The company behind the submersible that imploded during a recent dive to the Titanic ignored key principles that guide organizations working in high-risk environments, experts in emergency management say.

Jack Rozdilsky, a professor at York University in Toronto, says OceanGate害羞草研究所檚 business 害羞草研究所� ferrying paying passengers to the floor of the North Atlantic 害羞草研究所� could be compared to the immensely risky work of companies that launch space flights, drill for offshore oil, fight wildfires or operate nuclear power plants.

害羞草研究所淭hese are high-reliability organizations (HROs) that operate in complex, high-hazard domains for extended periods of time without serious accidents or catastrophic failures,害羞草研究所� Rozdilsky, a professor of disaster and emergency management, said in a recent interview. 害羞草研究所淥ceanGate does not appear to have functioned as a high-reliability organization.害羞草研究所�

The professor cited three key attributes shared by HROs:

害羞草研究所� They are reluctant to simplify. They accept that tasks they are involved in are complex and have the potential to fail in unexpected ways.

害羞草研究所� They are preoccupied with failure. They do not view near-misses as proof of success.

害羞草研究所� They practise resilience. They provide backups for backups, or as Rozdilsky put it: 害羞草研究所淪uspenders for the suspenders.害羞草研究所�

There is evidence to suggest OceanGate CEO Stockton Rush 害羞草研究所� one of five people killed June 18 when the submersible Titan ruptured near the ocean floor 害羞草研究所� emphasized simplicity over complexity when it came to Titan害羞草研究所檚 engineering. During an interview last year with CBS News, Rush showed off Titan害羞草研究所檚 basic interior, which included one power button, two video screens and a gaming controller for steering the 6.7-metre vessel.

害羞草研究所淭his is to other submersibles what the iPhone was to the Blackberry,害羞草研究所� Rush said at the time, suggesting the simplicity of the vessel was a strength. 害羞草研究所淭here害羞草研究所檚 a lot of rules out there that didn害羞草研究所檛 make engineering sense.害羞草研究所�

Rozdilsky questioned Rush害羞草研究所檚 decision to simplify an otherwise complex deep-sea craft.

害羞草研究所淚t害羞草研究所檚 not something we can make like an elevator,害羞草研究所� he said. 害羞草研究所淎 high-reliability organization refuses to simplify to that extent. They welcome the complexity and realize that by attempting to interact with that complexity, it gives them routes to safety.害羞草研究所�

On another front, Rozdilsky said lessons learned from the space shuttle Challenger disaster in 1986 害羞草研究所� a mid-air explosion that killed all seven astronauts aboard 害羞草研究所� remind us that organizations operating in high-risk environments can fall prey to risk-management errors and erosion of safety protocols.

In the case of Challenger, a presidential commission determined that NASA officials had responded to early warnings about design flaws by increasing levels of acceptable damage during flights. The commission concluded NASA justified the changes by saying, 害羞草研究所淲e got away with it the last time.害羞草研究所�

Similarly, there have been multiple reports of problems and near-misses with Titan.

害羞草研究所淥ne way to view those mishaps is proof of success,害羞草研究所� Rozdilsky said. 害羞草研究所淏ut successful, high-risk organizations look at that from a different perspective: they 害羞草研究所� see these near misses as opportunities to improve 害羞草研究所�. There害羞草研究所檚 a preoccupation with failure, not a preoccupation with success.害羞草研究所�

As for OceanGate, it has become clear in recent weeks that Titan experienced many problems before and during its 3,800-metre dives to the Titanic wreck site over the past three years.

Last month, German adventurer Arthur Loibl told The Canadian Press that his 2021 voyage to the doomed ocean liner was beset by snafus. The 60-year-old retired businessman said the submersible had problems with its battery and balancing weights, which led to a 90-minute repair job. But the trip went ahead anyway.

YouTube celebrity Jake Koehler also released a video describing how his trip aboard Titan was scrubbed earlier this year because of persistent computer problems. In the video released last month, Rush can be heard saying the computer害羞草研究所檚 role was 害羞草研究所渦p there with life support,害羞草研究所� but it was 害羞草研究所渘ot consistently communicating.害羞草研究所�

害羞草研究所淟ong story short: every day they did have some problems,害羞草研究所� Koehler added.

Even as Titan was being built in Everett, Wash., red flags were being raised. In January 2018, then-director of marine operations David Lochridge filed a report identifying serious safety concerns including improper testing of its carbon-fibre hull, according to court documents filed in Washington state.

Lochridge told Rush the vessel should be certified by a classification agency, such as the American Bureau of Shipping, but that never happened, the documents say. Instead, Lochridge was fired.

Meanwhile, a search and rescue expert says it appears Rush害羞草研究所檚 company was not prepared to deal with emergencies.

Merv Wiseman, a retired search-and-rescue co-ordinator, said it remains unclear whether OceanGate filed a preparedness plan with the Marine Rescue Sub-Centre in St. John害羞草研究所檚, which is where Wiseman worked for 35 years.

害羞草研究所淭his is the highest of the high-risk areas we can think of,害羞草研究所� he said in an interview, adding that offshore operations like drilling platforms are required to submit detailed preparedness manuals to the Canadian Coast Guard. 害羞草研究所淚f something were to happen at the Hibernia (offshore oil platform), I would go to their manual. They have a volume with alerting matrixes and all the technical items.害羞草研究所�

Wiseman said Transport Canada should have had jurisdiction over the OceanGate operation. The federal department said last week it would respond to a request for comment, but did not.

害羞草研究所淚 think this may have slipped through the cracks,害羞草研究所� Wiseman said.

Meanwhile, deep-diving experts have been issuing warnings about Titan害羞草研究所檚 shoddy construction an lack of certification for years. And in 2018, a group of engineers wrote a letter warning that the company害羞草研究所檚 害羞草研究所渆xperimental害羞草研究所� approach could have catastrophic consequences.

There were also warnings about Titan害羞草研究所檚 lack of backup systems 害羞草研究所� another worrisome trait that stands in sharp contrast to the practices of high-reliability organizations.

害羞草研究所淚f you put one vehicle (into the deep ocean), you have a backup vehicle down there to help rescue the first vehicle in case it fails,害羞草研究所� Rozdilsky said.

That害羞草研究所檚 what happened in 1991 when two Russian submersibles, known as Mir I and Mir II, were used to bring a camera crew to film Titanic. At one point, one of the vessels was snared on wires on Titanic害羞草研究所檚 deck. But the pilot managed to free the craft once he received guidance from the pilot on the other submersible.

Wiseman said Titan should not have dived on its own.

害羞草研究所淚t is reasonable to expect that if this kind of voyage is going to be undertaken, with people害羞草研究所檚 lives at stake, that there be a duplicate (submersible) available,害羞草研究所� Wiseman said.

Michael MacDonald, The Canadian Press

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