Transportation Safety Board of Canada (TSB) has published its investigation report into the 2023 implosion of the Titan submersible and issued six recommendations in relation to the tragedy.
On June 18, 2023, Titan, a submersible tourist craft owned by US-based company OceanGate, imploded while descending to the wreck of the ocean liner Titanic with five people on board.
At the time of the occurrence, the operation was supported by Polar Prince, a Canadian cargo vessel operated by Canadian company Horizon Maritime Services, which towed Titan from St John’s, Newfoundland and Labrador, to dive locations, and provided a base for OceanGate’s operations at sea.
Horizon Maritime also provided this service to OceanGate in 2021 and 2022.
The TSB's investigation found that Titan’s carbon-fibre hull failed progressively, with damage accumulating during each dive. The hull’s as-built properties were never tested to ensure they met the theoretical specification used in the design, and its construction did not follow standard engineering practices.
The board learned that OceanGate’s risk management was further affected by social and psychological factors, as well as the structure of the company. Consequently, the company did not know how long the hull would remain safe when used repeatedly for dives to the depth of Titanic's wreckage and failed to identify and mitigate key risks associated with its operation.
Beyond the design of the Titan and the organisational structure of OceanGate, the investigation identified a broader gap in the international oversight of submersibles. International Maritime Organisation guidelines regarding design and operation of submersibles are non-binding to member states, resulting in inconsistent oversight around the world.
In this case, Transport Canada was aware that Titan was operating from St. John’s with the support of a Canadian vessel. However, Titan received no oversight.
The TSB said this situation is not unique; in fact, in Canada, it is relatively common for vessels to receive no oversight from Transport Canada. The investigation found that the lack of regulatory oversight to identify safety deficiencies resulted in increased risk to those involved in Titan’s operations.
Transport Canada’s oversight activities were further limited by a lack of formal information sharing among federal organisations.
OceanGate had numerous interactions with several government departments including Fisheries and Oceans Canada, the Canada Border Services Agency, Global Affairs Canada, and Parks Canada. However, information gathered by these organisations was not shared with Transport Canada, leaving it without a complete picture of the operation and the risks it posed.
"When it came to Titan, critical information existed across multiple federal government organisations, but no one was responsible for connecting the dots," said Yoan Marier, Chair of the TSB. "Without a complete picture of the operation, Titan continued to operate in Canada without regulatory oversight.
"We have been calling for stronger regulatory surveillance in the marine sector for years. Lives are at risk when safety gaps are left unaddressed."
This investigation revealed systemic safety gaps in the oversight of submersible operations, both in Canada and internationally. As a result, the TSB is issuing six recommendations to address deficiencies in the areas of regulatory oversight, technical standards for submersibles, and safety management.
Click here to read Baird Maritime columnist Hieronymus Bosch's take on the Titan tragedy and on OceanGate co-founder and CEO Stockton Rush, who was one of the five people who perished when the submersible imploded.
