The Titan submersible disaster could have been prevented, the U.S. Coast Guard said in a report Tuesday that held OceanGate CEO Stockton Rush responsible for ignoring safety warnings, design flaws and crucial oversight which, had he survived, may have resulted in criminal charges.

Rush and four passengers were killed instantly deep below the North Atlantic in June 2023 when Titan suffered a catastrophic implosion as it descended to the wreck of the Titanic. A multiday search for survivors off Canada grabbed international headlines, and the tragedy led to lawsuits and calls for tighter regulation of the burgeoning private deep sea expedition industry.

The Coast Guard determined that safety procedures at OceanGate, a private company based in Washington state, were “critically flawed” and found “glaring disparities” between safety protocols and actual practices.

Jason Neubauer of the Marine Board of Investigation said the findings will help avoid future tragedies.

“There is a need for stronger oversight and clear options for operators who are exploring new concepts outside of the existing regulatory framework,” he said in a statement.

Salvatore Mercogliano, a professor of maritime history at Campbell University in North Carolina, said OceanGate was able to exploit gray areas in maritime law that made it unclear who was responsible for enforcing regulations.

Now, he said, the Coast Guard and other international maritime agencies will be looking to improve coordination and implement clearer mechanisms for enforcement, especially for private submarines.

“Unfortunately almost all maritime regulation is written in blood, and something had to happen first,” Mercogliano said.

OceanGate suspended operations in July 2023. Spokesperson Christian Hammond said the company has been wound down and was fully cooperating with the investigation, and he offered condolences to the families of those who died and everyone affected.

Investigators pointed to a culture at OceanGate of downplaying, ignoring and even falsifying key safety information to improve its reputation and evade scrutiny from regulators.

The company ignored “red flags” and had a “toxic workplace culture,” with firings of senior staff and the looming threat of dismissal used to dissuade employees and contractors from expressing safety concerns.

Rush, a former flight test engineer for fighter jets, founded the company in 2009 after years of experience in aerospace and aviation.

The Marine Board concluded that Rush had an “escalating disregard for established safety protocols,” which contributed to the deaths. If Rush were alive, the board would have passed the case to the U.S. Department of Justice and he may have faced criminal charges, it said.

The company reclassified submersible passengers as “mission specialists” to bypass regulations on small passenger vessels and claim its subs were oceanic research vessels. Former mission specialists and OceanGate employees said their participation was “purely for a ride in the submersible, not for scientific research,” the report said.

Rush and OceanGate received numerous warnings about Titan’s fraudulent classifications. In 2017, Rush was told by a Coast Guard Reserve officer hired by OceanGate that his planned Titanic dive would be illegal.

Rush said “he would buy a congressman” if ever confronted by regulators, the officer testified.

Over the years the company resorted to increasingly deceptive strategies, the report said. By 2021 an OceanGate attorney falsely told a Virginia federal court, which was presiding over Titan’s authorization to conduct dives, that the vessel was registered in the Bahamas.

To obtain his credentials, Rush submitted a fraudulent sea service letter signed by OceanGate’s chief operations officer to the Coast Guard’s National Maritime Center, the report said. In it Rush claimed past service as a crew member on Titan and misrepresented the size of the vessel, when in fact it had never been registered or admeasured.

Mounting financial pressures in 2023 led to a decision by OceanGate to store the submersible outdoors in the Canadian winter, and the hull was exposed to temperature fluctuations that also compromised the vessel’s integrity, the report said.

The implosion also killed French underwater explorer Paul-Henri Nargeolet, known as “Mr. Titanic”; British adventurer Hamish Harding; and two members of a prominent Pakistani family, Shahzada Dawood and his son Suleman Dawood.

Nargeolet’s family filed a $50 million lawsuit last year alleging that the crew experienced “terror and mental anguish” before the disaster. The lawsuit accused OceanGate of gross negligence.