A toxic workplace culture that silenced safety concerns and fired employees who spoke up contributed to the fatal implosion of the Titan submersible that killed five people in June 2023, a U.S. Coast Guard investigation found.
The 300-page report released Tuesday details how OceanGate Inc. created an environment where CEO Stockton Rush concentrated all decision-making power in his hands and retaliated against staff who raised safety issues about the deep-sea vessel.
“This marine casualty and the loss of five lives was preventable,” said Jason Neubauer, who chaired the investigation.
Leadership ignored safety warnings
The investigation found Rush fired his director of operations in January 2018 after the employee conducted a safety inspection and recommended a conservative approach. During that meeting, Rush told the assembled group his director’s safety approach was “fundamentally opposite” to what he wanted.
“That’s why we hired [the director of operations], you know. It is for that level of detail and safety approach to it, was the primary attraction to bringing [the director of operations] on board. And now we’ve gotten to a point where his experience and his estimation of the correct way to do is fundamentally opposite of the approach that I want to take,” Rush said, according to the report.
The director was fired shortly after, sending a clear message to remaining staff that opposing views would not be tolerated, investigators found.
Employees silenced through intimidation
The report describes a pattern where OceanGate used “firings of senior staff members and the looming threat of being fired to dissuade employees and contractors from expressing safety concerns.”
When a Coast Guard Reserve petty officer employed by OceanGate warned about regulatory problems in 2017, Rush reportedly responded with hostility and claimed he could “buy a congressman” if the Coast Guard became a problem.
In 2022, a contractor raised concerns about navigation system errors and a loud bang heard during an ascent. An OceanGate director told the contractor: “You have a bad attitude, you don’t have an explorer mindset, you know, we’re innovative and we’re cowboys and a lot of people can’t handle that.” The contractor was sent home before her contract expired.
Financial pressure compromised safety
The investigation found OceanGate’s financial instability made workplace conditions worse. By 2023, the company asked employees to temporarily give up their salaries for future repayment. High turnover meant full-time staff were replaced with contractors and volunteers.
“The safety was being compromised way too much,” a former director of engineering told investigators while reflecting on tension between financial struggles and obligations to customers who paid years in advance.
Inadequate safety oversight
Despite having a 155-page health, safety and environmental manual, only four pages addressed dive-specific safety procedures. The company had no designated director of safety, leaving Rush to serve as CEO, safety officer and primary pilot.
The board of directors functioned mainly as a “figurehead to add credibility,” with meetings described as informational sessions where Rush showcased accomplishments and made decisions without meaningful input.
Multiple system failures
Beyond the toxic culture, investigators found OceanGate failed to follow proper engineering protocols, conduct meaningful analysis of monitoring data, and maintain the vessel properly during off-seasons.
The company also misrepresented the Titan’s safety record by including dives from a scrapped earlier hull to inflate the operational experience of the final vessel, which had only 11 test dives to a maximum depth of 170 metres before being used for passenger trips to the Titanic wreck at 3,840 metres.
Recommendations for change
The Coast Guard made 17 safety recommendations, including stronger oversight of submersible operations, better coordination between federal agencies, and improved whistleblower protections.
The report calls for new agreements between occupational safety agencies and the Coast Guard to clarify investigation protocols and improve coordination when employees report safety concerns.
