[SystemSafety] NTSB Report on the Titan Loss

[Prof. Dr. Peter Bernard Ladkin]

At https://www.ntsb.gov/investigations/AccidentReports/Reports/MIR2536.pdf

Dated October 2, but I understand it was released yesterday. The NTSB produces very high quality 
analytical documents after careful investigation. This is one of them.

It is damning. Which will be no surprise to anyone who has been following the story. It directly 
fingers OceanGate's poor engineering and poor operational practices, as well as their lack of 
understanding of the monitoring data they collected during their dives.

The casualty dive was Dive 88. At the end of Dive 80 there were clear signs of delamination 
occurring (some very loud noises) and the NTSB says that "Because OceanGate’s analysis 
ofTitanpressure vessel strain gage [sic] and acoustic emission (real-time monitoring system) data 
was flawed, the company was unable to identify that the pressure vessel was damaged after dive 80 
and that it needed to be immediately removed from service." (Finding 6). The submersible was further 
damaged on Dive 82, but "of unknown origin".

Recommendations are to the US Coast Guard. That the USCG look into establishing standards that would 
cover such operations (OceanGate was deliberately operating out of a non-US port and in 
international waters, to avoid existing US regulations). And implement those standards, if necessary 
through legislation. And recommend to the IMO that the IMO make their 2001 document MSC.1/Circ. 981, 
"Guidelines for the Design, Construction and Operation of Passenger Submersible Craft” mandatory, 
which would then cover the maritime operations of any of its member states, including the US.

PBL

Prof. Dr. Peter Bernard Ladkin
Causalis Limited/Causalis IngenieurGmbH, Bielefeld, Germany
Tel: +49 (0)521 3 29 31 00