Five people died in a deep-sea disaster that captured the attention of the entire nation, and a new report puts the blame for the Titan submersible tragedy squarely on the man who ran the Everett-based OceanGate company.

A faulty design, safety recommendations that were ignored, and a toxic work environment all contributed to the implosion of the experimental vessel in 2023 while it dove more than two miles deep to explore the wreckage of the Titanic.

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During the submersible’s final dive, the crew lost contact after an exchange of texts about Titan’s depth and weight as it descended. One of the last messages from Titan’s crew to its support ship before the submersible imploded stated, “all good here."

When the submersible was reported overdue, rescuers rushed ships, planes and other equipment to an area about 435 miles south of St. John’s, Newfoundland. Wreckage of the Titan was subsequently found on the ocean floor about 330 yards off the bow of the Titanic, Coast Guard officials said. No one on board survived, including OceanGate founder Stockton Rush.

KOMO News spoke directly with Jason Neubauer, the chair of the U.S. Coast Guard’s Marine Board of Investigation (MBI), about the various factors that led to the deadly outcome of OceanGate’s final undersea voyage.

“The primary factors that we determined were really OceanGate's failure to pursue any certification or full testing of the hull itself. Then, when you combine that with a lack of maintenance and monitoring of the data they received from the hull at the end of operations, I think those two factors really combined to lead up to the disaster,” Neubauer said. “I think it's interesting in this case that OceanGate never registered the TITAN. I believe that was intentional to stay off the radar."

The experimental watercraft was built with a hull made from carbon fiber and titanium. During a previous mission, a loud bang was heard as the vessel ascended, but Neubauer said the data gathered on that incident was not acted upon.

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“There were warnings throughout the 2022 operating season that should have been heeded,” Neubauer said. “During that incident, we're confident that it was a delamination of two layers of the carbon fiber between the first and second layer that occurred. Then after that there was movement of the hull - very slight but enough under those pressures to be a problem."

MBI also agreed that had Stockton Rush survived, the former OceanGate CEO could have faced criminal charges.

“That would have been the Marine Board's recommendation to the commandant of the Coast Guard,” Neubauer said, “to have a criminal investigation, or at least proceed and have manslaughter considered by the Department of Justice."

OceanGate suspended operations in July 2023.