
1964.
Public Domain via Wikimedia Commons
The United States Coast Guard Marine Board of Investigations released its report on the Titan submersible implosion in 2023. The report found that the company failed to follow engineering and safety protocols for the use of the submersible. It also criticized OceanGate CEO Stockton Rush for his failures to use such protocols, the firing of those who were critical of the vessel design or lack of safety protocols and evading regulatory scrutiny.
“For several years preceding the incident, OceanGate leveraged intimidation tactics, allowances for scientific operations, and the company’s favorable reputation to evade regulatory scrutiny. 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, which had historically contributed to a strong safety record for commercial submersibles. 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.”
The report concludes that the accident was preventable. Jason Neubauer, chair of the marine inquiry states: “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.”
The report recommended the many actions to prevent such an occurrence happening again. Some of them are:
- Establish industry working group to provide better guidance on the rules for classifying and certifying submersibles.
- Regulatory oversight of submersibles that perform oceanographic research operations. All submersibles of this kind must meet existing inspected passenger vessel requirements.
- Current holders of submersible designations will have those designations revoked so that they now comply with passenger vessel requirements.
- Coast Guard will need to review and update policy on surface vessels not subject to inspection regarding submersible operations. These ships must comply with all the rules and regulations regarding the operation of submersibles with annual attestations. The owners and operators of these vessels that operate outside of the area they originally applied for must obtain a new letter of designation from the Coast Guard.
- The Coast Guard needs to make regulations clear as to what constitutes a legally chartered submersible operation and who is inside in addition to its operation. Currently scientific personnel are defined differently than civilians.
- New regulation that will require all submersibles manufactured, owed, or operated by a US entity (including any submersible operating in U.S. waters) carrying anyone other than the owner to be built to standards set by the US Coast Guard and maintained under those standards.
- Vessel documentation requirements for U.S. submersibles that conduct commercial or scientific operations to obtain Coast Guard Certificate of Documentation which will then be properly recorded with its number into a database. This will allow the Coast Guard awareness of the submersible fleet registered and in operation in the United States. The federal government would take over the registration of these submersibles (commercial and scientific) from states.
- Require review of Coast Guard Marine Safety Manual to close regulatory gaps regarding the use of submersibles, and to resolve conflicts where one policy guidance conflicts with another. For example, one guidance can allow a recreational submersible to have six people aboard but conflicts with another requirement. Also close any regulatory gaps which allow circumvention of inspection and safety protocols.
- Establish better procedures so that when OSHA is notified of a safety issue that the Coast Guard will be able to intervene immediately.
- Coast Guard needs to add resources and expertise in handling issues related to ships of novel design.
- Evaluate procedures with US Navy and others as to readiness for both domestic and international situations regarding submersibles needing assistance.
- Work to develop with international organizations to define “passenger submersibles” so that a mandatory international standard is created.
- Coast Guard implement a new mandate for enhanced communications for all submarines and submersibles conducting commercial or scientific operations. Such vessels must have the ability to report emergencies and have contingencies in place to contact surface vessels with voice communications.
- Requirement that operation of submersibles for commercial or scientific operations that Coast Guard be notified. Notification must include the dive plan, emergency response, and water depth.
The Coast Guard did not issue any fines or sanctions against OceanGate since the company has ceased doing business.
Sources
“Coast Guard Marine Board of Investigation Releases Report on Titan Submersible,” Press release, last modified August 5, 2025, https://www.news.uscg.mil/Press-Releases/Article/4265651/coast-guard-marine-board-of-investigation-releases-report-on-titan-submersible/.
United States Coast Guard, Report of the Marine Board of Investigation Into the Implosion of the Submersible TITAN (CG1788361) in the North Atlantic Ocean Near the Wreck Site of the RMS TITANIC Resulting in the Loss of Five Lives on June 18, 2023, August 5, 2025, http://media.defense.gov/2025/Aug/05/2003773004/-1/-1/0/SUBMERSIBLE%20TITAN%20MBI%20REPORT%20(04AUG2025).PDF.




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