PORTLAND, Maine (AP) — The deadly Titan submersible disaster that raised global alarms about private deep-sea tourism was the result of preventable safety failures and deliberate efforts to avoid oversight, according to a U.S. Coast Guard report released Tuesday.

All five people inside the Titan died in a catastrophic implosion as it descended to the wreck of the Titanic off Canada, and the dayslong search for the missing vessel grabbed international headlines. The Coast Guard convened its highest level of investigation in the aftermath.

The Titan was owned by OceanGate, a private company based in Washington state. The operator of the submersible, OceanGate head Stockton Rush, died in the implosion.

The report found the company’s safety procedures were “critically flawed,” citing “glaring disparities” between their safety protocols and actual practices. The disaster has led to lawsuits and calls for tighter regulation of the developing private deep sea expedition industry.

Preventing the next Titan disaster

Jason Neubauer, with the Marine Board of Investigation, said that the findings will help prevent future tragedies.

“There is a need for stronger oversight and clear options for operators who are exploring new concepts outside of the existing regulatory framework,” he said in a statement.

OceanGate suspended operations in July 2023. A spokesperson for the company said it has been wound down and was fully cooperating with the investigation.

“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,” said the spokesperson, Christian Hammond.

Coast Guard report details ‘red flags’ at OceanGate

Throughout the report, which spans more than 300 pages, investigators repeatedly point to OceanGate’s culture of downplaying, ignoring and even falsifying key safety information to improve its reputation and evade scrutiny from regulators. OceanGate ignored “red flags” and had a “toxic workplace culture,” while its mission was hindered by lack of domestic and international framework for submersible operations, the report says.

Numerous OceanGate employees have come forward in the two years since the implosion to support those claims. The report says firings of senior staff members and the looming threat of being fired were used to dissuade employees and contractors from expressing safety concerns.

“By strategically creating and exploiting regulatory confusion and oversight challenges, OceanGate was ultimately able to operate TITAN completely outside of the established deep-sea protocols,” the report found.

The Titan’s inadequacies

Investigators found that the submersible’s design, certification, maintenance and inspection process were all inadequate. Coast Guard officials noted at the start of last year’s hearing that the submersible had not been independently reviewed, as is standard practice.

Mounting financial pressures in 2023 led to a decision by OceanGate to store the Titan submersible outdoors over the Canadian winter, where its hull was exposed to temperature fluctuations that compromised the integrity of the vessel, the report said.

The Marine Board concluded that Rush, OceanGate’s CEO, “exhibited negligence” that contributed to the deaths of four people. If Rush had survived, the case would have been handed off to the U.S. Department of Justice and he may have been subject to criminal charges, the board said.

The Marine Board said one challenge of the investigation was that “significant amounts” of video footage evidence that had been captured by witnesses was not subject to its subpoena authority because the witnesses weren’t U.S. citizens.

The victims of the Titan disaster

In addition to Rush, the implosion killed French explorer Paul-Henri Nargeolet, British adventurer Hamish Harding and two members of a prominent Pakistani family, Shahzada Dawood and his son Suleman Dawood.

The family of Nargeolet, a veteran French undersea explorer known as “Mr. Titanic,” filed a more than $50 million lawsuit last year that said the crew experienced “terror and mental anguish” before the disaster. The lawsuit accused OceanGate of gross negligence.

The Titan’s final dive

Titan had been making voyages to the Titanic site since 2021. The Titan’s final dive came on June 18, 2023, a Sunday morning when the submersible would lose contact with its support vessel about two hours later. The submersible was reported overdue that afternoon, and ships, planes and equipment were rushed to the scene about 435 miles (700 kilometers) south of St. John’s, Newfoundland.

Wreckage of the Titan would subsequently be found on the ocean floor about 330 yards (300 meters) off the bow of the Titanic, Coast Guard officials said.

The Marine Board of Investigation held several days of hearings about the implosion in October 2024. During those hearings, the lead engineer of the submersible said he felt pressured to get the vessel ready to dive and refused to pilot it for a journey several years earlier.

Tony Nissen told the board that he had told Rush: “I’m not getting in it.”

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Associated Press writers Kimberlee Kruesi in Providence, Rhode Island, and Leah Willingham in Boston contributed to this report.