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Two years after passengers hoping for a glimpse of the Titanic wreckage 

 in the Titan submersible implosion off the coast of Newfoundland, Canada, the U.S. Coast Guard issued a 

 Tuesday, saying the tragedy should have never happened.

"This marine casualty and the loss of five lives was preventable," Titan Marine Board Investigation Chair Jason Neubauer said in a statement. "The two-year investigation has identified multiple contributing factors that led to this tragedy."

 finds that the man who designed and piloted the Titan submersible, OceanGate CEO Stockton Rush, ignored safety warnings, skirted regulations and exhibited negligence.

Investigators say Rush would have likely faced criminal charges if he'd survived. He and four passengers were killed in the implosion.

The Coast Guard's report also cites the submersible's inadequate design. For example, its hull was made of cheaper, carbon fiber instead of a more commonly used, stronger steel alloy.

Investigators also found a lack of certification, maintenance and inspections for Titan, as well as a toxic work culture. A spokesperson for OceanGate, a company once based in Washington, confirmed Tuesday it has since "wound down operations" and has been cooperating with the investigation.

The Coast Guard findings mirror what former OceanGate employees testified last summer during a 

 in Charleston, S.C. They told investigators the company routinely put profits over safety and silenced critics.

Former OceanGate engineer David Lochridge said he'd 

 that Titan wasn't safe. He testified that it was "inevitable something was going to happen, and it was just when."

Lochridge also told investigators he was fired after expressing his concerns to Stockton.

Another witness, former OceanGate scientific director Steven Ross, recalled a dive aboard Titan just days before its final voyage. He testified there had been an issue with its balancing system and the submersible slammed passengers to the back of the vessel as it resurfaced.

He said he "ended up standing on the rear bulkhead" while another passenger was left "hanging upside down."

There was also testimony from several witnesses about "crackling sounds" heard inside Titan's hull during several dives. But the expeditions continued with some costing $250,000 per person.

 as crews searched for Titan after it lost contact with its mother ship, hoping to find survivors. Instead, rescuers discovered the wreckage, Titan's tail cone sitting upright on the ocean floor, near the Titanic. Human remains were later recovered.

The four passengers killed were French explorer Paul-Henri Nargeolet, British adventurer Hamish Harding and two members of a prominent Pakistani family, Shahzada Dawood and his son Suleman Dawood.

As part of its report, the Coast Guard has offered safety recommendations aimed at strengthening oversight of the submersible industry. Its findings will be reviewed by the Coast Guard commandant, who then decides what actions should be pursued.

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Victoria Hansen

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Two years after passengers hoping for a glimpse of the Titanic wreckage died in the Titan submersible implosion, the Coast Guard issued a scathing report, saying the tragedy shouldn’t have happened.

Coast Guard says Titan submersible deaths were preventable and faults company’s CEO

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