“A preoccupation with failure.” Why the Titan submarine was doomed from the start
HALIFAX — The company behind the submarine that imploded during a recent dive to the Titanic flouted key principles that guide organizations operating in high-risk environments, emergency management experts say.
Jack Rozdilsky, a professor at York University in Toronto, says OceanGate’s business – carrying paying passengers to the bottom of the North Atlantic – can be compared to the hugely risky work of companies launching spaceflights, drilling for offshore oil , fight forest fires or operate nuclear power plants.
“These are highly reliable organizations (HROs) that operate in complex, high-risk domains for extended periods of time without major accidents or catastrophic failures,” Rozdilsky, a professor of disaster and emergency management, said in a recent interview. “OceanGate does not appear to have functioned as a very reliable organization.”
The professor listed three key characteristics shared by HROs:
— They are reluctant to simplify. They accept that tasks they are involved in are complex and can fail in unexpected ways.
— They are in the process of failure. They do not view near misses as proof of success.
— They practice resilience. They provide backup for backup, or as Rozdilsky put it, “suspenders for the braces.”
There is some evidence that OceanGate CEO Stockton Rush — one of five people who lost their lives on June 18 when the Titan submarine ripped near the ocean floor — emphasized simplicity over complexity when it came to Titan’s engineering. During an interview last year with CBS News, Rush showed off Titan’s basic interior, including a power button, two video screens and a game controller to operate the 6.7-meter ship.
“This is to other submarines what the iPhone was to the Blackberry,” Rush said at the time, suggesting the ship’s simplicity was a strength. “There are a lot of rules that technically didn’t make sense.”
Rozdilsky questioned Rush’s decision to simplify an otherwise complex deep-sea vessel.
“It’s not something we can make like an elevator,” he said. “A high-reliability organization refuses to simplify to that extent. They welcome the complexity and realize that by trying to deal with that complexity, it gives them pathways to safety.”
On another front, Rozdilsky said the lessons learned from the 1986 Space Shuttle Challenger disaster — a mid-air explosion that killed all seven astronauts on board — remind us that organizations operating in high-risk environments can succumb to fall to risk management errors and erosion of security protocols.
In the case of Challenger, a presidential commission determined that NASA officials had responded to early warnings about design flaws by increasing acceptable damage in flight. The committee concluded that NASA justified the changes by saying, “We got away with it last time.”
Likewise, there have been multiple reports of problems and near misses with Titan.
“One way to look at those accidents is proof of success,” Rozdilsky said. “But successful high-risk organizations look at that from a different perspective. They … see these near misses as opportunities to improve … There’s a preoccupation with failure, not a preoccupation with success.”
As for OceanGate, it has become clear in recent weeks that Titan experienced many problems before and during its 3,800-meter dives to the Titanic wreckage over the past three years.
Last month, German adventurer Arthur Loibl told The Canadian Press that his journey to the doomed ocean liner in 2021 was ravaged by snafus. The 60-year-old retired businessman said the submarine had problems with its battery and balancing weights, leading to a 90-minute repair. But the journey continued anyway.
YouTube celebrity Jake Koehler also released a video describing how his trip aboard Titan was canceled earlier this year due to persistent computer problems. In the video released last month, Rush can be heard saying the computer’s role was “up there with life support” but “wasn’t communicating consistently.”
“Long story short, they had some problems every day,” added Koehler.
Even when Titan was being built in Everett, Washington, red flags were raised. In January 2018, then-director of maritime operations David Lochridge filed a report identifying serious safety issues, including improper testing of the carbon fiber hull, according to court documents filed in Washington state.
Lochridge told Rush the ship had to be certified by a classification society, such as the American Bureau of Shipping, but that never happened, the documents say. Lochridge was fired instead.
Meanwhile, a search and rescue expert says it appears Rush’s company was not prepared for emergencies.
Merv Wiseman, a retired search and rescue coordinator, said it remains unclear whether OceanGate has filed a preparedness plan with the Marine Rescue Sub-Centre in St. John’s, where Wiseman worked for 35 years.
“This is the highest of the high-risk areas we can think of,” he said in an interview, adding that offshore operations such as oil rigs must submit detailed preparedness manuals to the Canadian Coast Guard. “If something were to happen at the Hibernia (offshore oil platform), I would go to their manual. They have a tome with warning matrices and all the technical items.”
Wiseman said Transport Canada should have had jurisdiction over the OceanGate operation. The federal agency said last week it would respond to a request for comment, but did not.
“I think this has slipped through the cracks,” Wiseman said.
Meanwhile, deep-diving experts have been warning for years about Titan’s shoddy construction and lack of certification. And in 2018, a group of engineers wrote a letter warning that the company’s “experimental” approach could have catastrophic consequences.
There were also warnings about Titan’s lack of backup systems – another worrying feature that contrasts sharply with the practices of highly reputable organizations.
“If you put one vehicle (in the deep ocean), you have a backup vehicle down there to help rescue the first vehicle in case it fails,” Rozdilsky said.
That happened in 1991 when two Russian submarines known as Mir I and Mir II were used to carry a camera crew to film the Titanic. At one point, one of the ships was tied to wires on the deck of the Titanic. But the pilot managed to free the craft after receiving guidance from the pilot on the other submarine.
Wiseman said Titan shouldn’t have dived alone.
“It is reasonable to expect that if this type of voyage is undertaken, where human lives are at stake, a duplicate (submarine) will be available,” Wiseman said.
This report from The Canadian Press was first published on July 3, 2023.
