A report from Canada’s Transportation Safety Board has highlighted regulatory failures that allowed OceanGate’s unregistered, unflagged, and uncertified Titan submersible to operate out St. John’s, Newfoundland, for years before it imploded on a tourist trip to the wreck of the Titanic in 2023.

“When it came to the Titan, critical information existed across multiple federal government organizations, but no one was responsible for connecting the dots,” says TBS chair Yoan Marier in a statement. “Without a complete picture of the operation, the Titan continued to operate in Canada without regulatory oversight.”

OceanGate first interacted with the Canadian government while Titan was still undergoing final assembly in Everett, Washington. In May 2021, Fisheries and Oceans Canada laid out plans to pay the company $25,000 to support deep-sea ecosystem research during missions to the Titanic the following year. But Global Affairs Canada denied OceanGate a research permit after the company claimed, inaccurately, that Fisheries and Oceans would act as its sponsor.

The Titan’s maiden voyage to the Titanic the next month was unsuccessful after one of its titanium domes fell off, and the ship carrying the sub, the Horizon Arctic, returned to St. John’s. But before any of the disappointed passengers who had paid over $100,000 to see the wreck could disembark, the ship was directed to a secure lockdown area of the harbor. There, a team of armed officers from Canada’s Border Security Agency boarded the Horizon Arctic. They interrogated the passengers about Covid-19 precautions and their role in the dives.

“They were extremely intimidating,” passenger Gary Philbrick tells WIRED. “I couldn’t get off the ship fast enough.”

The agents also asked why OceanGate was operating without a research permit. David Concannon, a lawyer who had worked with OceanGate in the past, told them that the Titan would only be diving in international waters, and the agents left. “They had zero interest in the sub. Absolutely none,” he tells WIRED. “They were there to look at paperwork.”

That was correct, says Etienne Seguin-Bertrand, an investigator with the Transportation Safety Board: “As long as the sub had been imported properly and any applicable duties paid, it wasn’t part of their mandate to make sure that it was properly registered and safe.”

Another agency, Transport Canada, is responsible for overseeing compliance with regulations for all vessels, including submersibles. These include requirements that vessels are registered, flagged, or certified, particularly if they are carrying passengers. It can inspect vessels and, if necessary, carry out enforcement. But Transport Canada had decided that the Titan was actually part of the Horizon Arctic’s cargo and therefore not a vessel subject to inspection.

In July 2021, a researcher from Fisheries and Oceans Canada traveled on a subsequent OceanGate mission as an observer. They reported back that the carbon fiber Titan had not been approved or certified by any regulatory body and was not carrying insurance. Their concerns never made it to Transport Canada’s team that oversees marine safety, though the report doesn’t make clear where the disconnect was. Fisheries and Oceans never followed through with its plan to fund Titan missions.

As OceanGate continued to operate from St. John’s in 2021 and 2022, the Titan made successful dives to the Titanic and several sites within Canadian waters. The company eventually interacted with a total of 10 Canadian federal agencies, including Parks Canada, the Department of National Defense, and the Royal Canadian Mounted Police. But the company’s operations were never directly reported to the team responsible for marine safety. “In terms of the actual people that were responsible for marine oversight, their focus was on the Canadian support vessel,” says TSB investigator Jason Melvin.

While TSB investigators did not have access to the wreckage of the Titan itself, which remains with the US Coast Guard, they did analyze portions of the carbon fiber left over from its manufacture. They calculated that a hull made to OceanGate’s exact specifications might have been able to make hundreds of millions of dives to Titanic depths before failing. However, the composite samples as built had porosity and waviness between layers and were ground down in a way that might have introduced defects. When the TSB tested the compressive strength of the carbon fiber, it indicated the material could fail in as few as 30 deep dives.

The Titan imploded on its 24th mission diving deeper than 1,000 meters. All five people on board died, including OceanGate’s chief pilot and CEO, Stockton Rush.

The TSB is recommending increased oversight of the riskiest vessels and improvements in information sharing between departments, and is requiring that all human-occupied submersibles be subject to international construction and safety standards.