By Taylor Romine, CNN

(CNN) — A lengthy report released by the US Coast Guard Tuesday identified glaring issues with the Titan submersible and the company that ran it, a little more than two years after five people were killed when the deep-sea craft imploded on its way to the Titanic wreckage.

From technical issues to company culture, the over 300-page document detailed the many steps that lead to an epic but “preventable” disaster and identified valuable lessons that the Coast Guard said could prevent future disasters.

The 2023 implosion of the submersible at the bottom of the ocean floor killed all five people on board, including Stockton Rush, the founder and CEO of OceanGate, the company which operated the Titan, and triggered a dayslong international search effort until debris was found.

While the report was shocking in its frankness about the mistakes made, industry leader William Kohnen said it “officializes” longstanding concerns.

Kohnen, the president and CEO of HYRDOSPACE Group Inc and a witness in last year’s hearings on the Titan submersible, told CNN Tuesday that the issues raised in the report are part of an ongoing conversation in the industry that has existed long before the incident – but is now front and center.

As the US Coast Guard’s investigation comes to a close, Kohnen, who raised safety concerns to Rush in 2018, reflects on the next steps for a growing industry that caters to both scientific research and ultra-wealthy tourism.

Better regulations are needed

The recommendations in Tuesday’s report made it clear that better regulations in the submersible industry are essential.

“The two-year investigation has identified multiple contributing factors that led to this tragedy, providing valuable lessons learned to prevent a future occurrence,” Jason Neubauer, the US Coast Guard Marine Board of Investigation chair, said in a statement.

The MBI, the US Coast Guard’s highest level of inquiry, called on the agency to pursue a new regulation requiring all submersibles in the US to be built and maintained under uniform standards.

The report cites “the lack of comprehensive and effective regulations for the oversight and operation” of submersibles designed or operated in the US.

In the Titan’s case, the MBI found the “primary contributing factors” to the implosion were OceanGate’s “inadequate design, certification, maintenance and inspection process,” a Coast Guard release said.

Kohnen said the need for comprehensive regulation is something the industry has “been preaching in the desert for 20 years.”

As the submersible industry continues to grow, rules are needed much in the same way rules were made during the creation of freeways, he said.

“By the time you have hundreds of cars, somebody came up with a very simple idea of drawing a line in the middle of the road and saying, look, everybody’s going to agree that you drive on either side of the line,” Kohnen said. “That’s really what we need to do here.”

“We’re not reinventing the wheel. It’s just a matter of scrubbing it, making it better, and then engaging other maritime authorities,” he added.

Kohnen also advocated for a third-party certification system for the safety of submersibles and their teams, saying it would help keep standards high across borders.

Future paid passengers on submersibles will not understand the risk they are taking if the industry continues without mandating third-party certification or other regulations, Kohnen argued.

“A waiver doesn’t work if the person signing it cannot give informed consent,” he said, adding, “Informed consent is just going to get more complicated for the next two generations, because there’s so much technology around how do you make sure that a citizen understands the risk they’re taking?”

Ethical standards in leadership

Another glaring problem found in the US Coast Guard’s report was the “toxic workplace culture” at OceanGate, instituted by Rush and his management style.

Rush held much of the decision-making power as he filled multiple roles within the company, centralizing his power and avoiding checks and balances from the company’s board.

“Overall, the MBI believes Mr. Rush deliberately sidelined OceanGate’s Board and did not solicit its collective expertise so he could proceed unchecked with his vision to conduct TITANIC expeditions, regardless of any mounting safety concerns,” the report stated.

When asked if the culture issues were isolated to OceanGate or reflect an industry-wide concern, Kohnen said he considers this situation a “civic dereliction of duty.”

“We teach our younger ones to become leaders and push and believe in what they’re doing, but that when you are in a position of high-level leadership, you have a huge responsibility not to create chaos,” he said. “This is really difficult. And I think OceanGate, at the leadership of Stockton (Rush) – it was a problem, and we communicated that with him.”

Five years before the implosion, Kohnen, who was at the time the chair of the Marine Technology Society – a group of leading ocean engineers, scientists, policymakers and educators – wrote a letter to Rush on behalf of about 40 other industry leaders expressing concerns with the safety of the Titan submersible. Rush and Kohnen debated some of the key concerns of the letter on a call.

Kohnen ultimately convinced the Oceangate CEO to change some of the language on their website to reflect its experimental status, but felt like the public still wouldn’t understand that the safety of the submersible hadn’t been verified.

“No one was restricting them from innovating and coming up with new technologies,” Kohnen said, arguing OceanGate had the right to dive the submersible on their own without passengers. But putting at risk others who didn’t understand the situation is where they crossed the line, he said.

Building relationships within the industry

Since the submersible’s implosion over two years ago, the industry has spent time reflecting on the importance of nailing down a standard across the board, Kohnen said.

“People are paying attention,” he said.

He thinks that another important step is making sure different facets of the industry and maritime authorities are connected to one another and build relationships with one another. Being able to call up a colleague and get their opinions on a situation could potentially save lives, he said.

“This five minute conversation can go a long ways into avoiding some big issues,” Kohnen said. “So just when we think it seems like too dumb to be a real problem, you find out, no, it is a real problem, and it’s not as simple to sort out as it appears.”

Kohnen said the industry’s annual conference will be hosted in the first international location in its history, with the hope of getting more attendance from countries around the world and to encourage international cooperation in regulations.

“It’s made a bit more difficult because these vehicles travel across international boundaries,” he said. “So it’s not enough to have just a local or a national solution. It really needs everyone holding hands here and saying, look, we’re going to kind of agree that we’re looking at these things the same way.”

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