First I’ve heard of it.
I have a recording set up for tonight.
I learned about it here, upthread. I’m looking forward to it.
I finally watched it. I had casually followed the case so I found this documentary to be good. What did others think of it?
“Stockton (Rush) wasn’t always right, but he was always sure he was right.” — Alfred Hagen, businessman and Titan “Mission Specialist”
Such hubris.
I thought it was pretty good too. But that Alfred Hagen guy was pretty terrifying as well, it seemed like he didn’t think Rush did anything all that wrong. If I worked for him in a situation where he made decisions about worker safety, I’d be looking for another job.
I know documentaries have to depend on who is willing to talk to them, but it would have been great if they could have gotten David Lochridge. He did testify at the hearings, I’m surprised they didn’t at least show that.
And the information that the Titan had a loud cracking noise at the end of dive “80” (counting the 49 dives from the previous Titan), at which point they continued dives for that season, then stored it for the winter on an unprotected open air dock in Newfoundland, then proceeded diving again the next year is mindboggling. I’d have fully expected that they’d bring it home and inspect & overhaul it after an uneventful year, much less one where they heard loud unexplained noises.
But, but, but … that would cost money. Money that Rush would rather have kept in his pocket.
Unfortunately for him, dollars are not legal tender were he is now.
If you can’t take it with you, I’m not going.
While watching the doc I was struck for the umpteenth time thinking, “When are other industries going to learn the lessons of aviation?”
The remote submersible woman spoke up with misgivings, the organization said anyone is empowered to do so, but they didn’t actually listen and instead let her go. Which suggests to me they read somewhere about the existence of aviation Crew Resource Management, but just skimmed it and probably missed the point. Like law enforcement, medicine and a few other fields, sadly.
I’m not suggesting aviation is perfect, but certain lessons were learned and the culture was successfully changed. The types of accidents that were common in earlier decades rarely occur today. And it is a culture change, it’s not just using checklists. If a low-time first officer says they have misgivings about a flight, we listen. We don’t quietly let them go and then do it anyway.
I once quit a company that was run by a guy who reminds me of Stockton Rush. Goddam smirking assholes who think they know better than everyone and gamble with peoples’ lives. While I don’t wish death on anyone, just about the only redeeming feature Rush had was that he was on the sub too.
Was it really the aviation industry that learned a lesson or were they forced to do so by government regulation?
Wasn’t that one of the easily identified idiocies of this totally preventable tragedy? That they skirted such regulation by operating in international waters? A lot of people were asking “Didn’t they sign off on the submersible?” Only there wasn’t really a they to begin with.
Commercial airlines generally can’t do the same - they take off or land in places where there exist relevant authorities who are very much interested in the safe operation of vehicles, especially when there are paying passengers aboard. And even then, airlines that operate in countries with more lax regulation have safety records that are correspondingly worse.
Probably when said industry grows from about 100 passengers a year to 100 million passengers a year. Maturity follows volume, in aviation and everywhere else.
Regulation was a part of CRM when it was instituted, but airline company buy-in was necessary and arguably a greater force. Airlines do better when their planes don’t make smoking craters. And it’s not just about making the company look better. There’s an old saying that the pilots arrive at the crash before anybody else, so CRM is a big part of MY personal safety as a crew member.
Certainly, Rush created his company and ran it in such a way that there were no regulators. Which in itself was a giant neon arrow pointing toward “unsafe”. Some time ago I read about how several non-governmental organizations which sign off on submersible safety were well aware that Rush was headed for trouble.
Without going into the weeds on precise numbers, I think a good argument can be made that medicine and law enforcement errors / malfeasance impact enough people that it’s astonishing we haven’t done something along the lines of how aviation changed itself.
When I’ve discussed George Floyd’s murder with police friends I’ve asked, “There were a bunch of cops right there. Not one of them thought to say, ‘Hey, maybe you shouldn’t be standing on that guy’s neck?’”
Their response has been a unanimous, “They were probably junior officers and were afraid of speaking up.”
So I say again, we addressed this sort of problem decades ago in aviation. For god’s sake, why are we still putting up with it in other industries?
But… I know I’m getting away from this thread’s subject. My point with regard to Titan is that despite the deliberate skirting of regulation, there were people on site who tried to do the right thing - call out safety issues. But they were ignored. So in the end, I suppose I agree with the people in the documentary who said this was easily foreseeable, and maybe it should be considered criminal.
Medicine has improved a bit. There are checklists. CRM training is slowly making its way to healthcare:
Not sure about law enforcement, but you’re surely right that they could stand some CRM transfer as well.
My point is really just that there isn’t going to be some concerted effort here as long as it’s just a handful of thrill-seekers that die. Almost every death on Everest is also almost certainly preventable with proper procedures, but it’s just not enough for anyone to care about. “Normal” people don’t do that sort of thing. Something will change only when thousands of people start dying in sub accidents.
Worse than that. Rush threatened lawsuits to destroy their professional standing.
I found this mind-boggling as well. Not only did they not inspect the hull for damage, but they left it outside all winter in Newfoundland exposed to the elements, including ice and snow and freeze-thaw cycles. Someone in the doc even pointed out the potential damage to the hull and especially to the mating surface between the carbon fiber and the titanium due to the expansion of water during these freeze-thaw cycles.
Someone else in the doc theorized that Stockton Rush must have known how it was all going to end, but had boxed himself into a corner financially and reputationally. He might not have overtly planned a murder-suicide, but he had to have known it was all going to end in disaster. The only question was whether he would be on board or not when the inevitable occurred.
Or maybe he was simply delusional. But the thing is, when considering the interaction between crushing ocean depths and an untested submersible, the power of positive thinking doesn’t mean shit. All that matters is engineering and physics.
Another detail that was new to me was the fact that they found a scrap of Stockton Rush’s jumpsuit sleeve in the debris of one of the end caps encased in sand which included two nearly intact business cards which his name clearly legible on them, some “Titanic” stickers, and a completely intact ballpoint pen.
P.S. One of the Coast Guard investigators in the documentary also pointed out that his carbon fiber hull was supposedly safe because Rush had acoustic monitors installed that would detect carbon fiber delamination before it became a problem.
Which is exactly what happened in Dive 80. The acoustic signal recorded during the dive was literally off the charts. The ROV tech reported to her supervisor that it sounded like delamination to her. Which Stockton Rush then proceeded to ignore. Worse, he made fun of the incident and then fired the tech.
This was no accident. It was willful, intentional negligence. If Stockton Rush had not died in the final dive, I have no doubt he would facing criminal charges for manslaughter.
While there are some government regulations that play a role, the culture change that @Llama_Llogophile refers to did, indeed, come from within what might be called the “aviation community”. In part because pilots don’t want to die in a fiery crash, either. Modern “crew resources management” as practiced by aviation in the more civilized world (I’ll get back to that later) is not mandated by the regulations. It is supported by the airlines and big players because it reduces costs, including crashes. It is supported by most crews because by and large it does work.
In other places in the world CRM is not a thing and it can often show up in the safety record. Sometimes even when taking off/landing in more civilized places, which is one way an airline can get banned from a country’s airspace.
The small submersible industry/culture actually was running along very well for decades with a very nice safety record despite inherent hazards of the actions. Then again, those folks spent a lot of money on safety and checks. Which is what Rush attempted to do a run-around on, including operating in international waters where no one had jurisdiction, and completely ignoring the advice of people more experienced and more knowledgeable than he himself was. This was in part because Rush wanted to make a profit at running deep-sea submersible tour groups and couldn’t see a way to do it if he followed in the footsteps of other folks (you know, the ones with an unblemished safety record). Rush was an outlier in the industry, one I’m somewhat surprised didn’t show up before. To some extent regulation wasn’t “necessary” because everyone else was already complying out of enlightened self-interest i.e. “I don’t want to die”. Then you get Mr. Ego showing up and the rest is history (and fish food).
I doubt there will be an international consensus (such as there is in aviation, even if not perfectly observed) until, as @Dr.Strangelove points out, you have a lot more people at risk.
One of the things that helped CRM adoption is that it was started by very big companies with lots of workers. Workers who could be instructed on what to do, then trained and monitored and if necessary counseled or disciplined. And yes, in the early days there was a lot of resistance which fell away partly as a result of the hold-outs retiring. it certainly helped that in that industry at that time, retirement was mandatory at age 60. Which drove turnover and also ensure there were no real old dogs out there; for darn sure your typical 75yo is a hell of lot more rigid than your typical 59yo.
By comparison, the US medical industry is 1 million individuals each in business for themselves or part of a small group of 10-15 peers. The bizjet industry is similar and has had real trouble implementing CRM and other aspects of what’s now called a “safety management system” or SMS.
Yes, there are large hospital practices, and more all the time. Just as there are airline-like bizjet operators such as NetJets. But those are in effect the exception that proves the rule.
Big organizations that demand consistent technical and personal behavior at work are able to push change. A million individuals doing their own thing and greatly valuing their personal and professional autonomy are a harder problem.
I’ve been playing some catchup on this topic a little after watching the documentary, mostly from YouTube. The documentary needed to have some of David Lochridge’s key messages in it; also a brief intro of OceanGate founding partner Guillermo Söhnlein and what he and Stockton Rush had as their company vision; and also OceanGate’s financial picture and financial pressures and the times they were close to not making payroll without some quick infusions of cash from Stockton.
Still, to the casual observer like me, the documentary was pretty good.
There will be key leadership at OceanGate brought under criminal charges.
After the BBC documentary, Netflix has now come out with one:
I just watched it (on Netflix — Titan: The OceanGate Disaster; director, Mark Monroe). It is good.
The more I learn about Stockton Rush and OceanGate, the more I see parallels with Elizabeth Holmes and Theranos.