In Titanic Submersible Probe, Chief Coast Guard Investigator has Record of Sweeping Systemic Changes in Merchant Vessel and Passenger Ship Safety

Coast Guard Captain Jason Neubauer, the head of the formal Marine Board Investigation into the Titanic diving vessel tragedy, led two of the most important investigations in modern American Maritime history, overseeing major investigations into the sinking of the SS El Faro and the burning of the dive ship Conception.

In each case, the Neubauer panels focused as much on the Coast Guard itself as the private owners and operators. The result was systemic reforms that sought to fix decades-old holes in the Coast Guard system of inspection and safety reform.

What does that mean for the Titan case? If Captain Neubauer stays true to form, he will be looking at the holes in regulation surrounding safety regulations for crafts such as the Titan.

And the report findings themselves will be outside the Coast Guard’s immediate realm. The Titan operated in international waters. The findings of an investigation — conducted jointly with the NTSB and investigators form other countries — most probably would be turned over to the Convention for the Safety of Life at Sea (SOLAS). A logical requirement might be to require that even experimental passenger vessels such as the Titan meet basic standards set by such agencies as the American Bureau of Shipping.

“Neubauer does not give up,” said one observer of the hearings. “He’s sort of a more cheerful, good-guy version of Inspector Javert”

In person, Captain Neubauer is good humored and respectful in his inquiries without prosecutorial tone. He sometimes cuts short provocative lines of questioning and court room type drama. Instead, he relies on careful and exhaustive lists of witnesses, expert third-party studies, and as importantly the wealth of emails and social postings provided by modern technology.

In this case, he is likely to see the Titan tragedy in terms not just of a vessel failure but a system failure. In at least one case, the Neubauer-led Marine Board bucked conventional wisdom that said the El Faro was an open-and-shut case of a negligent captain steaming into the heart of Hurricane Joaquin. Even “60 Minutes” subscribed to the theory.

“Everyone thought that would be a two week Marine Board,” said one participant on the board. “No one would have argued with a simple interpretation of the tragedy.”

Instead, Neubauer and joint investigators of the National Transportation Safety Board, pressed forward with a multi-year probe that included extraordinary deep-sea searches at the 15,000 foot level. The searches at extreme depth found the wreck of the El Faro — only to find the sought-after “black box” had become separated from the wreck. The device signal batteries had expired and there was little chance of finding it.

The Coast Guard and the NTSB pursued the search and against all odds found the box on the ocean floor and retrieved it,

That was the beginning of another technical challenge — the enhancement and restoration of the audio tapes on the bridge of the SS El Faro. After weeks of work, what emerged was a heartbreaking narration by the victims of the tragedy struggling against the hurricane and the failure of ship systems and the captain to respond to his officers’ concerns.

“Neubauer does not give up,” said one observer of the hearings. “He’s sort of a more cheerful, good-guy version of Inspector Javert”

The result of the El Faro investigation led to only minor civil charges against Tote Maritime, even though the board concluded that the company inadequately inspected the ship and in converting it to a container ship weakened its seaworthiness.

But the change in Coast Guard inspection policy was industry-changing. The report similarly criticized the American Bureau of Shipping, a non-profit inspection service. The Coast Guard leadership embraced the report and at one point placed all Coast Guard stations on “stand down” until the stiffer inspections were enacted.

This forced many old US Flag ships to leave service — including those under military service. The American fleet was so unsafe, its numbers sank to levels that worried Pentagon leaders who speculated the country could no longer sustain wars abroad. It made new ship construction a priority.

The dive boat Conception tragedy of 2019 occurred when 33 divers sleeping on board the ship died when a fire broke out and escape routes were blocked. The failure to provide clear escape routes on small passenger ships and dive ships was a long-standing criticism of Coast Guard regulations. The new safety regulations enacted in 2021 required boat operators to have clear escape routes available, effective fire detection systems and extinguishers, and provisions for handling potentially items such as rechargeable batteries that can ignite and explode.

The captain of the vessel was also charged criminally — a case still pending in court.

Note: an early version of this story stated the Titan was not registered under any country’s “flag.” Some reports, however, state that the Titan was registered with the Bahamas. Such “flag of convenience” countries have standards that can vary widely. Some are as high and at times higher than the United States, while others are loosely regulated if at all when it comes to inspections and safety standards.