Link to full official USCG news release
Excerpts from the US Coast Guard press release — The U.S. Coast Guard Marine Board of Investigation (MBI) released … (a) more than 300-page ROI outlines key findings and contributing factors in the casualty and includes 17 safety recommendations aimed at strengthening oversight of submersible operations, improving coordination among federal agencies and closing gaps in international maritime policy.
“This marine casualty and the loss of five lives was preventable,” said Jason Neubauer, Titan MBI chair. “The two-year investigation has identified multiple contributing factors that led to this tragedy, providing valuable lessons learned to prevent a future occurrence. There is a need for stronger oversight and clear options for operators who are exploring new concepts outside of the existing regulatory framework. I am optimistic the ROI’s findings and recommendations will help improve awareness of the risks and the importance of proper oversight while still providing a pathway for innovation.”
The board determined the primary contributing factors were OceanGate’s inadequate design, certification, maintenance and inspection process for the Titan. Other factors cited in the report include a toxic workplace culture at OceanGate, an inadequate domestic and international regulatory framework for submersible operations and vessels of novel design, and an ineffective whistleblower process under the Seaman’s Protection Act.
MBI recommendations include restricting the Oceanographic Research Vessel designations for submersibles, expanding federal and international requirements to all submersibles conducting scientific or commercial dives and requiring Coast Guard documentation for all U.S. submersibles. The board also recommended adding Coast Guard personnel capacity at Coast Guard Headquarters to support new construction oversight and field inspections involving submersibles and vessels of novel design.
Further recommendations include requiring operators to submit dive and emergency response plans to the local Coast Guard officer in charge, marine inspection; evaluating the Coast Guard’s subsea search and rescue capabilities; and working with the International Maritime Organization to define passenger submersibles and expand international safety requirements for submersibles operating on the high seas. The board also called for a new Occupational Safety and Health Administration and Coast Guard agreement to clarify whistleblower investigative protocols and improve interagency coordination.
Link to the Report of Investigation
(From the report) 1.7. The USCG was the lead U.S. agency for all evidence collection activities involved in this marine casualty investigation. In accordance with 46 CFR subpart 4.40 and 49 CFR part 850, the National Transportation Safety Board (NTSB) conducted joint evidence collection during the fact-finding phase of the concurrent investigations. The National Oceanic and Atmospheric Administration (NOAA); Federal Bureau of Investigation (FBI); Bureau of Alcohol, Tobacco, Firearms, and Explosives (ATF); Armed Forces Medical Examiners System (AFMES); Department of Defense DNA Identification Laboratory; Rhode Island Medical Examiner; and Kemper Engineering Services, provided technical assistance.
Link to Bart Kemper’s Keynote address and paper centered on the Titan’s design and fabrication practices, which centered on Verification and Validation (V&V), also known as Verification, Validation, and Uncertainty Quantification (VVUQ) as the standard of care for innovation outside of established engineering codes.
The NTSB investigation into the root cause of the engineering issues is still ongoing.
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