By IJ Arora, Ph.D.
On June 18, 2023, the Titan submersible imploded near the bottom of the ocean while conducting a dive to view the wreck of the Titanic. This event resulted in the deaths of all five people on board.
In this article I postulate whether using a process-based system based on a standard such as ISO 9001 could have helped prevent this tragedy. The inputs on the management system at OceanGate (parent company of the Titan) are not exactly known and are currently being investigated. However, from what is known and published, and based on my experience, I think this tragedy can allow us to investigate how a well-implemented management system might have enabled objective inputs and proactive decision making to prevent this and other such occurrences. At these ocean depths much can happen which may not be defined as risk. Management systems, however, exist to help organizations convert hazards into risks, which can then be addressed or avoided.
From the sinking of the Titanic in 1912 until today, the opportunity to achieve commercial gain has tempted many an organization to take large risks. The Titan is only the latest example. When human lives are involved, who has the responsibility to keep such adventures safe? Further, if there is a need to regulate these activities, on whom does the onus fall? The owners and CEOs who direct such adventures take the risk to be the first to market and to innovate. Of course, they do not want to be regulated. But without adequate oversight, these leaders tend to put themselves into hazardous situations, and at times they put the lives of others at risk as well.
Care must be exercised when identifying and addressing risks, for a certain level of subjectivity can creep in. Risks can be addressed by mitigation or by taking them as inputs to use for opportunities for improvement via innovation and technology (clause 6.1 of ISO 9001). However, when that risk itself is uncertain, it must be regulated and mandated to be considered. Information on what kind of risk appreciation was done by OceanGate is not available. Therefore, I will not directly address the risk aspect; my intent is to work backward from the tragedy itself in an attempt to see it in the light of a well-functioning risk-appreciation approach. This is my opinion only. Does the risk always need to be mitigated? Can top management not take on the risk and accept it? Do we know if the passengers were aware of the risk and still accepted it? For example, people who go parasailing or bungee-jumping take risks, and these industries are both unregulated. Therefore, there is a need for a broader discussion toward making these activities as safe as possible. This takes us back to the sinking of the Titanic, which lead to publication of the Safety of Life at Sea (SOLAS) Convention in 1914.
Although the results of the investigation are pending, various sources have identified that the CEO of OceanGate rejected a titanium metal hull for a much less expensive carbon fiber composite one. Would adequate planning for changes (clause 6.3), read in conjunction with control for design changes (clause 8.3.6), have provided better inputs for a more evidence-based approach? From the reporting, and in my opinion, the CEO lost an appropriate measure of customer focus. Of course, the investigation report will provide more information. However, in this case, there is no question that the product did fail, and five people, including the CEO, are dead.
Using an ISO 9001 approach, the company would first have to start with determining the context of the organization and the operations (clause 4.1) as well as the needs of all relevant interested parties (clause 4.2). Further, clause 5.1.2 asks management to ensure a customer focus throughout the organization by ensuring compliance with statutory requirements (subclause a) and the appreciation of risk (subclause b). In addition, the system would have enabled operation controls to manage risk as required by clause 6.1, and audits of the system (clause 9.2.2) to get objective inputs on the state of the system. Clause 6.1 would have required an adequate and effective appreciation of risks and an action plan to mitigate them, for the Titan operated in a most challenging environment 12,000 feet below sea level.
A process-based management system (PBMS) helps an organization think systematically and drive continual improvement (clause 10.3). As part of delivering conforming products and services, the system would have implemented quality control measures. It must be remembered that inspection may not add value because the product is already ready, but it does protect the client and the organization by rejecting the nonconforming products. Did OceanGate forget to (or choose not to) have audits or inspections in real terms of objectivity? The tragic result seems to suggest this. Again, we can only wait for the investigation report.
It is interesting to note that the organizational and operational setup of OceanGate ensured that no country can actually investigate. Whatever the company did was outside of specific national jurisdiction, because the dives took place in international waters. The submersible was launched from a Canadian vessel and the company itself was a U.S. organization founded in 2009 and based in Everett, WA. Where international law applies, there perhaps must be a resolution through the International Maritime Organization (IMO). The Titan was lost in international waters but was not classed by a classification society. Did it have to be classed? Or, being below the existing seagoing vessel requirement in terms of gross tonnage, was the company able to circumvent this requirement? That would once again require re-thought. In a 2019 article in The Washington Post, the authors quoted a blog answer from OceanGate to the question, “Why is the Titan not classed?” The answer was that marine accidents are caused by operator error and not by mechanical failure. The basis of their thinking on this topic is not known. If the company had a functioning management system, I believe that they would have had a better appreciation of risks (clause 6.1), ensured increased customer focus (clause 5.1.2) and improved safety, and more logical planned changes (clause 6.3), for example by evaluating the change from a carbon fiber to a titanium hull.
David Lochridge, former director of marine operations at OceanGate, left the company in 2018 after expressing serious concerns about quality control, the submersible not being classed, and the lack of safety checks. In effect, he left because he saw that top management was lacking in customer focus, and he did not want to be part of that kind of executive team.
The investigation of this tragedy will eventually draw some conclusions. Perhaps in the future, such ventures will be covered by proactive regulations to ensure safety based on a better appreciation of risks. After all, this proactive approach to future safety must be based on collecting knowledge and lessons learned (clause 7.1.6). I would also opine that the values of having a well-implemented management system based on a standard should be a first step. Additionally statutory requirements should be welcomed in such risky ventures. Clause 8.3.3 on design and development inputs was particularly valid for the OceanGate organization, but almost all the requirements of the clause were ignored. In determining the requirements for the Titan and OceanGate, in the absence of statutory requirements and regulations, the executive team should have considered clause 8.2.2 and defined the requirements for themselves. “Those considered necessary by the organization” should have made the organization fully appreciate the risks (clause 6.1) to ensure customer focus (clause 5.1.2). Regrettably, the CEO and the customers are dead.
In conclusion, the death of all five people in the Titan was a tragedy. Was it an avoidable tragedy? The purpose of this short article is to bring out how organizations can better ensure that their outputs are conforming, meet requirements for customer focus by managing changes, and appreciate the risks inherent in the context of the organization. Might I be so bold as to say, this means that they should have developed a management system and implemented it in the spirit of the chosen standard. In this case I am measuring the lapses against ISO 9001.
About the author
Inderjit (IJ) Arora, Ph.D., is the President and CEO of QMII. He serves as a team leader for consulting, advising, auditing, and training regarding management systems. He has conducted many courses for the United States Coast Guard and is a popular speaker at several universities and forums on management systems. Arora is a Master Mariner who holds a Ph.D., a master’s degree, an MBA, and a 32-year record of achievement in the military, mercantile marine, and civilian industry.