US Coast Guard Displayed Ingenuity and Resourcefulness in Titan Response
The catastrophic implosion of the Titan submersible that killed five people in 2023 could have been prevented, a US Coast Guard investigative board found on Tuesday, calling the vessel’s safety culture and manager OceanGate's operational practices “critically flawed.”
The Titan vanished during a descent to the Titanic wreck on a tourist expedition, losing contact with its support ship. After a tense four-day search, its shattered remains were discovered strewn across the seabed 1,600 feet (488 meters) from the bow of the wreck.
The report includes information on the US Coast Guard response, saying:
Despite a seven-hour initial notification delay dictated by OceanGate's communications plan, and the added hindrance of OceanGate’s decision not to confirm any backup deepwater capable assets or voluntarily report their dive operation as recommended by the USCG National SAR Plan, the Coast Guard in conjunction with multiple partners responded to the TITAN distress notification with ingenuity and resourcefulness.
The complex deep-sea environment combined with the remote high seas dive site presented extraordinary operational challenges to the rescue mission, yet the international effort showcased the power of unity of effort in what initially appeared to be a desperate race against time. The Coast Guard's unwavering commitment to its SAR operating philosophy drove a relentless pursuit of all available resources until all hope of rescue was exhausted.
OceanGate's 2023 Project Execution Plan identified external deep-sea rescue resources, yet the company failed to proactively engage, notify, or prepare any third-party services for the TITAN expedition. More critically, OceanGate and the POLAR PRINCE lacked the essential on-scene resources – an ROV or a secondary submersible – to conduct their own immediate search and rescue attempts in the event of an emergency.
Recognizing its own limitations in deep-sea searches exceeding 3,000 m, the Coast Guard effectively leverages military and commercial submersible and ROV operators to provide crucial support in the rare event of an underwater emergency. Those capabilities were tapped for the TITAN response and within four days, the Coast Guard mobilized assets capable of reaching the ocean floor.
The Coast Guard Captain responsible for search suspension authority highlighted this achievement during MBI testimony: "Many would have considered this an almost impossible task. Yet, from Sunday to Thursday morning, we had an ROV on the ocean floor at the site of the TITANIC. Experts from SUPSALV have called this unprecedented given the logistical challenges involved in deploying those ROVs."
While the TITAN SAR response included the arrival of multiple ROVs on scene initially, they lacked the appropriate depth capabilities and subject matter expertise to effectively conduct search operations. As a result, one ROV was lost early in the SAR effort as an attempt was made to operate it well beyond its rated depth.
The USCG was able to coordinate the delivery of more capable ROVs on-scene on June 21st and 22nd that could reach 6,000-meter depths. On June 22, 2023, at approximately 10:30 a.m., a Pelagic Research Services ROV discovered a debris field of the TITAN submersible’s forward cone and tail piece, with a second debris field discovered shortly thereafter containing the TITAN’s aft portion of the cone. These discoveries led to conclusive evidence of a catastrophic loss of the submersible and all five persons on board.
OceanGate suspended all operations after the incident. A look at the investigation report’s index demonstrates the scope of problems it found with the company’s operations leading up to the tragic need for US Coast Guard help:
• Inadequacy of Structural Engineering Analysis
• Lack of Determination of Identifying Failure Points of TITAN’s Design
• Failure to Follow Boeing’s Manufacturing and Testing Specifications
• Insufficient Understanding of Carbon Fiber Material Properties for Deep-Sea
• Use of an Un-tested / Un-certified Acrylic Window
• Flawed Implementation and Application of TITAN’s RTM System
• Implications from the Shift in Hull Strain Data After Dive 80 Incident
• Insufficient Understanding of Adhesive Joint for Deep-Sea Application
• Detrimental Effects on TITAN’s Hull After 2022 TITANIC Expedition
• Circumvention of U.S. Laws and International Standards
• Weak Regulatory Framework for Submersibles and Operations
• OceanGate’s Toxic Safety Culture
• Undermining Authority and Overriding Established Hierarchy
• Absence of a Designated Director of Safety and Mismanagement of Risks
• Lack of Formal Pilot Training or Appropriate Credentialing
• Disregard for Safety Concerns Voiced by Outside Entities
• Failure to Properly Troubleshoot Hull After Acoustic Events/Safety Culture
• Misrepresentation of Paying Passengers as Mission Specialists
• High Rate of Employee Turnover and Financial Pressures
• Improper Storage and Transportation of TITAN.