
Multiple failures to follow standard safety protocol led to the deadly implosion of a private submersible visiting the Titanic wreckage in 2023, according to a final report published Tuesday.
The US Coast Guard investigation outlined a litany of issues with operator OceanGate's conduct, as well as design flaws in its Titan submersible, that contributed to a "preventable tragedy" in which all five passengers were killed.
The 335-page report said "OceanGate's failure to follow established engineering protocols for safety, testing, and maintenance of their submersible, was the primary causal factor" for the implosion.
It also accused the company of "intimidation tactics...to evade regulatory scrutiny."
OceanGate had a "toxic workplace environment which used firings of senior staff members and the looming threat of being fired to dissuade employees and contractors from expressing safety concerns," the report said.
OceanGate chief executive Stockton Rush was joined on the doomed expedition by British explorer Hamish Harding, French deep-sea explorer Paul-Henri Nargeolet, Pakistani-British tycoon Shahzada Dawood and his son Suleman.
Seats on the submersible cost $250,000 per person.
Communications were lost with the SUV-sized submersible about an hour and 45 minutes into its dive on June 18, 2023, kicking off a dramatic search that briefly captivated the world.
Over two miles underwater when the hull collapsed, all occupants "were exposed to approximately 4,930 pounds per square inch of water pressure," resulting in "instantaneous death," the report said.
Two seconds later, the monitoring team on the support ship "heard a 'bang' emanating from the ocean's surface, which the investigation later correlated to the Titan's implosion."
Debris was found a few days later on the ocean floor, about 1,600 feet (500 meters) from the bow of the Titanic, and human remains were recovered when the sub was brought to the surface.
In its report, the Coast Guard said that OceanGate had continued to use Titan despite "a series of incidents that compromised the integrity of the hull and other critical components of the submersible without properly assessing or inspecting the hull."
It also identified design flaws with the unique carbon fiber hull "that weakened the overall structural integrity."
The US Coast Guard said that the vessel was not "registered, certified, inspected, or classed" by any international flag administration or recognized organization.
Last year, the family of Nargeolet sued OceanGate for $50 million, accusing the US-based company of gross negligence.
Known as "Mr. Titanic," he had visited the wreckage 37 previous times.
Shortly after the tragedy, OceanGate halted all operations.
The wreckage of the Titanic sits 400 miles off the coast of Newfoundland and has become a lure for nautical experts and underwater tourists since its discovery in 1985.
The ship hit an iceberg and sank in 1912 during its maiden voyage from England to New York, with 2,224 passengers and crew on board. More than 1,500 people died.
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