US Coast Guard Report on Titan Submersible
126 comments
·August 5, 2025dwheeler
QuantumGood
It was very clearly very early on that critical risks were known, unmitigated, and misrepresented. I don't think the kind of person(s) that know and misrepresent are the kind to learn and avoid similar mistakes, though publicizing issues like this will increase pressure on them to hide their lies better. They had a messianic CEO dismissing concerns with bluster and bravado
stavros
One thing to keep in mind here is that the CEO didn't hide the flaws to make a profit, otherwise he wouldn't have been on board the submersible. He hid them because he believed they were wrong.
kermatt
He believed they were wrong because they got in his way: https://www.businessinsider.com/titan-submarine-ceo-complain...
hinkley
"The most important thing is not to fool yourself, and you are the easiest person to fool."
post_break
The thing that I find amazing about this sub, is that the final hull survived all those trips, and then before the final one let everyone know it was toast, and Stockton ignored it. He was careless with peoples lives, but his sub actually did what he set out to do, and if he listened to the instruments, he'd still be alive, he could have made another hull, and he could be taking more trips down there for better of for worse. The porthole design was poor, the carbon fiber had tons of defects, the controller, everything was cobbled together, yet it held up until it didn't.
Ralfp
It didn't implode on next dive, it was much worse.
On dive 80 during surfacing people heard a "loud bang" from the submersible (according to a witness it sounded like a gunfire).
They looked at their "RTMS" system and found recording of loud noise from the hull. But only three days later they did the dive 81 (with customers). After this dive their tension sensors shown that their carbon hull no longer compresses under pressure like it used to. They then made plan to inspect the hull after dive 83. But instead they left Titan winter on the parking lot in Saint Johns where it was not protected from any exposure because that was cheaper.
During summer they hauled it for a dive 88 (I don't know why they jumped from 81 to 88, prolly cancelled dives because of the weather?). During hauling it become loose and started knocking against the hauling platform (LARS) because of the waves. Day later they did a dive where it imploded.
On side note, they had no way to access and inspect the carbon hull without having to completely dissemble vehicle, and that too was considered too pricy to do.
This was a disaster of organization with messianic CEO dismissing all concerns with bravado and legal treats that got what was coming to them. If you want to, here's transcript of him scolding and then laying out one of engineers because they took safety concerns outside of the company:
https://media.defense.gov/2024/Sep/20/2003550726/-1/-1/0/CG-...
dogleash
"Not at all, because carbon fiber is better compression then tension. And that's what nobody understands. It's completely opposite of what everyone else says. Everyone's, oh, carbon fiber can't handle compression. They're full of shit, and I've proven they're full of shit."
- Man crushed by custom carbon fiber submersible
Spoom
"Now, if it fails, then you have to stop, and it's -- again, this is not something that just happens all of a sudden. It doesn't just implode. It screams like a mother before it implodes."
- Man crushed by an instantly imploding submersible
A_D_E_P_T
The funny thing is that it's trivially untrue of carbon fiber, which has a compressive strength ~40% of its tensile strength.
lesuorac
> But instead they left Titan winter on the parking lot in Saint Johns where it was not protected from any exposure because that was cheaper.
This came up in the hearings. It's standard practice to do this but it's probably different leaving say the metallic Antipodes [1] outside than carbon fiber.
jcranmer
The report here more or less outright says that leaving it outside was a major factor in the incident. The incident on dive 80 was adjudged to be partial delamination of the carbon fiber layers, and leaving it outside subjected it to freeze-thaw cycles that propagated the delamination into near-total delamination, which promptly failed the next time the hull was pressurized. Although there is also the aborted dive 87, which subjected to the submersible to a lot of percussive damage via wave action.
js2
This transcript is of CEO Stockton Rush interviewing redacted "Director of Marine Operations"? Do I have that right?
Why is there a transcript of the CEO interviewing one of his own employees, apparently in front of the NTSB, from 2018?
Edit: the transcript is between Stockton Rush and his former director of marine operations, David Lochridge, plus three other staff. [...] Lochridge: "That meeting turned out to be a two-hour, 10-minute discussion… on my termination and how my disagreements with the organisation, with regards to safety, didn't matter." [...] The 2018 meeting was recorded.
shortrounddev2
I believe it was a recorded phone call
joshstrange
> They then made plan to inspect the hull after dive 83. But instead they left Titan winter on the parking lot in Saint Johns where it was not protected from any exposure because that was cheaper.
The things I'm working on have a much lower (zero?) chance of death but this is a tale as old as time. _Looks longingly into the backlog..._
iJohnDoe
Some real gems here and learned some things I wasn't aware of.
> "Now, if it fails, then you have to stop, and it's -- again, this is not something that just happens all of a sudden. It doesn't just implode. It screams like a mother before it implodes."
> On dive 80 during surfacing people heard a "loud bang" from the submersible (according to a witness it sounded like a gunfire)
Well, there you go.
> But instead they left Titan <during the> winter on the parking lot in Saint Johns where it was not protected from any exposure because that was cheaper.
> During hauling it become loose and started knocking against the hauling platform (LARS) because of the waves. Day later they did a dive where it imploded.
Early on, it was made clear that carbon fiber hulls could not easily be inspected for integrity issues like metal hulls can be. I'm not an expert, but I'm guessing sensitive instruments have been around for a while for the purpose of inspection. Having a hull you cannot easily inspect would/should make most people/companies nervous.
throw9394944
> This was a disaster of organization with messianic CEO dismissing all concerns with bravado
While I love this list, I do not like that you are blaming everything on CEO.
This company followed current ethical policies, and used them to exclude actual experts and skilled people. CEO operated in environment that supports this behaviour, and only cares about irelevant metrics!
Ralfp
Its fair to blame Stockthon because he fired or treated to sue everyone who didn’t buy into his spiel about this being revolutionary disruption of private submarines. Leves of staff rotation were insane in this company, their lead eng. at the time of implosion was a software dev because everybody else left or was laid off.
avgDev
Not surprised this is posted by a throwaway account. I would think this is Rush himself, if he was alive of course.
lesuorac
I'm not sure he had the money to make another hull. I think that's the crux of the issue, he didn't have a usable system and he didn't want to give up his ambition.
lupusreal
Money was a big part of the problem. The whole point of making it out of carbon fiber was to make it light and therefore cheap to operate. He could have made a long DSV with plenty of room for passengers out of metal, the Aluminaut DSV was such a craft with proven performance, but then he would have needed to buy or rent a more expensive ship to operate it with.
duskwuff
> Money was a big part of the problem.
Yep. There are a ton of incidents described in the report which all stink of penny-pinching. Probably one of the most obvious is reusing the titanium end cap components from the first submarine; this may have played a role in the failure of the Titan, as the mating surfaces may have been damaged or incompletely cleaned when rebonding them to the new hull.
lenerdenator
All of this really should have made someone stop and ask if this was the part of the human experience that really needed cost reduction.
But it didn't, so... shrugs.
null
shortrounddev2
Other than the finances of it, he was a total narcissist who refused to believe anyone else knew more about anything than he did. Even when presented with hard data he chose to ignore it and killed himself as a result.
dwheeler
> The thing that I find amazing about this sub, is that the final hull survived all those trips, and then before the final one let everyone know it was toast, and Stockton ignored it. He was careless with peoples lives, but his sub actually did what he set out to do, and if he listened to the instruments, he'd still be alive...
I disagree. In fact, I think that's quite unlikely.
First, unlike a metal hull, carbon fiber hulls accumulate subtle damage on compression that's hard to detect. Then, when they fail, they tend to fail catastrophically. So "this hull worked before" isn't evidence of success in this case, as it normally would be, it's evidence that you're getting closer & closer to the disaster.
Second, I think Stockton would have just kept diving, even if this event hadn't failed. He might have even gotten more reckless (though per the report he was already extremely reckless). If you keep playing Russian Roulette, and occasionally add another bullet, eventually the game will end. There is no evidence he was going to stop until he was killed by his own decisions.
None of this takes away the tragedy of it. It's sad, and will remain so.
WalterBright
> unlike a metal hull, carbon fiber hulls accumulate subtle damage on compression that's hard to detect
All metals suffer from that, too. It's called fatigue damage. It bedeviled the aviation industry for a long time because there was no reliable way to detect the fatigue damage.
Eventually, an ad hoc formula was developed to calculate the fatigue damage, and then replace parts that were getting close to the limits.
That's why airliners are scrapped after something like 62,000 flight cycles.
hinkley
Aluminum is especially bad this way. And we make airplanes out of it.
chowells
I think you missed the thrust of OP. The submersible had instruments in it to report on the hull condition. They all were reporting it had previously experienced severe strain before the last dive, and they were designed as tripwires. If they tripped, the hull should have been considered unsafe and not used again. They were ignored.
It is a shock that they actually worked and reported the hull was unsafe before it failed. Given everything else, it's not a surprise in the slightest that they were ignored.
post_break
Exactly, the hull performed, then the instruments told them with a loud bang that it was toast.
jordanb
It didn't do a lot of dives before it failed. The dive number was the number of "dives" oceangate did using any hull. Additionally most of those dives were 20 feet down in a marina for testing.
petsfed
>The porthole design was poor, the carbon fiber had tons of defects, the controller, everything was cobbled together, yet it held up until it didn't.
Emphasis mine.
Everybody hammers on the controller like using a gaming controller was somehow more indicative of the unseriousness of the endeavor than, you know, the firing of the guy who said the hull was unsafe. Based on what I've read, that was one of the few authentically competent design decisions of the whole bloody thing. Why waste time and resources building, designing, and most importantly lifetime testing something that you can buy off the shelf for $30 US?
The US Navy has been using off-the-shelf game controllers for years now[0], because they work. And as a bonus, the submarine designers can be confident that if Stockton Rush or Seaman Manchild or whoever throws his controller in a fit of rage when his submarine doesn't work right, the controller will still work afterwards.
Absolutely, there were problems with the control scheme (reportedly, the motors were wired into the control board wrong, so the x- and y-axes were reversed). But that's not the fault of some usb controller communicating with the control box. That's the fault of the people working on the actually bespoke portions of the submarine.
0. https://www.cnet.com/science/us-navy-launches-submarine-mane...
morpheos137
Stockton Rush would have fit right in in Silicon Valley. Rush and stock on.
null
southernplaces7
[flagged]
shortrounddev2
There's a documentary about it on Netflix and the impression I came away with is that, while there are fundamental engineering problems associated with a carbon fiber design, they could have probably overcome them in one way or another.
The problem with oceangate is that their CEO was an arrogant narcissist who thought he knew better than everyone, and if anyone stood in his way he would explode with anger at them and fire them. It was a company with absolutely no culture of safety and a cult of personality where people were punished for being honest. The CEO knew about the problems and still somehow believed, to his core, that everyone else (including hard data!) was wrong. He believed in his own infallibility so deeply that it killed him
hajile
I've heard both assertions. I tend to believe that Carbon Fiber is a fine material to use.
This submersible used untested techniques. They didn't adhere the layers together properly and apparently never bothered to X-ray the tube as that would have shown at least some of the defects. It also seems like there were other design issues with how the tube was paired to the ends.
Most importantly, the deaths were caused by negligence during operation and maintenance. They had the data showing when the hull was damaged on the previous expedition, but either never did their due diligence and analyze it or ignored the results. Even during their last expedition, they may well have avoided death if the alarms had been heeded.
EDIT: to answer the people who seem skeptical, there are companies making carbon fiber vessels that have successfully gone much deeper than those Titanic dives. We're still in the learning stages with the technology, but we'll eventually find the combinations and standards that can make it safe to use (at which point, it may become better than our current solutions). Until then, maybe we shouldn't be shoving people into damaged experimental vessels to see what happens.
https://www.compositeenergytechnologies.com/underwater-carbo...
https://www.researchgate.net/publication/376273321_Carbon_Fi...
hinkley
Their carbon fiber laying system sure looks an awful lot like the one used by oceangate. Can anybody here explain the nuances I'm missing?
rawgabbit
The Coast Guard report section “5.6 Insufficient Understanding of Carbon Fiber Material Properties for Deep-Sea Applications” addresses your arguments.
Yes. It can be safe. The problem is that its crystalline structure can fail instantaneously without any ability to detect beforehand. In this case the sub was likely improperly manufactured and improperly stored and damaged from previous dives and from transport. The company “planned” to inspect but as no non destructive testing was possible, they didn’t bother.
fortran77
> I tend to believe that Carbon Fiber is a fine material to use.
It's a fine material to use for unmanned submersibles!
Ylpertnodi
>I tend to believe that Carbon Fiber is a fine material to use.
For deep underwater? Apart from the series of stupidities you go on to list, I'd love to hear your reasons as to why?
I'm a carbon f bike rider, even down to carbon spokes and I do not trust the material, knowing that pressure, or force, applied in the wrong direction will make it crack!. As for carbon in a circle...no way.
Ralfp
You don't need to watch Netflix series. There is a transcript of entire conversation between Stockthon and David Lochridge where the former scolds the latter for taking his safety concerns outside of company and firing him:
https://media.defense.gov/2024/Sep/20/2003550726/-1/-1/0/CG-...
bouchard
The Netflix documentary has some extra interviews with employees, clients, etc. which are interesting. (1hr 51min runtime though)
rawgabbit
Quote:
>Not at all, because carbon fiber is better compression than tension. And that's what nobody understands. It's completely opposite of what everyone else says. Everyone's, oh, carbon fiber can't handle compression. They're full of shit, and I've proven they're full of shit. If you want to see that, you take a look at the third scale model that we tested.
6SixTy
Carbon Fiber just isn't suited for submarine type of loads. It really doesn't like being compressed, and it tends to give you no warning before snapping.
jjk166
Carbon fiber is actually a pretty good material for submarine type loads. Submarines have to balance their need for an extremely strong hull with the need for buoyancy. For a given size, to make your hull stronger, you must make your walls thicker, which makes you heavier. The only options are to make the sub bigger, increasing the internal volume, or making the hull out of something with a better strength to weight ratio, or more accurately a better strength to specific gravity ratio.
In carbon fiber composite, it's actually the epoxy which provides the compressive strength, and while it has very good compressive strength, the real advantage is its very low density. It is only just barely denser than water, so you can make your hull extremely thick with essentially no loss in buoyancy. Carbon fiber does fail catastrophically, but they could have just made the hull so thick that they were never getting anywhere near the failure point. Further, since carbon fiber is built up in plied layers, you don't have the same sorts of processing limits as with thick metal plates.
The basic concept of Titan was sound, it was just horribly horribly executed. With their flagrant violation of basic engineering and safety practices, they would have killed people no matter what they made their sub out of.
caffeinated_me
This isn't the first carbon fiber submarine, although it is the first manned one. The US Navy tried out an unmanned model in the 80s, and got much better results- they were expecting at least 1000 successful dives before stress fatigue was an issue.
Here's a detailed report on it. Pages 32-33 has their take on material analysis, probably the most relevant to this failure
https://apps.dtic.mil/sti/pdfs/ADA270438.pdf
I'm personally more suspicious of oceangates manufacturing process than the material, but I'm far from an expert here.
potato3732842
"Isn't suited" is a stretch. They still managed to make a few good dives with it despite comically bad decisions in just about every key area. Imagine what a well funded company with experience in CF, robust QC and non-laughable operating procedures could do.
It's not ideal on a first pass analysis in the same way concrete can't to shit in tension yet with a bunch of carefully placed steel and number crunching magic it works great. I think they proved that CF has the same potential. A more serious attempt could likely work in some capacity.
loudmax
There's been a vibe shift. A cult of personality around an arrogant narcissist who fires people for publishing hard data when it contradicts him is apparently what a lot of people seem to want right now.
dragonwriter
Yeah, now we're all in the sub.
vipa123
And we'll have entirely predictable results from the shift.
js8
I think it's how selfishness manifests under (neo)liberalism, as self-promotion. The narcissists are extremes of that.
throw0101c
> The problem with oceangate is that their CEO was an arrogant narcissist who thought he knew better than everyone, and if anyone stood in his way he would explode with anger at them and fire them. It was a company with absolutely no culture of safety and a cult of personality where people were punished for being honest.
Sounds like someone else that's been in the news these last few months.
lenerdenator
Months?
Try decade.
Twirrim
> The problem with oceangate is that their CEO was an arrogant narcissist who thought he knew better than everyone, and if anyone stood in his way he would explode with anger at them and fire them.
There has to be a point at which you go "fuck it" and stop working for such a guy, even if you haven't been the target of his temper. I lasted 9 months at a company that had a CEO who wasn't explosive, but toxic in so many ways. His company had a 90% staff turnover over any given 18 month period, primarily everyone outside of senior leadership. If senior leadership had stopped propping him up, and quit that company would have been dead and buried far quicker. Thankfully that company wasn't involved in anything that could endanger anyone's lives.
cogman10
> Investigators determined the Titan’s real-time monitoring system generated data that should have been analyzed and acted on during the 2022 Titanic expedition. However, OceanGate did not take any action related to the data, conduct any preventative maintenance or properly store the Titan during the extended off season before its 2023 Titanic expedition.
So, a bunch of giant red warning flags AND they didn't bother to properly store the casket. I feel bad for the passengers, Stockton got the FAFO award he deserved.
ItsBob
The Netflix documentary was great and the thing that I took away from it most was that in fractions of a second all the passengers literally blinked out of existence: They were here and then within a ms, they literally vanished (I assume... they didn't elaborate on it but I can guess!)
The temperature and pressure in that tiny fraction of a second was probably 10s of thousands of degrees and hundreds of jumbo jets smashing into them so fast that their bodies didn't even register the trauma.
Blew my mind.
Nearly forgot that they heard the explosion on the surface ship, 2 miles above the sub... that kinda screws with my head tbh!
avgDev
It is quite interesting. The implosion took about 10 milliseconds.
It takes the brain 13 milliseconds to register an image.
It takes the brain 100-200 milliseconds to register pain.
They could have heard some cracks but most likely had no knowledge of the implosion. Their bodies just turned into mist.
yawpitch
Mist is kind of the exact opposite of what their bodies turned into. Compression does really, really interesting things to meat and bone sacks with lots and lots of tiny airspaces. They wouldn’t have been conscious of anything, but they would have been more mince / paste / goo / frothy clot than anything as clean and homogenous sounding as mist.
dmoy
> Nearly forgot that they heard the explosion on the surface ship, 2 miles above the sub... that kinda screws with my head tbh!
Water carries sound really well. Whale songs can still be detected what, thousands of miles away or something ridiculous?
It is kinda freaky to think about.
tantalor
All of that was already familiar to people who had seen The Abyss (1989)
jcgrillo
this also happened rapidly: https://en.m.wikipedia.org/wiki/Byford_Dolphin
ridgeguy
Fiber-reinforced composites are basically analogous to spaghetti dispersed in glue. Really strong in tension, when the (in this case, carbon) fibers are taking nearly all of the load. In compression, the fibers have nearly zero resistance to flexure, and the load is mainly being taken up by the glue (the matrix, in composite-speak). When the fiber/matrix interface fails due to fiber flex-induced shear force, you're done.
I just can't imagine why a submersible structural designer would select composites for this application. IMHO, this project was doomed from the moment of that design decision, even setting aside all the other idiocy.
throwawayoldie
> I just can't imagine why a submersible structural designer would select composites for this application
Maybe it's easier to imagine if you consider the designer in question not as a submersible structural designer per se, but rather a nepo baby cosplaying as one.
bell-cot
> I can't imagine why ...
"Cheap, cheap, cheap" ain't just a thing that birdies say.
dwheeler
James Cameron gave an interview that did a great job explaining the problems. In particular, carbon fiber is great for planes, but a terrible idea for compressive forces like going deep underwater. See: "James Cameron on the OceanGate sub disaster" https://www.youtube.com/watch?v=EwSaZfwBrz8
ortusdux
The USCG hearing was fascinating, especially Matthew McCoy's testimony -
https://www.newsweek.com/oceangate-employee-resigned-co-foun...
Luker88
I don't know how anything works at sea.
Assume I have the money to go on a trip, am I supposed to do background checks on people and technology by myself?
From this report I gather that either the sea industry is completely unregulated, or this guy ignored all rules and nobody did a check even after something like 80 dives.
Both options sound kinda insane to be honest.
Can anyone more knowledgeable elaborate?
csb6
Typically ships need to be certified by a classification society (an organization that inspects ships and makes sure they meet technical safety standards) in order to operate commercially. The Oceangate sub was not certified by any of these authorities because certification was viewed as “red tape” in the way of their “innovations”, and they would have almost certainly failed to be certified (a bad look if you are trying to convince people it is safe).
I think the rules/laws around commercial deep sea sub companies were unclear because most deep sea subs are research vessels or private projects (e.g. James Cameron’s sub), not tourist operations.
nemomarx
Traditionally deep sea exploration has been under regulated and gotten by because everyone involved is very cautious and spending a ton of money on over engineering. Rush wanted to change that in order to make it an accessible tourist industry thing, so we might see safety regulations now.
ethan_smith
Maritime regulation exists in layers (flag states, classification societies, port authorities), but OceanGate deliberately operated in regulatory gaps by classifying Titan as an "experimental" vessel and launching from international waters to bypass oversight.
throwawayoldie
And there were no "passengers", legally speaking, just "mission specialists".
bouchard
Looking at interview footage of Stockton Rush, it seems he really wanted to be a disruptor and accomplish something which everyone else (i.e., experts) deemed impossible. He thought he could do what SpaceX did for space, but for underwater exploration.
zarzavat
> He thought he could do what SpaceX did for space
Even SpaceX, with unlimited resources, tried carbon fibre, couldn't get it to work, and switched to stainless steel. Different application but still. It's not a budget material.
firesteelrain
Problem is anyone can make a boat and kill themselves in it. Hard to hide a Falcon 9 rocket and get astronauts to go on it. It's highly regulated. You can put anyone on a dingy in the ocean and die.
avgDev
Rush could be placed in Wikipedia under hubris.
His hubris killed people. He ignored experts. He ignored warnings. This outcome was predictable.
xeromal
The problem is that SpaceX was told the same and it succeeded despite the ods. History is harsh to people who fail.
avgDev
SpaceX did not send manned missions for a while.
If the hull failed without people it would be no big deal. However, Rush was running out of money so he felt rushed and got reckless.
jjmarr
That's every startup founder to an extent.
What differentiates a good founder from a bad one is being right.
eptcyka
Nah, it is about finding ways to fail an experiment without failing the whole business, bonus points for not killing anyone in the process.
nathan_compton
This is a weird way to think of it, making it seem as thought its just a matter of chance whether the founder is right or not. The difference, if there is one, is that some founders can pivot when they see their approach won't work or, at least, throw in the towel before people die or too much many is wasted.
Maybe that makes them bad startup founders? I don't know. In my opinion "Startup Founder" is a role which should play second to "ethical human being."
bigbacaloa
[dead]
nathan_compton
Thank god things can be both funny and horrible, because this story delighted and horrified me.
Put "Moved Fast and Broke Stuff" on Rush's tombstone.
lupusreal
*cenotaph
danjl
Death by business model. The company was based on the concept that existing regulations and design constraints were overly conservative, and their customers paid the price.
null
The report has many gems about the tragedy. Basically, there were clear physical causes, which in turn were caused by hubris:
PHYSICAL CAUSES
"4.2.4.4. American Bureau of Shipping (ABS) Classification Society Background" ... "The ABS Underwater Rules do not permit the use of carbon fiber composites for Pressure Vessels for Human Occupancy (PVHOs)"
"4.2.4.5. Det Norske Veritas and Germanischer Lloyd (DNV GL)" ... 4.2.4.5.3. According to a DNV Surveyor, carbon fiber has not been accepted as suitable material for the construction of submersible PVHOs, especially when subject to external pressure experienced at ocean depths. According to DNV GL, carbon fibers are not considered suitable for significant compressive loading conditions."
"5.1. Inadequacy of Structural Engineering Analysis. OceanGate’s TITAN submersible design was a complex, high-risk, deep-sea submersible. The design and testing processes for TITAN did not adequately address many of the fundamental engineering principles that are considered crucial for ensuring safety and reliability for operations in such an inherently hazardous environment..."
"5.6 Insufficient Understanding of Carbon Fiber Material Properties for Deep-Sea Application. The TITAN’s pressure hull was constructed using carbon fiber, a material chosen by Mr. Rush for its “impressive” strength-to-weight ratio. [However] the use of carbon fiber in deep-sea environments remains unproven—unlike the materials with established safety records. There are currently no recognized national or international standards that approve of the use of carbon fiber pressure hulls for submersibles. Carbon fiber has demonstrated its effectiveness in other applications where the material is primarily under tension (e.g., aircraft hulls where the pressure inside the passenger compartment is pressing outwards). However, in deep-sea conditions, the pressure hull experiences extreme compressive forces, a scenario for which carbon fiber has no established track record and is generally understood to be less effective."
* * *
HUMAN DECISIONS
The physics is just the physics. There was no law of nature that forced them to take the steps they took. Instead, we have points like these:
"5.12. OceanGate’s Toxic Safety Culture. OceanGate’s operational and safety practices were critically flawed, which contributed to the catastrophic implosion of the TITAN submersible. At the core of these failures was a disconnect between the company's stated safety protocols and its actual practices. ... This highlighted systemic issues where submersible safety protocols were either egregiously inadequate or willfully disregarded, leaving critical risks unmitigated. The analysis reveals a disturbing pattern of misrepresentation and reckless disregard for safety in OceanGate's operation of the TITAN submersible, with Mr. Rush seemingly using inflated numbers to bolster the perceived safety and dive count of the final TITAN hull...
Examples of OceanGate CEO’s disdain for traditional submersible safety protocols were abundant. For example... This dismissive approach to safety culture was not limited to engineering decisions. OceanGate’s management actively retaliated against employees who raised legitimate compliance related concerns..."
This was a tragedy, because people died and this was all completely avoidable. It's the only event like this in many, many decades. I hope others will leran and avoid making similar mistakes.