The Transportation Safety Board of Canada (TSB) has published its investigation report into the 2023 implosion of the Titan submersible. On June 18, 2023, the Titan submersible, owned by U.S. based company OceanGate, imploded while descending to the wreck of the Titanic with five people on board. As a result of its investigation, TSB has also issued six recommendations.
At the time of the incident, the operation was supported by a Canadian cargo vessel operated by Canadian company Horizon Maritime Services Ltd., the Polar Prince, which towed the 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 investigation found that the 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. 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 the Titanic and failed to identify and mitigate key risks associated with its operation. Beyond the design of the Titan and the organizational structure of OceanGate, the investigation identified a broader gap in the international oversight of submersibles. International Maritime Organization 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 the Titan was operating from St. John’s with the support of a Canadian vessel. However, the Titan received no oversight. 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 the Titan’s operations.
Transport Canada’s oversight activities were further limited by a lack of formal information sharing among federal organizations. 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 organizations was not shared with Transport Canada, leaving it without a complete picture of the operation and the risks it posed.
Yoan Marier, Chair of the TSB said, “When it came to the Titan, critical information existed across multiple federal government organizations, but no one was responsible for connecting the dots. 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.”
This investigation revealed systemic safety gaps in the oversight of submersible operations, both in Canada and internationally. As a result, the Board is issuing six recommendations to address deficiencies in the following areas:
- regulatory oversight
- technical standards for submersibles
- safety management
Read the final report: TSB M23A0169 report - Titan