OceanGate Titan report: Why better communication matters more than more rules

Image credit: OceanGate

Introduction

The story of the Titan submersible accident should be familiar to most people and this blog isn't intended to talk about the circumstances of the accident itself, we're instead going to talk about what we can really learn from it.

The Marine Board of Investigation’s report into the tragedy provides a comprehensive look at what went wrong. It’s a sobering read, and unsurprisingly, most online discussions have focused on Stockton Rush (Oceangate's CEO), and the culture at OceanGate. While those elements matter, they aren’t the whole story—and they don’t offer the most actionable lessons.

If the goal is prevention, the answer isn’t about adding more rules or pointing fingers. It’s about improving communication systems, making it easier for concerns to be heard, and ensuring that whistleblowers are better protected and supported. Because the reality is: rules already existed and they were bent or broken. What really failed was the process of getting critical safety information to the right people at the right time.

What the report highlights

The report goes into detail on design choices, operational decisions, and oversight gaps. But when you strip away the technical language, one theme stands out: information didn’t flow where it needed to.

• David Lochridge, OceanGate’s Director of Marine Operations, raised serious concerns in 2018 about the Titan’s safety—specifically around viewport certification and testing standards.

• His concerns never got through to the authorities who could have acted, like the U.S. Coast Guard or OSHA.

• After voicing his worries internally, Lochridge was dismissed. That action sent a strong signal to others: speaking up came with significant personal risk.

  
  

This isn’t unique to OceanGate. It’s a systemic issue that appears in multiple industries—aviation, healthcare, maritime, even corporate environments. The mechanism to report issues safely and effectively often breaks down because of:

• Fear of retaliation (loss of job, legal action, reputation damage).

• Unclear or complex reporting pathways.

• Agencies lacking redundancy in communication channels, meaning a single point of failure can silence a warning.

  
  

Why adding more rules isn't the best answer

Many of the recommendations in the report involve the review and enhancement of regulations for passenger submersibles. That’s logical and necessary – but not sufficient.

Why? Because:

• Rules are static. They can’t cover every scenario, especially in emerging technologies where innovation outpaces regulation.

• Rules only work if people follow them. If culture or incentives discourage reporting, the best-written regulation will sit unused.

• Complexity can backfire. Every new rule adds another layer of bureaucracy, which can make the process slower and harder to navigate.

  
  

The most significant change we can make isn’t adding another page to the rulebook—it’s simplifying how people raise concerns and ensuring they’re heard without fear.

What needs to change

Here are the three areas where we can make the biggest difference:

1. Easier access to reporting channels

• Create clear, simple reporting pathways for safety concerns that go directly to oversight agencies.

• Ensure these channels are well-publicised—not buried in legal documents or obscure websites.

• Make them available in multiple formats (phone, email, secure online forms) and accessible globally.

  
  

2. Multiple points of failure in communication

• Agencies like OSHA or the USCG should have redundant systems so one missed email or one person leaving the organisation doesn’t stop a report from being acted on.

• Implement tracking and acknowledgment systems so whistleblowers know their report was received and is being processed.

• Consider anonymous escalation options where possible.

  
  

3. Legal and cultural protection for whistleblowers

• Strengthen legal safeguards that protect individuals from retaliation – both internally and externally.

• Provide clear guidance to organisations: retaliation is not just unethical, it’s unlawful and preventing it is enforceable.

• Encourage leadership training that frames whistleblowing as a safety function, not a betrayal.

I want to highlight that, to their credit, these sort of changes have already been implemented by the relevant US agencies before the MBI report was released.

Learning from other industries

Aviation has faced similar challenges. Decades ago, accidents were often followed by blame-focused investigations. Over time, the industry shifted to a “just culture” model, where the emphasis is on learning, not punishment. Paired with robust confidential reporting systems like ASRS (Aviation Safety Reporting System), this change has saved countless lives.

• Key lesson: Systems that reward honesty and make reporting simple produce better outcomes than systems that punish errors and add complexity.

  
  

What this means for high-risk, innovative ventures

When new technologies emerge—whether submersibles, space tourism, or autonomous vehicles—they often operate in regulatory grey zones. That makes a strong reporting culture even more critical. Pioneers take risks, and risk can’t be eliminated. But the consequences of risk can be managed when:

• Information flows freely to the people who can act.

• Individuals don’t have to choose between their conscience and their career.

• Oversight bodies have systems designed for redundancy, speed, and clarity.

  
  

Closing thoughts

The Titan tragedy was preventable—but prevention isn’t about perfection or writing another regulation. It’s about communication, trust, and protection. If we want to honour those lost and truly learn, we need to make it:

• Easier to speak up.

• Safer to speak up.

• Harder for those voices to be ignored.

Adding more rules might make us feel like we’re doing something. But building better communication systems—and the culture to support them—is what will really change the future.

The theme of this blog has been about improving safety. If you change that theme to 'performance', especially in a business sense, the same lessons still apply. If a leader refuses to listen and/or punishes those who speak up then performance will suffer, with potentially serious consequences.

Call to action

For leaders reading this: ask yourself:

• Would someone in your team feel safe raising a concern about a critical issue (safety or otherwise)?

• Would that concern reach you—or the people who can act—before it’s too late?

  
  

If the answer is “I’m not sure,” now is the time to make changes.

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Mike and Sam – Founders of On Target

Mike Mason and Sam Gladman are the co-founders of On Target, a leadership and team development company that brings elite fighter pilot expertise into the corporate world. With decades of combined experience in high-performance aviation, they specialise in translating critical skills such as communication, decision-making, and teamwork into practical tools for business. Through immersive training and cutting-edge simulation, Mike and Sam help teams build trust, improve performance, and thrive under pressure – just like the best flight crews in the world.