In February, I had an opinion piece published in Strategic Risk magazine. I talked about how cultivating a healthy risk culture is a strength in an organisation as employees are the first line of defence in mitigating risks. I used my experience supporting the RN submarine service:
“Whilst the buck stops at the executive level when faced with all the consequences and opportunities of organisational risks, these risks are managed at an operational level. They are filtered down to each employee. This is most evident in a high-dependency risk culture environment where there is no margin for error, such as the Royal Navy (RN) submarine service.”
When news of the missing Titan submersible broke last month, my immediate thoughts were of the search and rescue mission. In the RN, a missing or sunken submarine is the worst-case scenario, and it is always planned for. However, it soon became obvious OceanGate did not prioritise crisis planning. It fell to the US Coastguard to mobilise this mission. Very soon it emerged how challenging the task was going to be, both finding the lost submersible and recovering it.
Sadly, we all know this search and rescue mission ended in tragedy. Yet as more and more information emerged about OceanGate’s operations, it became clear that this tragedy was inevitable at some point in Titan’s operational life.
There have been plenty of flags around the Titan. These have been well reported during the search and since confirmation of the Titian’s implosion. These are the most noteworthy:
The viewport for passengers to see the Titanic was certified to 1300m. The Titanic lies at 4,000m.
2018: OceanGate’s Director of Marine Operations David Lochridge was fired after demanding more rigorous safety checks. A couple of months later, on OceanGate's “experimental approach”, the Manned Underwater Vehicles committee of the Marine Technology Society wrote to CEO Stockton Rush. They warned that his approach could lead to a “catastrophic disaster”.
2020: The Titan was completely rebuilt following cyclic fatigue tests. Independent experts also voiced concerns that the hull weakened with every dive.
2021: On titanium and carbon for OceanGate’s hull, co-founder and CEO Stockton Rush said:
“I'd like to be remembered as an innovator. I've broken some rules to make this. I think that I’ve broken these with logic and good engineering by me. The carbon fibre and titanium [hull] - there's a rule you don't do that. Well, I did.
2023: On criticisms, differing views and safety culture expressed post-tragedy, OceanGate’s co-founder Guillermo Söhnlein said on 27 June 2023:
“There are completely different opinions and views about how to do things, how to design submersibles, how to engineer them, how to build them, how to operate in the dives. I know from first-hand experience that we were extremely committed to safety. And safety and risk mitigation was a key part of the company culture.
There is a lot more to add here. However, these highlighted facts and quotes illustrate the areas of agreement and differences in risk culture between OceanGate, and other leaders in the marine submersible sector. Rush’s response to criticism was combative, and he even admitted to breaking the rules. He was a self-styled innovation maverick in his field and appeared proud of himself. And tragically, this apparent arrogance and defiance of physics and engineering rules ultimately led to his death and four other souls. What can we immediately learn from this tragedy though?
Innovating starts with the idea, and follows through the development and research of that idea, followed by the design and production or use of that idea. It is critical to minimise any major risks associated with a product at this stage to develop any innovation. Mainstream investors are less likely to back high-risk investments. And critically, this is where Rush followed this more maverick and high-risk approach. The development of the Titan had the backing of several private financiers and interested parties that wanted to see the most famous shipwreck in the world – the Titanic. Regular risk assessments and due diligence during innovation are key.
Responsibility is used a lot these days, primarily in organisational governance and upholding their purpose – it’s the ‘R’ in Corporate Social Responsibility. More fundamentally, where a product or service is delivered to people, there is a responsibility to do that safely. This applies to all sectors and products, including sandwiches. Remember the tragic case of Natasha Laperouse and her fatal Pret-a-Manger sandwich? This is not a new concept for company directors. Despite all the public statements made by Rush and his supporters before the tragedy, the stark evidence suggests this was not the case. He risked both his own, and his passengers' lives through his lack of responsibility as he had “broken some rules” in his innovative design.
There are many high-dependency sectors where a strong risk culture is absolute as lives depend on it. Aviation, oil and gas, mining, chemical production, nuclear energy generation – the list continues. As a certified recreational SCUBA diver, I fully understand the underwater world is hazardous and there is a high-risk culture for personal safety. The marine submersible sector also requires a risk-based culture for safe operations. What is clear with OceanGate is that it operates its own version of a safe operating environment and the culture that comes with it. It also worked outside legislative jurisdictions and certified marine submersible standards. These were all major contributing factors to Titan's tragic demise.
There is no doubt that the investigation now underway will reveal the full facts leading up to and the cause of the tragedy. It will also examine the plans and contingencies in place with Ocean Gate for both search and rescue. In addition, it will recover what is left of the Titan. What is obvious, however, is that the specialist search and rescue resources required were huge, specialist in nature and supplied by government agencies. These agencies were prepared, but it appears OceanGate was not to the level of response required for Titan’s loss. It was eight hours before the submersible was reported missing. At this stage, I am not inclined to speculate why – that will come out in the investigation. However, in such a hazardous and high-risk environment, this time lag is astonishingly long. Effective crisis preparedness outlines when to escalate and activate a crisis response.
A lot will be learned from this incident and many case studies will be written. However, the likely impact on the marine submersible sector is that it will set back innovation around underwater exploration and tighten up regulatory requirements. This is ironic given Rush’s position on both. At this early stage, however, we can at least learn from Rush's very grave mistakes. Balancing innovation, and responsibility, cultivating an effective risk culture and having appropriate crisis preparations in place is the skill and key to successful and safe high-risk operations.
Picture Credit: Ocean Gate Twitter account
further reading- Sheena's LinkedIn post on initial observations, plus crisis communications planning advice