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Titanic tourist submersible goes missing with search under way
Wyróżniono dnia 7 Lip 2026 przez 0 0: A final postmortem report on the Oceangate Titan submersible: everything they could have done wrong went wrong.
Final report is out.
Implosion:
Impossible to use carbon fiber hull to be defect-less and some of the processes to manufacture the cylinder hull led to defects.
Unconventional methods were used by people lacking knowledge of the processes involved.
No pressure load or repeat failure tests with full-scale models were done by Titan.
Minimum testing of 2 1/3 scale models done showed failure at 3000m and 3300m with both models failing due to pressure.
Lack of reports on manufacturing including grinding down of carbon fiber layers which reduces strength and could have put in defects.
Conclusion
"During the design, construction, and testing of the Titan, operational decisions were influenced disproportionately by measurable outcomes such as cost savings related to testing and validation of the submersible’s design. Considerations that were less tangible, such as how safety was being compromised to achieve those savings, tended to be undervalued or overlooked."
Two warning systems : strain monitoring and acoustic monitoring
Acoustic Monitoring
Real Time
No Audible Alarm
Pilot had to specifically be looking at system.
Easily distracted by external acoustics.
Monitoring system was set to three colors, but no testing of thresholds had ever been done.
If hit red it meant abort dive, but no one knew how much time a reading of red meant for catastrophic failure of hull.
There is record of multiple red threshold events including the one 4 days prior. All were ignored and never investigated since it would requiring dismantling of the ship costing time and money.
Conclusion:
"The acoustic emission monitoring system was being relied upon to provide enough advance warning for the submersible to surface in the event of an impending hull failure. However, this system had not been tested to demonstrate that it would consistently provide enough advance warning, and it did not function as intended during the occurrence."
Strain Monitoring
Post-Dive : Not in Real Time
Unknown how system data related to structural integrity.
Never tested on full scale models.
Some gauges were nonworking possibly due to detaching when hull constructed.
Unknown if accidental or purposeful.
Others were unable to detect anything but local issues without all gauges working.
"The investigation determined that strain data was being downloaded by Ocean Gate, but the analysis of the data and its results were both inconsistent and Ocean Gate had no defined course of action to address anomalies. "
Analysis of data showed positive structural issues from strain monitoring at 600m, but data was not known to be reliable.
There was a possible hull failure four days before the incident which was ignored.
A notable event had occurred on a dive on 15 July 2022, 4 days before the subsequent dive on 19 July 2022 when non-linear readings were present. During the dive on 15 July 2022, a loud bang was heard from inside the submersible while it was surfacing. Ocean Gate did not conduct a thorough inspection of the pressure hull following this event, so it cannot be determined whether this event precipitated the non-linear readings on 19 July 2022.
Conclusion:
"OceanGate had developed the strain monitoring system to provide data for post-dive analysis to identify potential problems with the pressure hull that could lead to failure on a subsequent dive. However, OceanGate’s analysis of the strain data was inconsistent and did not result in the pressure hull being removed from service before its failure."
Damage to carbon fibre cylinder
Analysis showed that if the hull had been at its lowest compression usage by the dive it would have already used 82% of life time fatigue.
It had not been used at lowest compression.
Multiple aspects showed reduction of hull integrity including:
Presence of severe ply waviness in localized regions of the carbon fibre laminate, as well as visible porosity.
Processes used in the manufacturing of the cylinder may have allowed defects to be introduced.
Vacuum bagging and curing the hull introduced the potential for delamination and porosities.
Grinding down the raised areas of the cylinder to make them flush with the cylinder’s design curvature potentially introducing defects on the surface of the cylinder, reducing the overall strength of the structure.
Prior Damage ignored (More info in pictures at beginning of post):
Forces imparted on the cylinder during recovery and deployment of the Titan to and from the aft deck of the Horizon Arctic in 2021 and 2022
Forces imparted on the cylinder from transporting the Titan by road back and forth from the company headquarters in Everett, Washington, United States, to St. John’s, Newfoundland and Labrador
Damage to the cylinder from the elements as a result of storing it outside in St. John’s from the end of July 2022 until 06 February 2023.
Damage from incidents that took place during operations
Titan colliding with the port bow of the Titanic on 03 July 2022
Loud bang when the Titan was surfacing from a dive on 15 July 2022
Titan was towed on the launch and recovery system (LARS) through the Atlantic Ocean in significant wave heights of up to 3.35 m which subjected it to higher accelerations than those recommended by industry guidance.
Conclusion:
"The reduced compressive strength of the Titan’s carbon fibre cylinder, as well as defects that were potentially introduced during manufacturing, operations, storage, and transport of the Titan, likely led the cylinder to fail progressively with damage accumulating during each dive cycle until it imploded, fatally injuring all 5 people on board"
Risk Management of OceanGate
No formal safety management system.
Subject Material Experts were either not included in process, ignored or fired for bringing up concerns.
Lack in SMEs with expertise in engineering and marine operations.
"It is likely that there was insufficient knowledge and expertise remaining within the organization to understand the risk that the lack of SMEs posed to the submersible."
"The social construction of safety risk was less of a bottom-up, group-driven process, and more of a continued reflection of the CEO’s worldview and where he felt operational risk existed"
Group-think
"Closed-mindedness, pressures toward uniformity, and overestimation of the group’s power, were evident at various points throughout OceanGate’s history, both in data collected during this investigation and in data made available in the public record since the occurrence. "
Confirmation Bias : Hull has not broken so Hull will not break.
Exasperated by refusal of external assessments.
No regulators allowed to asses.
No classification team allowed to assess.
No independent person to assess anything everything was done in house by people already involve din group think.
Conclusion:
"Risk management at OceanGate was hindered by the structure and composition of the company as well as by the influence of power dynamics and social and psychological factors. As a result, OceanGate did not identify and mitigate key risks associated with the structural integrity of the Titan."
Refusal to adhere to "voluntary" oversight rules:
Refusal to Pursue classification with a classification society
Refusal to register with a flag state that provides oversight of submersibles and become subject to that country’s domestic regulatory oversight.
"The interactions that OceanGate had with regulators in various countries did not affect its intended operations—to conduct deep-ocean dives in an unregistered, uncertified, and unclassed submersible with passengers on board. "
Conclusion:
"If oversight of submersibles, such as through classification or registration with a flag state,relies largely on voluntary action from owners and operators, submersibles are likely to operate without oversight, increasing the risk they will not be compliant with international and national safety regulations and guidelines that provide a minimum level of safety."
TC Marine Safety and Security
OceanGate made sure to not make the authority aware they were operating in their waters.
They did this by using other Canadian vessels tow it.
"TCMSS does not proactively seek out unregistered vessels. It relies on owners and operators to register their vessels. While TCMSS does not seek out vessels that are unregistered, it may use enforcement instruments if an unregistered vessel is identified in the course of other regulatory oversight. A registered vessel can be targeted, monitored, and subject to enforcement; an unregistered vessel is largely invisible unless encountered incidentally.
Why TCMSS did not enforce registry on Titan:
"It was not clear to TCMSS that the Titan was a vessel under the Canada Shipping Act 2001, which resulted in uncertainty about whether the Act applied to the submersible. "
"Although the Titan was operating out of St. John’s on a Canadian-flagged support vessel, TCMSS had not verified the Titan’s
registration status, so it was unaware that the Titan was not registered anywhere. "
"Those responsible for marine safety at TC were unaware that the submersible was operating in Canadian waters or in Canada’s exclusive economic zone."
Conclusion:
"Canada’s approach to regulatory oversight of vessels enabled the Titan to operate without any independent verification to identify safety deficiencies, which resulted in increased risk to those involved in the Titan’s operations."
Emergency Preparedness
"OceanGate’s rescue plan for an emergency at deep-ocean depths where the Titan could not resurface using its own capabilities relied on emergency contacts with remotely operated vehicles (ROVs) coming to assist.
"When conducting diving operations, OceanGate also did not have any contracts in place with these ROV operators."
THERE WAS NO EXACT EMERGENCY PLAN IN PLACE IF SOMETHING WENT WRONG.
THERE WERE NO VERIFIED CONTACTS OF WHO WOULD HELP IN AN EMERGENCY.
THERE WAS NO TESTING TO SEE IF ANY OF THE REMOTE CREWS COULD ACTUALLY HELP IN AN EMERGENCY.
"During the SAR response, several external vessels outfitted with ROVs were on scene. The 1st ROV deployed was not capable of reaching the depth required."
The vessel could not be opened unless attached to the LARS and opened by people outside the submersible.
" Titan did not have a hatch so its crew and passengers could not egress on the surface without the Titan first being reattached to the LARS and the forward dome being unbolted by people outside the submersible. "
"OceanGate also did not have a means of determining where the Titan was underwater if the tracking and communication systems on the submersible were not functioning"
Conclusion:
"If submersible operators do not have detailed emergency response plans to manage all possible emergency scenarios, including readily available and proven rescue resources, the lives of those involved in the submersible’s operations are at risk.
Safety Management Practicies
Ocean Gate and Polar Prince were to have separate operations and Polar Prince's SMS would not cover OceanGate.
OceanGate though was depended on Polar Prince for its activities.
Polar Prince crew had no experience with the unique operations that OceanGate was undertaking
Yet there crews were made to do work that OceanGate could not.
"The separation of the operations left the master of the Polar Prince in a conflicted position.This was because, on the one hand, the master was to treat OceanGate and its personnel as completely separate, but on the other hand, he retained the obligation and responsibility for the safety of all crew and passengers associated with the vessel"
There were no document on what Polar Prince should do in emergency and without any document but Oceangates on procedures for missed communication they had to have that supersede maritime best practices.
Conclusion:
"When groups work on board a vessel without comprehensive guidance from a bridging document to integrate safety management between their operations and those of the vessel, there is a risk that operations will be conducted without the necessary safeguards, potentially compromising the safety of people, vessels, and the environment"
List of all Dives with multiple issues seen:
Exact Findings
Findings as to causes and contributing factors
These are the factors that were found to have caused or contributed to the occurrence.
The as-built properties of the Titan’s carbon fibre cylinder were never validated to ensure they met the theoretical values used in the design process, and the construction and testing of the Titan did not follow standard engineering practices. As a result, OceanGate did not know for how long the pressure hull would remain safe when used repeatedly for dives to the depth of the Titanic.
OceanGate had developed the strain monitoring system to provide data for post-dive analysis to identify potential problems with the pressure hull that could lead to failure on a subsequent dive. However, OceanGate’s analysis of the strain data was inconsistent
and did not result in the pressure hull being removed from service before its failure.
The acoustic emission monitoring system was being relied upon to provide enough advance warning for the submersible to surface in the event of an impending hull failure. However, this system had not been tested to demonstrate that it would
consistently provide enough advance warning, and it did not function as intended during the occurrence.
The reduced compressive strength of the Titan’s carbon fibre cylinder, as well as defects that were potentially introduced during manufacturing, operations, storage, and transport of the Titan, likely led the cylinder to fail progressively with damage
accumulating during each dive cycle until it imploded, fatally injuring all 5 people on board.
Risk management at OceanGate was hindered by the structure and composition of the company as well as by the influence of power dynamics and social and psychological factors. As a result, OceanGate did not identify and mitigate key risks associated with the structural integrity of the Titan.
Findings as to risk
These are the factors in the occurrence that were found to pose a risk to the transportation system. These factors may or may not have been causal or contributing to the occurrence but could pose a risk in the future.
If oversight of submersibles, such as through classification or registration with a flag state, relies largely on voluntary action from owners and operators, submersibles are likely to operate without oversight, increasing the risk they will not be compliant with
international and national safety regulations and guidelines that provide a minimum level of safety.
Canada’s approach to regulatory oversight of vessels enabled the Titan to operate without any independent verification to identify safety deficiencies, which resulted in increased risk to those involved in the Titan’s operations.
If submersible operators do not have detailed emergency response plans to manage all possible emergency scenarios, including readily available and proven rescue resources, the lives of those involved in the submersible’s operations are at risk.
When groups work on board a vessel without comprehensive guidance from a bridging document to integrate safety management between their operations and those of the vessel, there is a risk that operations will be conducted without the necessary safeguards, potentially compromising the safety of people, vessels, and the environment.
Miscellaneous Findings
These findings resolve an issue of controversy, identify a mitigating circumstance, or acknowledge a noteworthy element of the occurrence.
OceanGate’s missed communications protocol allowed time for communication problems to be fixed or resolve on their own and did not require emergency procedures to be initiated immediately.
Limited information sharing between TC and other government departments results in TC missing opportunities to access information that could be useful in assessing risk in commercial vessel operations and determining the appropriate level of oversight.
Reccomendations
The Department of Transport define criteria and priorities for risk-based oversight of Canadian commercial vessels that are not required to be certified, such that these criteria and priorities make it possible to evaluate the risk posed by the operation of these vessels and lead to additional oversight
The Department of Transport define criteria and priorities for risk-based oversight of commercial vessels not registered or captured by port state control processes, and that these criteria and priorities make it possible to evaluate the risk posed by the operation of these vessels and act accordingly
The Department of Transport establish processes to obtain information from other government departments about commercial vessel operations such that it can evaluate the risk of those operations and act accordingly
The Department of Transport advocate to the International Maritime Organization that the guidance in Maritime Safety Committee Circular 981 be incorporated into international conventions or codes.
The Department of Transport require all human-occupied submersibles that are registered in Canada, operating with a Canadian support ship, or operating in Canadian waters or Canada’s exclusive economic zone, to comply with the requirements of the International Maritime Organization’s Maritime Safety Committee Circular 981.
The Department of Transport ensure that, when 1 or more groups work onboard a Canadian vessel or a vessel to which the Coasting Trade Act applies, safety management principles of the group(s) are integrated to the operations of the vessel, including the use of a bridging document, to clarify how operations will be coordinated and how safety will be managed.
The only good thing about this tragedy that the CEO went down with his ship. If that CEO wasn't on that sub on that day, he would distastefully gaslight everyone on his responsibility like he did with all the safety concerns.
This report really makes you appreciate the stickler for rules that you normally would want to tell off for being anal about every little dotted-i.
James Cameron is a typical Hollywood goof in many ways, but you can’t deny that the man fucking loves oceanography.
We he said that Stockton Rush “broke every rule that we have”, he really wasn’t kidding. Seeing him and Robert Ballard on the news verbally castrating Rush for his retardation was highly satisfying to watch.
Who knew that being instantly liquified at 5600 psi would result in injury that could be fatal. For context, a 50 psi blastwave is instant death through sheer force and can shatter concrete.
The only good thing about this tragedy that the CEO went down with his ship. If that CEO wasn't on that sub on that day, he would distastefully gaslight everyone on his responsibility like he did with all the safety concerns.
Everyone made fun of the people who died on the Titan but the one who deserved to died was Rush. Nothing in this report exceeds the absurdity of some pro-deregulation boomer driving a plastic submarine with a game controller and clipping it against the Titanic. "Yeehaw, Jesus press X to take the wheel!"
This is about on par with when American Airlines was using a fucking forklift to take engines off of a DC10 and putting the engines back in via eyeballing it, only to lead to hundreds dying later because they kept damaging the engine to pylon mounts. It’s this but that attitude applied to every single facet of the operation. What astounding retardation.
This sort of attitude is just total nigger rigging that in any other industry (aviation, as Rush wanted to go to space and would have to go through aerospace) would’ve had him thrown out the door in no time. You don’t ever try to do this shit without implicitly knowing it’s wrong. What a disgusting retard for taking other lives down with him.
Whole thing reminds me of Theranos. First the group thinking and the worship of the authority of a CEO underqualified to manage either the business or the tech. Then, the whole silicon valley attitude that disregards traditional thinking and regulations. If you are building some stupid website or app you can get away with it, but once you start playing with people's lives with the same methods you are heading for jail or death.
The only good thing about this tragedy that the CEO went down with his ship. If that CEO wasn't on that sub on that day, he would distastefully gaslight everyone on his responsibility like he did with all the safety concerns.
Part of me wishes he hadn't been there because he died instantly, still assured he was the smartest man in the room and that nothing was wrong....
I would've been better had he spent the last 3 years in court blubbering and melting down as each of these damning instances of arrogance and incompetence arise, desperately trying to deflect it all away on everyone else as he twists in the wind.
Only if your own life is included. Otherwise these days, the former is impossible, the latter is in the very rare chance you encounter an angry Italian.
I'm sure I've seen this before, but I still lol'd.
Imagine the synchronized "ooof" from everyone in the soda can when dude rammed into an object that hasn't moved in more than a 100 years with a fucking shitty video game controller. It's just so ridiculous.
The only good thing about this tragedy that the CEO went down with his ship. If that CEO wasn't on that sub on that day, he would distastefully gaslight everyone on his responsibility like he did with all the safety concerns.
The shortcuts and clear avoidance of adhering to any safety regulatories for budgetary and speed reasons is exactly what I expected from this company, it's what many companies try, they're just not as stupid to get customers involved. He must have envisioned himself a pioneer, the one to shake up the submersible community like James Cameron. His greed and hubris were his downfall, it's too bad he managed to convince some people to die with him in his cheap-ass sub.
I wouldn't trust the testimonies of former engineers and employees due to the fact that they could've been responsible for the problems wile laying all the blame on their boss. Also, everyone bitching about the lack of testing need to accept that it wasn't just Oceangate that is to blame: a lot of the testing would've required help from 3rd parties and universitites and those places told Oceangate to fuck off. So you can't lay all the blame on the CEO who literally went down with the ship.
I wouldn't trust the testimonies of former engineers and employees due to the fact that they could've been responsible for the problems wile laying all the blame on their boss. Also, everyone bitching about the lack of testing need to accept that it wasn't just Oceangate that is to blame: a lot of the testing would've required help from 3rd parties and universitites and those places told Oceangate to fuck off. So you can't lay all the blame on the CEO who literally went down with the ship.
