very stressed and as a result, [they] were making decisions that compromised safety"
• Both domestic and international regulatory frameworks for submersible operations were "insufficient to address the complexities of modern submersible technologies and practices" when the Titan tragedy happened
• Finally, had Rush survived the incident, investigators would have recommended that the Department of Justice consider on whether to pursue a separate criminal investigation adding that he could have been subject to criminal liability

Esme Stallard
Climate and science reporter

The Coast Guard is critical of almost every aspect of OceanGate and the way it was run, and listed eight different factors for Titan's failure.

But it said the primary causal factor was the failure of the company to follow "established engineering protocols" for safety and testing.

The Titan submersible, and its previous iterations, were made of carbon fibre - a strong material but one that has not been used for a deep diving sub before.

It is known to be unreliable under pressure, and its layers are known to come apart in a process called delamination.

The submersible did complete 13 successful dives to the Titanic in the two years preceding the tragedy. But the Coast Guard criticised the company's continued use of the submersible without checking its hull after a number of safety issues that were picked up in its monitoring.

During Dive 80 - less than a year before the fatal incident - passengers on board reported hearing a loud bang.

At the time CEO Stockton Rush said the noise was just the sub shifting in its frame. Sensors later revealed it was delamination.

The report also makes 14 safety recommendations in order to avoid repeats of the incident in future.

Many of them concern the interactions between different organisations and groups involved in the commercial submersible industry - for instance advising that the US Coast Guard (USCG) pursue "proper regulatory oversight" of submersibles.

Recommendation three calls for existing submersibles to have their ORV letter of designation revoked (which identifies it as a research vessel), with the owners then required to be certified under new passenger vessel requirements.

The report also suggests that the US Coast Guard (USCG) should have resources dedicated to "providing field support for vessels of novel design".

And, the report recommends that the USCG should require sub owners to notify them before they conduct operations - including sending a dive plan and emergency response plan.

The Marine Board of Investigation report also looked at whether any blame could be attributed to the US Coast Guard (USGC).

It found that there were "no acts of misconduct, incompetence, negligence, unskillfulness, or violations of law by USCG employees or any other personnel that contributed to this casualty".

In his dual role as OceanGate CEO and the Titan sub's pilot, Stockton Rush "exhibited negligence that contributed to the deaths of four individuals", the report concludes.

The investigation "identified evidence of a potential criminal offense" and Rush "may have been subject to criminal liability", it adds.

Had he survived, the US Coast Guard would have recommended Rush be referred to the US Department of Justice "for their consideration on whether to pursue a separate criminal investigation", it says.

It is the DoJ, not the Coast Guard, that would have determined whether any crime was committed following its own analysis, the report says.

But a separate DoJ investigation "will not occur in this instance due to the death of Mr Rush".

The report said there were no acts of misconduct, incompetence, negligence, unskillfulness, or violations of law by the Coast Guard or any other person that contributed to the implosion.

Image source, DAWOOD FAMILY

The family of Titan sub passengers Shahzada and Suleman Dawood have released a statement calling for tougher regulation and oversight in light of the coast guard's report.

British-Pakistani businessman Shahzada and his 19-year-old son Suleman were two of the three paying customers who died in the implosion.

The report confirms "unregulated behaviour, a lack of accountability, and a fundamentally flawed design" led to the deaths of those on board, the family statement reads.

"No report can alter the heartbreaking outcome, nor fill the immeasurable void left by two cherished members of our family," it adds.

“We believe that accountability and regulatory change must follow such a catastrophic failure," it says, adding the family hopes the tragedy will serve as a turning point to bring "meaningful reform, rigorous safety standards, and effective oversight" to the submersible industry.

"If Shahzada and Suleman’s legacy can be a catalyst for regulatory change that helps prevent such a loss from ever happening again, it will bring us some measure of peace."

Aside from the eight primary causes of the implosion, the report lists four other factors that contributed:

1. OceanGate's safety cultural and operational practices were "critically flawed" - with "glaring disparities between their written safety protocols and their actual practices"
2. OceanGate's CEO Stockton Rush misrepresented Titan as indestructible, which provided "a false sense of safety" for passengers
3. The company's senior leadership enabled a culture allowing financial shortfalls and customer expectations to be prioritised over responsibilities
4. A lack of comprehensive regulations for the oversight of manned submersibles

The report also observes that OceanGate failed to launch an investigation into a whistleblower's complaint in 2018.

Had this taken place, it suggests, early intervention could have resulted in OceanGate either aligning with regulatory requirements or abandoning its plans for Titanic expeditions altogether - therefore avoiding the implosion.

Image source, PA Media

The Titan sub's implosion was caused by the loss of structural integrity of its carbon fibre hull, leading to the "instantaneous" death of everyone on board, the US Coast Guard's investigation has determined.

"This loss of structural integrity caused the sudden catastrophic implosion of the hull," the report says.

The people on board were "exposed to approximately 4,930 pounds per square inch of water pressure, resulting in the instantaneous death of all five occupants".

We've some detail on the primary factors given in the report for the sub's implosion. They are:

• OceanGate's design and testing processes for the sub didn't address the "fundamental engineering principles" necessary for an "inherently hazardous environment"
• OceanGate didn't conduct an analysis to understand the expected cycle-life of the sub
• The company was over-reliant on a real-time monitoring system of the sub's condition and failed to meaningfully analyse the data
• OceanGate's continued use of Titan, despite a series of incidents that compromised the sub without properly assessing this
• The sub's carbon fibre construction led to flaws that weakened its structural integrity
• OceanGate failed to conduct detailed investigations after it had experienced mishaps
• The company had a "toxic workplace environment" that used the firing of staff members to dissuade them from expressing safety concerns
• OceanGate failed to conduct preventative maintenance on the hull while it was not being used before its ill-fated 2023 expedition

The report says OceanGate CEO Stockton Rush, who died on board the submersible, was able to ignore vital data in the run-up to the incident due to a lack of oversight.

"The lack of both third-party oversight and experienced OceanGate employees on staff during their 2023 Titan operations allowed OceanGate’s Chief Executive Officer to completely ignore vital inspections, data analyses, and preventative maintenance procedures, culminating in a catastrophic event," it says.

The CEO of the submersible company, a British billionaire explorer, a French diver, and a father and son were all on board the Titan submersible that imploded in June 2023.

Stockton Rush, 61, was the chief executive of OceanGate, the firm which owned the Titan submersible.

He was an experienced engineer who had previously designed an experimental aircraft and worked on other small submersible vessels.

British adventurer Hamish Harding, 58, ran Action Aviation, a Dubai-based private jet dealership, and completed several exploration feats.

He visited the South Pole multiple times - once with former astronaut Buzz Aldrin - and flew into space in 2022 on board Blue Origin's fifth human-crewed flight.

Image source, Dawood Family/ Lotus Eye Photography/ Reuters

British businessman Shahzada Dawood, 48, was from one of Pakistan's richest families. He was travelling on the sub with his son Suleman, 19, a student at the University of Strathclyde in Glasgow, where he had just completed his first year at the university's Business School.

Dawood lived with his wife, Christine, and other child, Alina, in Surbiton, south-west London. The family were spending a month in Canada prior to the dive.

Also on board was Paul-Henry Nargeolet, 77, a former French Navy diver.

Nicknamed Mr Titanic, he reportedly spent more time at the wreck than any other explorer and was part of the first expedition to visit it in 1987, just two years after it was found.

In the years leading up to the incident, OceanGate "leveraged intimidation tactics, allowances for scientific operations, and the company’s favorable reputation to evade regulatory scrutiny," the report adds.

"By strategically creating and exploiting regulatory confusion and oversight challenges, OceanGate was ultimately able to operate Titan completely outside of the established deep-sea protocols," it says.

The report lists the primary causal factor for the implosion as the "failure to follow established engineering protocols for safety, testing and maintenance of their submersible".

It adds that the report also identified:

• The need for proper corporate governance
• A professional workplace culture
• Improved regulatory oversight

We'll bring you more on this as we dig through the 335-page report.

Alison Francis
Senior science journalist

The US Coast Guard (USCG) has spent two years looking into the Titan disaster - and it’s been a long and complex investigation.

In September 2024, the USCG held a two-week long public hearing, where witnesses - including former OceanGate employees, Titan passengers and deep sea experts - gave evidence.

The wreckage of Titan, recovered from the sea floor, has also been carefully examined.

The USCG is aiming to establish what went wrong and to make recommendations to prevent a disaster like this from happening again. The report from its Marine Board of Investigation looks at:

• What caused the incident - and how the sub failed
• Whether there was any evidence that there was an act of “misconduct, incompetence, negligence, unskillfulness, or wilful violation of law” that contributed towards the disaster
• Whether there is evidence that a criminal act has been committed
• Whether there is a need for new laws or recommendations