When disaster strikes, we often look for technical failures, environmental factors, or human error as the root cause behind the tragedy. However, after watching Netflix’s recently released documentary, Titan: The OceanGate Submersible Disaster, I was struck by the similarities with the Challenger Space Shuttle disaster in 1986 – and how risk culture and hubris played central roles in both.

In each disaster, overconfidence, ego, and a disregard for expert advice led to catastrophic failures and the loss of multiple lives. These disasters highlight two crucial points for all organisations:

1. Hubris and a flawed risk culture are deadly when it comes to managing high consequence risk events
2. Root cause analyses need to look beyond the technical, environmental and human causes and assess the behaviours and attitudes of personnel which may have contributed to the event

Background

Challenger Space Shuttle Disaster (1986)
On 28 January, 1986, the Challenger space shuttle, carrying seven crew members, tragically exploded just 73 seconds after launch. The immediate cause was the failure of an O-ring seal on one of the solid rocket boosters, which allowed hot gases to escape and ignite the external fuel tank. The engineers at Morton Thiokol, a third-party contractor who had built the boosters, were extremely concerned about the low temperatures on the day of the launch, fearing that the O-rings would become brittle and fail. Despite these warnings, NASA’s leadership, under immense pressure to maintain the shuttle’s launch schedule which had already incurred multiple delays, decided to proceed.

OceanGate Submersible Disaster (2023)
On 18 June, 2023, the Titan submersible, operated by OceanGate, imploded during a dive to the wreckage of the Titanic. All five people aboard were killed, including OceanGate’s CEO, Stockton Rush. The cause was determined to be a structural failure likely stemming from the use of untested materials, such as carbon fibre, and the lack of independent safety certifications. Rush ignored warnings from OceanGate’s own engineers and external experts, opting instead to downplay safety concerns, and failing to rigorously assess the risks of their unproven technology, in favour of pushing the boundaries of deep-sea exploration.

How Leadership and Culture shaped both Tragedies

Despite the differences in the industries, these two disasters share striking similarities.

Leading Indicators Ignored

Prior to both disasters, data was available to management that highlighted potential issues with the structural integrity of the two vessels. Challenger’s O-rings had shown degradation on a previous flight when operating at a temperature of 53 °F. Morton Thiokol recommended to NASA that shuttles not be launched below 53 °F, fearing brittleness and failure of the O-rings. Temperatures lower than 53 °F were also outside the temperature range that the O-rings had been tested in. This data was presented to NASA management the night prior to Challenger’s launch, when a ‘go/no go’ decision needed to be made. NASA applied pressure to Thiokol management to change their recommendation. Thiokol management, ignoring their own engineers’ concerns, relented, noting the data as ‘inconclusive’. NASA took that as ok to launch. When Challenger was approved for launch the following day, it was 36 °F – 30 °F lower than any previous space shuttle launch.

OceanGate had installed Real Time Monitoring (RTM) data into the hull of Titan, which monitored acoustic emissions. As the submersible descended into the ocean and was subject to increased levels of pressure from the water, acoustic emissions could be heard when carbon fibres in the hull snapped. These emissions were detected by the RTM and recorded on a graph which showed their intensity.

Earlier in OceanGate’s 2023 season, a loud bang was heard coming from the hull on dive #80 when the sub was still relatively close to surface level. Video footage shows that Rush later brushed this off, saying, “every deep-diving sub will make a noise at one point.” However, the RTM data collected from subsequent dives #81 and #82 showed the structural integrity of the hull was clearly declining. It is unclear whether this data was reviewed after the completion of the dives. Dive #83 would be OceanGate’s last.

Dismissal of Expert Advice
Stockton Rush’s dominant influence over OceanGate led to repeated dismissals of safety experts, both internal and external, who raised alarms about the submersible’s structural integrity:

• One external report received by OceanGate, regarding the pressure that the carbon fibre hull would be able to withstand at various levels of depth, included a graph showing a picture of a skull and cross bones at the depth that OceanGate was wanting to dive to.
• At the end of the 2022 season, the season prior to the fateful dive, engineers warned Rush not to store the submersible outside in sub-zero temperatures between seasons, as water getting inside the carbon fibres and freezing could have catastrophic consequences. These warnings were not heeded, apparently due to the cost it would have taken to transport and store the submersible elsewhere.
• The Netflix documentary includes original audio of Rush responding to a report from one of OceanGate’s senior engineers, who had raised a number of safety concerns after conducting a thorough inspection of the submersible over several days. In the audio, Rush can be heard saying, “This is the way we’re doing it. Period.” He didn’t want to have anyone working for the company who didn’t fully support what he was doing. This meeting led to both the engineer who had raised the concerns, and the head of Human Resources, who now saw Rush in a different light, leaving the company.

Rush chose to disregard safety experts in favour of continuing high-profile dives and pushing the boundaries with new technology. These dismissals highlight the significant influence that leadership’s ego can have on the risk management process.

In the case of Challenger, as noted above, Morton Thiokol had originally recommended NASA not launch. NASA were not happy with this recommendation, accusing Morton Thiokol of changing the launch criteria. After discussing among themselves, and disregarding their own engineers’ data and protestations, senior management at Morton Thiokol changed their recommendation. Negotiations for a future multi-million-dollar contract between NASA and Morton Thiokol were underway at the time.

NASA’s leadership chose to ignore the risks to meet a tight launch deadline and public expectation, while pressuring its contractors to provide NASA with the answer it required for the deadline to be met.

External Pressures and Deadlines

In both events, looming deadlines and external pressures played a pivotal role in decision-making:

• NASA faced external pressures from the public and the government to proceed with the launch, especially with the media spotlight on Christa McAuliffe, who would be the first teacher in space. NASA had already had multiple delays to the launch date, which were highly publicised, and needed to launch by a specific time on 28^th January – 12.38pm – in order to reach the correct orbit
• OceanGate was also under time pressure with a small window in which to carry out expeditions each summer. The previous three expeditions of the 2023 season had failed to have a successful dive due to various technical and weather issues. It was also under financial pressure to maintain paying clients and meet the demand for exclusive Titanic expeditions.

In both instances, external reputation and deadlines were prioritised over technical safety, leading to critical risk data and leading indicators being ignored.

Failures in Risk Culture

Risk culture refers to the shared values, practices, and attitudes that an organisation holds when it comes to identifying, assessing, and managing risks. It is the collective mindset that influences how risks are communicated, how decisions are made, and how safety is prioritised. A strong risk culture ensures that risks are treated seriously and communicated openly across all levels of an organisation. This culture must empower experts to raise concerns without fear of retribution, encourage transparency in risk discussions and, in the context of NASA and OceanGate, prioritise safety over all other objectives.

In both disasters, there were serious failures in risk culture:

• At NASA, a bureaucratic culture led to an environment where engineers at Morton Thiokol felt pressured to suppress their concerns
• At OceanGate, the CEO’s authoritarian control stifled independent oversight and openly discouraged dissenting opinions about the submersible’s safety

At both NASA and OceanGate, hubris was evident in leadership’s unwavering belief in their technology and their dismissal of expert warnings. In particular at OceanGate, it was reported in the media that the submersible had been tested at 4,000m below sea level – the level they were expecting to dive to on expeditions to the Titanic. However, this was not true, with the sub only being tested down to 3,939m. Rush was firmly of the view that the hull wouldn’t be ‘totally fine’ at one depth, and then ‘totally not fine’ at a depth only slightly deeper. However, as the RTM data showed, the hull was never, in fact, ‘totally fine’. Hubris often blinds leaders to potential risks and can foster a dangerous culture of invincibility, where feedback and concerns from others are ignored or belittled. In high-stakes industries like aerospace and deep-sea exploration, this kind of overconfidence, as evidenced through these two disasters, can be fatal.

Incorporating Behaviour Into Root Cause Assessments

To incorporate behavioural factors and look beyond the technical, environmental and human-error causes when conducting a root cause analysis, start by asking questions such as:

1. How effectively were risks communicated, particularly between different levels of the organisation (e.g., engineers, management, and frontline staff)?
2. Were employees encouraged to raise concerns, and if so, were those concerns heard?
3. Was there any reluctance to report or acknowledge issues due to fear of blame, retaliation, or reputational damage?
4. How did leadership respond to warnings or advice from experts, and what impact did that have on decision-making?
5. Was there a tendency to normalise risky behaviours or dismiss early warning signs due to previous successes or a belief that “it won’t happen here”?
6. Were short-term goals (e.g., meeting a deadline or making a sale) prioritised over long-term safety and sustainability?
7. How did the organisation handle past near-misses or minor incidents — were they treated as learning opportunities, or were they ignored?
8. Was there clear accountability for safety and risk management within the organisation?
9. Did risk owners have the authority to implement necessary changes?
10. Was there any external pressure (e.g., from clients, regulators, or the public) that influenced decision-making or led to a compromise on safety?
11. Were there signs of complacency that led individuals to assume risks were under control without further, or sufficient, examination or testing?
12. Did team members bypass standard procedures or protocols to save time, increase efficiency or reduce costs?

Conclusion

The Challenger and OceanGate disasters were both tragically preventable events driven, at least in part, by hubris and flawed risk cultures within their respective organisations. In both cases, leadership allowed hubris and external pressures to dominate decision-making, resulting in the dismissal of safety concerns and a failure to prioritise risk mitigation over ambition. These events should serve as stark reminders of the dangers that arise when organisations foster cultures where hubris and behavioural traits eclipse sound risk management practices.

To prevent future disasters, organisations must prioritise building a risk culture that encourages transparency, supports independent oversight, and values safety above all. Leaders should embrace humility in acknowledging risks, listen to experts, and recognise that innovation should never come at the cost of human life.

When conducting root causes analysis, potential behavioural causes should be considered with just as much weight as the technical, environmental and human error causes.

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Claire Berry (CA, CFE, CPRM, AMIIA) is the Founder and Director of Green Pen Consulting, providing tailored risk management and internal audit support to solo operators and small teams.

With nearly 20 years’ experience across audit, risk and governance roles, prior to establishing Green Pen Consulting Claire was Group General Manager – Risk & Internal Audit for an ASX100 entity in the chemical manufacturing industry. Claire credits this high hazard environment for significantly increasing her focus on health and safety, both within the workplace and at home.

Claire also authors the monthly Green Pen Digest newsletter, keeping readers up to date on the latest news and events across the accounting and auditing industries.