The findings of a two-week US Coast Guard hearing into last year's implosion that killed five people in the Titan submersible on a North Atlantic dive to the wreckage of Titanic will be analysed with an eye toward understanding what contributed to the tragedy and, in the words of one investigator, ensuring "that nobody has to endure a future similar occurrence".
The Marine Board of Investigation hearing delved into a series of fateful missteps before the implosion, concluding on Friday with a pledge to shape future safety standards with recommendations that will "improve the entire framework of the maritime domain," board chairman Jason Neubauer told reporters.
"My priority is to get this investigation done expeditiously because I feel there are global issues at stake," he said, leaving open the possibility of additional hearings and adding that he was unable to provide a firm timeline on a final report.
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A procession of more than two dozen witnesses, from former employees of expedition promoter OceanGate to industry experts to maritime investigators, testified about how the company's ambitious CEO Stockton Rush allegedly put profits ahead of a safety, shunned regulation and robust testing, and ignored repeated warnings about the potential danger of its experimental vessel.
Rush was killed in what authorities concluded was a "catastrophic implosion," which also claimed the lives of businessman Shahzada Dawood and his 19-year-old son, Suleman Dawood; businessman Hamish Harding; and French diver and Titanic expert Paul-Henri Nargeolet.
William Kohnen, a prominent figure in the industry and a key witness at the hearing, told CNN Sunday that the tragedy has presented the submersible industry an opportunity to fix outdated regulations that have been in place for decades.
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"We are at a point in history where we must come up with a basic system of governance to oversee submarine travel," Kohnen, president and CEO of Hydrospace Group, a California-based engineering firm, said.
"Small submarines have emerged in increasing numbers and the technology is not going back.
"The need to maintain order and public safety requires updated regulations or in many cases brand new regulations where there are none today."
The Titan lost contact with its support ship on the morning of June 18, 2023, less than two hours after it began its ill-fated descent to the wreckage of another infamous maritime disaster more than 100 years earlier.
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Authorities found the Titan's wreckage on the floor of the North Atlantic Ocean days later, several hundred yards from the Titanic's remains, according to the Marine Board of Investigation, which is the highest level of inquiry by the Coast Guard.
Until that morning, a manned deep-ocean submersible had never imploded, according to industry experts.
Here are some takeaways from the hearing's final week.
'Trying to get into the mind' of OceanGate's CEO
The hearing presented a portrait of a doomed expedition that resembled a modern-day Greek tragedy with Rush as the leading protagonist behind an Everett, Washington-based company that developed and operated the 23,000-pound (10,432kg) submersible which took deep-pocketed passengers on US$250,000 ($361,282) dives.
Representatives for OceanGate declined to comment on specific questions about the testimony regarding Rush.
In a statement, the company said it was no longer operating, extended its condolences to relatives of the victims, and noted it has cooperated with the Coast Guard and National Transportation Safety Board investigations.
"There are no words to ease the loss endured by the families impacted by this devastating incident, but we hope that this hearing will help shed light on the cause of the tragedy," the company said.
Neubauer said the testimony gave important insight into the potential motivation in Rush and his company.
"Certainly part of our investigation is trying to get into the mind of who was the master of the vessel and the CEO … and understand what would push the individual to do the operations they were conducting," he told reporters.
Peter Girguis, a Harvard University professor and oceanographer who monitored the hearing, told CNN evidence of Rush's ego-driven approach and heedlessness to repeated safety concerns appears to loom large in the disaster.
"Stockton Rush will be remembered alongside many others who in their quest for fame and their journey towards success were willing to put the lives of other people at risk," Girguis said.
"Stockton Rush could have done this dive by himself but it would not have had the notoriety of taking a famous Titanic explorer to the bottom, an English businessman and one of their sons … The whole thing he was trying to do was, to be the guy who made access to the deep sea easy.
"And access to the deep sea is not easy and when we do it right, it's absolutely safe. But I would never describe it as easy."
Final investigation report could recommend criminal charges
The board's final report could include recommendations to the Coast Guard leadership, ranging from new safety regulations for submersibles to a referral to the US Justice Department for possible criminal charges.
"And if there were a criminal investigation conducted, it would be completely separate from the administrative investigation, which is the marine board," Neubauer said.
Karl Stanley, a submersible operator who runs a tourism company in Honduras, testified last Tuesday about his work with Rush on another OceanGate submersible with an earlier version of the Titan hull.
The carbon fibre hull made cracking sounds during a 2019 dive, he said, as if it were breaking apart.
Stanley recalled what he described as Rush's obsession with his legacy as a deep sea explorer and his "desire to leave his mark on history" while skirting safety concerns about the experimental nature of the vessel.
"This cannot be considered an accident, it was a crime," Stanley told CNN via email after his testimony.
"While Stockton was clearly the main actor there are plenty of others that need to be held accountable for what happened."
Donald Kramer, an engineer with the National Transportation Safety Board, testified that the carbon fibre hull had many imperfections, including wrinkles, pores and voids that potentially weakened the structure.
Coast Guard officials said the agency's commandant would make a final decision on a referral of criminal charges to the Justice Department.
"Stockton Rush was the CEO and he led these decisions," Girguis said of the way OceanGate operated.
"And to me, the role of others should be determined and there should be some culpability but, at the end of the day, the buck does stop with him.
"He's principally responsible for this tragedy and there were others who enabled him. It remains to be seen how those who enabled him will be held responsible."
Safety compromised as finances were 'getting very tight'
The hearing featured testimony about what one witness called a "smoke and mirrors" company culture centered on profits rather than science and best practices.
The company one time even asked employees to forego pay as it faced economic challenges.
OceanGate employees were asked to "defer our paychecks" at the start of 2023, Amber Bay, the company's former director of administration, testified on Tuesday.
"We were looking to make ends meet," said Bay, describing "an offer that Stockton had derived, I believe with an attorney or whomever, that we could delay our paychecks and be paid a small amount of interest and recapture it at a specific time."
Her testimony echoed that of Phil Brooks, OceanGate's former director of engineering, who testified on Monday that he believed the request illustrated economic challenges that resulted in sacrifices to safety.
Brooks said the company asked employees to volunteer "to forego getting paid for periods of time with the promise that they would get us caught up in paychecks after the first of the year."
"I don't think anybody did it, but it was clear that the company was economically very stressed and, as a result, that they were making decisions and doing things that resulted, I felt, that the safety was just being compromised way too much."
The economic and safety issues caused Brooks to leave OceanGate, he said.
But Bay denied witnessing "a desperation" within the company to meet expectations.
She acknowledged an "urgency to deliver on what we had offered, and a dedication and perseverance towards that goal," but said the company "wouldn't do anything from my purview or conduct dives that would be risky just to meet a need".
"There was definitely checks and balances in place to make certain things were operating as safely as possible," she said.
Emails between Rush and Stanley in 2019, released during the hearing, shed light on the pressures and challenges the CEO and the company faced at the time.
In one email, Rush told Stanley that an "even more disturbing misunderstanding is your concern that I will either intentionally or unintentionally succumb to pressure and take advantage of our clients".
"I don't think if you push forward with dives to the Titanic this season it will be succumbing to financial pressures, I think it will be succumbing to pressures of your own creation in some part dictated by ego to do what people said couldn't be done," Stanley wrote back.
Hearing concludes with moment of silence for victims
Five years before the Titan implosion, the chair of the Marine Technology Society – a group of leading ocean engineers, scientists, policymakers and educators – drafted a letter on behalf of about 40 other industry leaders expressing concerns about its safety.
The letter was not formally delivered to OceanGate, but Rush eventually read it, and he and Kohnen, a respected industry figure, debated some of its key concerns in a phone call.
"Our apprehension is that the current 'experimental' approach adopted by OceanGate could result in negative outcomes (from minor to catastrophic) that would have serious consequences for everyone in the industry," said the letter, written by Kohnen in March 2018.
Specifically, the letter alleged the language on OceanGate's website was "confusing and misleading" and implied the Titan was "classed," meaning certified to industry standards. Rush agreed with that concern and later updated the website to say the submersible was "experimental."
Kohnen testified he was initially pleased with that change but he also felt the public did not understand the implications of the distinction. "It was a lesson learned," he said.
The letter took issue with OceanGate's decision not to try to get the Titan classified.
Rush argued the process would take too long and be too expensive. Classification experts, the CEO insisted, did not understand his technology.
Kohnen pushed back and said OceanGate needed a third party to properly validate the Titan's safety. Rush did not budge.
"It wasn't registering," Kohnen testified.
"In the end, we had to agree to disagree."
Kohnen lamented that not "many people ever told Stockton, 'No.' I don't think he understood that concept very much."
Rush, at the end of their phone conversation, threatened to leave the Marine Technology Society.
"Stockton, you never paid to be part of the association. You are a member of the brotherhood. You belong to the community. You have a responsibility to everybody… So, no, you cannot leave," Kohnen recalled telling Rush.
After the hearing, Kohnen told CNN: "The preponderance of evidence that has been brought to light is staggering. By any other definition, this was technical, deliberate, premeditated, and wrong on many levels… The extent of the consequences will need to be left to the legal system to sort out."
Rush had the right to build the Titan with any technology he felt brave enough to embark on, Kohnen said.
"The only thing he could not do, was to take other people on his dives. That is where the entire story changes," he said.
The hearing concluded Friday with condolences from an attorney for OceanGate and a representative of the National Transportation Safety Board and a request by Neubauer for participants at the North Charleston, South Carolina, proceeding to stand for a moment of silence for "those who perished" in the North Atlantic Ocean 15 months ago.
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