Titan sub: New report into 2023 implosion reveals ‘systemic safety gaps’

Canada’s Transportation Safety Board (TSB) has published an investigation report into the 2023 implosion of the Titan submersible, revealing how a lack of formal information-sharing among federal organisations led to the submersible ultimately operating without oversight.

The report comes a year after the US Coast Guard Marine Board of Investigation (MBI) issued a damning report on the implosion, revealing a combination of inadequate design, inadequate regulations and a toxic workplace contributed to the disaster.

Titan implosion

On 18 June 2023, the Titan submersible, owned by US-based company OceanGate, imploded while descending to the wreck of the Titanic with five people on board. All of the passengers were killed.

Aboard the submersible were Stockton Rush, the American chief executive officer of OceanGate; Paul-Henri Nargeolet, a French deep-sea explorer and Titanic expert; Hamish Harding, a British businessman; Shahzada Dawood, a Pakistani-British businessman; and Dawood’s son, Suleman.

In 2024, video footage from the US Coast Guard revealed the wreckage of the Titan submersible, including its tail cone, resting on the ocean floor.

The expedition was supported by the Canadian cargo vessel Polar Prince, operated by Horizon Maritime Services. The vessel towed Titan from St John’s, Newfoundland and Labrador, to dive sites and acted as a support platform for OceanGate’s offshore operations. Horizon Maritime had provided the same service during OceanGate expeditions in 2021 and 2022.

Findings of Canadian investigation

The investigation finds that Titan‘s carbon fibre hull deteriorated progressively, with damage building up over multiple dives. According to the report, the hull’s finished properties were never tested against the theoretical specifications used during the design process, and its construction did not follow standard engineering practices.

Investigators also concluded that OceanGate’s approach to risk management was “affected by social and psychological factors, as well as the structure of the company”. As a result, the company did not know how long the hull could safely withstand repeated dives to the depth of the Titanic and did not identify or address several significant operational risks.

The report points to broader issues surrounding the oversight of submersible operations. Guidance issued by the International Maritime Organization on the design and operation of submersibles is non-binding for member states, leading to varying levels of oversight around the world.

In Canada’s case, investigators found that Transport Canada knew Titan was operating from St John’s with support from a Canadian vessel, yet the submersible was not subject to regulatory oversight. The report notes that this is not a unique case and that some vessels in Canada operate without direct oversight from Transport Canada.

The investigation also identifies shortcomings in information sharing between federal organisations. OceanGate had dealings with Fisheries and Oceans Canada, the Canada Border Services Agency, Global Affairs Canada and Parks Canada. Information gathered by those organisations was not passed on to Transport Canada, leaving the department without a complete view of the operation and its associated risks.

“When it came to the Titan, critical information existed across multiple federal government organisations, but no one was responsible for connecting the dots,” says Yoan Marier, chair of the TSB.

“Without a complete picture of the operation, the 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.”

The TSB says the investigation has uncovered “systemic safety gaps” in the oversight of submersible operations in Canada and internationally, and has made six detailed safety recommendations, intended to address shortcomings across three areas: regulatory oversight, technical standards for submersibles and safety management.

Details of the recommendations can be found in the report, which is available online.