Findings from TSB investigation M23A0169: Implosion of the Titan submersible and loss of life

Investigations conducted by the Transportation Safety Board of Canada (TSB) are complex since an accident rarely results from a single cause. In the case of the 2023 implosion of the Titan submersible which resulted in the death of five people on board, several factors led to the accident. The five findings below detail the causes and contributing factors that led to this occurrence. Additionally during the course of the investigation, the TSB also made four findings as to risk and two other findings.

Findings as to causes and contributing factors

1. 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.
2. 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.
3. 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.
4. The reduced compressive strength of the Titan’s carbon fibre cylinder, as well as defects that were potentially introduced during manufacturing, operations, storage, and its transport, likely led the cylinder to fail progressively with damage accumulating during each dive cycle until it imploded, fatally injuring all five people on board.
5. Risk management at OceanGate was hindered by the structure and composition of the company as well as by the influence of power dynamics, 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

1. 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.
2. 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.
3. 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.
4. 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.

Other findings

1. 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.
2. 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.