The deadly Titan submersible that killed five people during an underwater voyage to the wreckage of the Titanic two years ago was a preventable incident, according to the U.S. Coast Guard, as owner OceanGate failed to follow engineering protocols for testing, maintenance and safety. 

The U.S. Coast Guard’s two-year investigation, which was published Tuesday, found that OceanGate, based out of Washington state, did not abide by “established” deep-sea protocols that, along with the lack of third-party oversight and experienced company workers, allowed OceanGate CEO Stockton Rush “completely ignore vital inspections, data analyses and preventative maintenance procedures, culminating in a catastrophic event.” 

“There is a need for stronger oversight and clear options for operators who are exploring new concepts outside of the existing regulatory framework. I am optimistic the ROI’s findings and recommendations will help improve awareness of the risks and the importance of proper oversight while still providing a pathway for innovation,” U.S. Coast Guard Marine Board of Investigation (MBI) chair Jason Neubauer said in a statement.

The probe found that OceanGate did not “ensure” an analysis was done to process the expected cycle of the Titan’s hull, the company over-relied on a real-time monitoring system to analyze the condition of the carbon fiber hull and kept using the Titan after a number of incidents that “compromised the integrity of the hull and other critical components of the submersible without properly assessing or inspecting the hull.”

The MBI also concluded that the Titan’s hull construction and design “introduced flaws that weakened the overall structural integrity” of it. 

The incident took place on June 18, 2023, and all five people on board died: Shahzada and Suleman Dawood, Paul-Henri Nargeolet, Hamish Harding and Rush. A search-and-rescue operation unfolded shortly after the vessel lost communications. After the incident, which grabbed international headlines, OceanGate shut down. 

“We again offer our deepest condolences to the families of those who died on June 18, 2023, and to all those impacted by the tragedy,” the company’s spokesperson told The Wall Street Journal, adding that OceanGate cooperated with the Coast Guard during the probe. 

The company, which was founded by Rush and Guillermo Söhnlein in 2009 in Everett, Wash., harnessed operation practices and maintained a safety culture that was “critically flawed,” according to the MBI investigation. 

“OceanGate's senior leaders fostered an organizational culture that allowed mounting financial shortfalls, customer expectations and operational demands to be prioritized over the Mission Director’s authorities and responsibilities for each TITANIC dive,” the investigators said in the report. 

The MBI report also outlined that the Occupational Safety and Health Administration (OSHA) lack of probe into the 2018 OceanGate whistleblower’s complaint, along with lack of “effective” coordination and communication between OSHA and U.S. Coast Guard was a “missed opportunity for potential early government intervention ahead of OceanGate's planned testing of the first TITAN hull.” 

“Early intervention may have resulted in OceanGate pursuing regulatory compliance or abandoning their plans for TITANIC expeditions,” the investigators wrote.