Safety Culture: The Titan Report

Call my wife!

On June 18, 2023, the submersible Titan imploded killing five people while on a dive near the Titanic — it was a tragedy foretold.

The fire and rescue service has much to learn from the incident for we also operate in environments with little or no tolerance for error and where failure to establish and follow procedures can result in very serious consequences.

One Titan manager labelled the team “cowboys” a reference to seat-of-the-pants operations with a disregard for safety — some firefighters are cowboys, too.

The United States Coast Guard (USCG) has released their report and it is a textbook on how not to run an operation where lives are in the balance. It closely details how an effective safety culture was absent from both engineering and operations. This absence fostered a cascading series of events which led to the fatal accident.

At OceanGate, the company which owned and operated Titan, it was either innovation or safety, as if there could be no middle ground.

Corners were cut, regulations and laws were ignored or circumvented and safety advocates were fired or resigned.

Titan was constructed as a tube using wrapped carbon fiber with titanium endcaps representing a new and untested approach to deep sea vehicles facing crushing pressures.

(USCG/OceanGate)

The deep sea vehicle community is relatively small and many in it were surprised and alarmed at OceanGate’s approach to development and their willingness to forgo testing and certification of Titan and its support systems.

OceanGate had an engineering section and an operations section which were often at war with one another as they created a vehicle capable of diving to depths beyond 10,000 feet. This inability to collaborate meant that safety considerations were ignored.

Engineers who expressed concern about potential flaws were fired and Stockton Rush, OceanGate’s leader, seemed to take a cavalier approach while testing and using Titan even as others commented on the problems in construction and operations.

The testing and use history is a litany of safety red flags.

• As Titan was being winched aboard the support vessel after a dive, the strain was so great that the bolts holding the 3,000 lb endcap door sheared and fell onto the deck.
• After another dive the ballast failed to release preventing Titan from resurfacing. Rush tried to coerce the crew to remain on the seafloor for 24 hours until a fix could be applied. One crew member told the support vessel to call his wife and have her buy a plane ticket home saying he was “done.”
• At the conclusion of another deep dive as Titan neared the surface, a very loud and sharp bang was heard not just on the vessel but also on a boat above. It was recorded by a system designed to capture data related to hull integrity. Though crew members expressed serious concern it was written off as Titan shifting on its frame rather than possible hull deformation.
• In an almost bizarre example, Titan was allowed to sit outside and uncovered in a parking lot over a Canadian winter because of the expense of trucking it back to Washington state where it could be refitted and maintained.

There were also repeated examples of mistakes readying and removing Titan during missions which caused aborted dives or dangerous recoveries.

The U.S. Coast Guard concluded that the damage which led to the fatal incident likely occurred on the dive which led to the loud bang referred to earlier. The sound was an indication of the carbon fiber separating and delaminating as the pressure eased when they neared the surface.

Any damage was further exacerbated by leaving the submersible outside over a harsh Canadian winter and towing it for thousands of miles to and from the launch sites.

The Coast Guard concluded that the safety culture at OceanGate was toxic and a major contributor to the fatal event stating, “OceanGate’s failure to prioritize safety stemmed from deep-rooted flaws in its leadership structure, culture, and operational practices.”

The Titan fatalities reinforce the importance of a robust safety culture:

• All participants must engage in open dialogue free from the threat (explicit/implicit) of retaliation.
• Equipment and systems must be subject to professional standards and on-going review.
• Training and procedures must be designed and implemented to standardize safe operations.
• Near-miss incidents and abnormal events must be thoroughly investigated to eliminate safety concerns.

Stay safe.