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NIST SAFETY COMMISSION

MINUTES1 OF THE MONDAY, MAY 22, 2023

HYBRID MEETING

ATTENDANCE: Virtual*

NIST Safety Commission 

Members Attending

Bagian, James

Hill, Darryl

Hoffman, David*

Jones, Allison

Kolly, Joseph

Merlic, Craig (Vice Chair)

Peters, Mark (Chair)

Designated Federal Officer

Shyam-Sunder, Sivaraj

NIST Leadership Board

Adams, James

Bahar, Mojdeh

Boehm, Jason

Brockett, Delwin

Brown, Essex*

Brown, Hannah

Chin, Joannie

Glenn, Rachel

Hooker, Stephanie*

Huergo, Jennifer

Jenkins, George*

Kushmerick, James (Jim)

Locascio, Laurie 

Mackey, Elizabeth

Olthoff, James

Porch, Susanne*

Pritchett, Jeanita

Romine, Charles (Chuck)

Sastry, Chandan

Schlatter, Katie

St. Pierre, Jim

Vanek, Anita

Vaughn, Robert (Skip)

Wixon, Henry

NIST Safety Commission 

FACA Secretariat:

Lloyd, Corrine

Travis, Dalia

Brown, Phoebe (Energetics)

Evans, Tracy (Energetics)

NIST Staff

Bald, Kevin*

Benz, Samuel*

Berilla, Michael*

Boggs, Ashley*

Bundy, Matthew*

Camenisch, April*

Dennis, Christopher*

Dohne, Kirk*

Fasolka, Michael*

Fato, Hope*

Fraser, Gerald*

Glick, Millie*

Good, Jeffrey*

Griffith, David*

Grove, Tom*

Hamid, Moose*

Hoehler, Matthew*

Huber, Michael*

Jacobson, David*

Kellerman, Christina*

Kirby, Brian*

Lane, Anne*

Masselle, Diana*

Ng, Lisa*

Nico, Jeffrey*

Rentz, Nikki*

Sharp, Nick*

Szakal, Andrea*

Varadi, Laslo*

Wavering, Al

Weaver, Jamie*

Wong, Wing*

Yashar, David*

Zhang, Yali*

Others

Fisher, Tim*-- American 

Society of Safety 

Professionals

1 These minutes are a summary of the topics discussed and do not reflect 

detailed content of the discussions.
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Call to Order and Roll Call – Mark Peters, Chair, NIST Safety Commission

Dr. Peters called the meeting to order and took roll call. All seven Commissioners were present, with 

Dave Hofmann joining virtually. The commissioners introduced themselves. Dr. Peters shared

instructions for participation for those who were in person and for those joining virtually. He noted that the 

meeting agenda and presentations are available on the NIST Safety Commission website link

(www.nist.gov/director/nist-safety-commission), gave an overview of the agenda, and introduced 

speakers for the morning session. He shared that the Commission delivered its Interim Final Report, 

available on that website. Since then, Commissioners have worked diligently on preparing the draft final 

report and they will work together on the draft report during the afternoon working session. He noted that 

since no requests were received by the closing date for the public comment session on the agenda, the 

time would instead be used for the Commission’s working session. Dr. Peters thanked all for attending 

this Commission meeting, thanked NIST leadership members for their engagement throughout the 

process, and then introduced Dr. Laurie Locascio, the Under Secretary of Commerce for Standards and 

Technology and NIST Director, to provide the Director’s update to the Commission. 

NIST Director’s Update – Dr. Laurie Locascio, Under Secretary of Commerce for 

Standards and Technology and NIST Director

Dr. Locascio welcomed the Commissioners and expressed her deep appreciation for their work over the 

past five months. She shared that the NIST Safety Commission’s Interim Final Report was shared with 

the Commerce Secretary and Deputy Secretary of Commerce, to whom she is accountable. She noted 

their continuing support of the Commission and their full support of her as she continues to make all of 

the necessary safety changes at NIST. She said that while NIST underpins competitiveness and has an 

obligation to continue its important work for the nation, the organization has an obligation to its people to 

make sure they can do their work safely. Upon establishing the Commission, she gave the Commission a 

short timeline; after the two safety incidents, NIST needed outside perspective, and the Commission 

brought a wealth of experience and knowledge. Dr. Locascio shared her own commitment, that of the 

entire leadership team, and the whole of NIST staff to the changes recommended in the Commission’s

report. She shared that inclusive change is coming and that she will provide a sense of scope and broad 

areas where change needs to occur, some accomplishments thus far, and activities that are planned. 

She said that NIST would incorporate external best practices and is seeking an outside safety firm to 

work with NIST in the coming years. Immediate plans to benchmark against National Renewable Energy 

Laboratory, Oak Ridge National Laboratory, and Argonne National Laboratory are moving forward. 

As a starting point, she noted, NIST must fully integrate safety into decision-making processes for all 

aspects of the mission, from planning through mission delivery, over the full life-cycle of programs and 

projects. To achieve lasting and meaningful change to improve safety, NIST recognizes that it must 

fundamentally change culture and its way of doing business. She said that began with commitment to 

safety by leaders across the organization. She held a mandatory, two-day meeting on approaches to 

safety and obstacles; the Commission’s Interim Report provided an important foundation for this. The 

discussion defined the need for participation by all in this movement. Shortly after, the NIST Leadership 

Board met to review safety practices that each Organizational Unit (OU) has adopted. Dr. Locascio also 

held a town hall with NIST staff on safety to share updates and noted an eagerness to participate and 

share ideas. A series of listening sessions is planned, to harness the energy and gather input at a 

grassroots level. 

Dr. Locascio has also chartered an Executive Safety Improvement Team to oversee and track to 

completion safety improvement actions intended to address specific NIST Safety Commission 

recommendations. This action-focused team is already establishing working groups from across the 

organization, including one that is looking at how safety can be more robustly integrated into performance 

plans. The team has three guiding principles: human factors for safety to make it easier to do the right 

things, trust through strong partnerships, and communications to make sure safety is clear. A recent idea 

proposed hiring a usability professional to make safety programs more effective through a user-centered 

approach. Examples of activities implemented in the last month include new hires, facilities repairs, safety 

assessments, and professional external safety consulting. First, significant budget has been set aside for 
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new hires. NIST’s Office of Safety, Health and Environment (OSHE) identified the need to hire six people 

in this fiscal year for the purpose of establishing an audit program, providing a competent person for fall 

protection, participating more broadly in hazard reviews, and taking the lead in workplace inspections. 

Funds for additional hiring for safety will be approved on a rolling basis. Dr. Locascio has prioritized 

establishment of an audit program, mandated that OSHE staff participate in all hazard reviews where 

potential severity of the hazard is severe or high, and mandated that OSHE staff serve as lead inspectors 

for all spaces governed by hazard reviews. Second, the Associate Director for Laboratory Programs has 

established a new fund of $1.5 million for safety replated repairs in this fiscal year. Requests are 

approved on a rolling basis and coordinated with the Office of Facilities and Property Management so that 

safety related repairs have priority. Third, Dr. Locascio has allocated over $400,000 for a comprehensive 

fall hazard assessment survey to identify potential fall hazards and regulatory non-compliance issues,

and to recommend interim abatement plans and long-term solutions. Fourth, NIST is in the process of 

hiring outside safety consultants to assess NIST’s safety management system and corrective action 

plans. 

Next, Dr. Locascio described three executive-level key action areas that are moving forward. The first 

key action area is focused on Leadership Expectations and Accountability: NIST must make safety an 

integral part of the NIST culture and commit to continuous improvement of safety practices and culture.

Dr. Locascio highlighted work that is underway in this area, some of which she covered earlier, such as 

the team reviewing performance reviews in which NIST wants to emphasize safety responsibilities, 

authorities, and accountability associated with each of its positions. She recently shared with all NIST 

staff the results of the NIST Safety Culture Survey, which included the responses of NIST associates for 

the first time. She noted that there is no quick fix to changing safety culture; it is difficult, takes vigilance,

and needs everyone at NIST to be part of the solution. Input is needed from all levels of the organization. 

Directors are provided survey results and comments for their Organizational Units (OUs) to develop

improvement actions that are responsive to the feedback; and those leaders will be assessed by their 

ability to do so. NIST needs the ideas, actions, and energy generated by the people who best know the 

workspaces, and the focused, sustained management attention from the top down to ensure goals are 

achieved. Facilitators from the National Safety Council will lead focus groups that will identify actions. 

The second key action area is focused on OSHE’s Role and Authorities. Dr. Locascio shared that NIST 

is raising the level of safety to the NIST Director’s office and empowering its safety professionals to 

ensure that safety is present in every critical discussion regarding the health of the organization. In 

response to the recommendations included in the Commission’s Interim Final Report, she has already 

begun making changes to the organization and leadership. The NIST Chief Safety Officer will now be

accountable to the NIST Director, inform resource allocations for facility improvements as part of the 

facilities budget review team, and be part of enterprise-level risk assessments. Other changes based on 

Commission recommendations include revisions that specify OSHE safety professionals have the lead on 

inspections of workplaces covered by hazard reviews, participate in all hazard assessments for 

hazardous work, and an OSHE staff member is detailed to the ERM office to assist with risk assessment 

method development. 

A third key action area is related to Processes, Tools, and Communications. Dr. Locascio added that the 

goal for this area is to ensure NIST has the best processes and tools so that safety can easily be 

integrated into its culture. She noted several items on this topic that stem from Commission 

recommendations. Efforts are already underway to assist OSHE in developing an audit and assessment 

program. NIST will also engage expert consultants and is examining commercial off-the-shelf packages 

to replace homegrown and often disparate approaches to safety management. She highlighted training 

to make sure that the incident in September is not forgotten. Plans are being finalized for a NIST Safety 

Day in late June, during which NIST will hold a safety stand down, pausing all work to come together to 

hear from the Executive Safety Improvement Team and others and for practical demonstrations, learning 

sessions, and exercises. 

Dr. Locascio provided an update on the NIST Center for Neutron Research (NCNR), which is making 

progress on improving its nuclear safety culture. As required by the confirmatory order signed with the 

NRC following its investigation into the February 2021 unplanned shutdown, a report to NIST and the 
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Nuclear Regulatory Commission (NRC) will be delivered soon and shared publicly. NIST was able to 

begin low power testing of the reactor in April, and that testing continues. 

Dr. Locascio again thanked the Commission and shared that the activities she described were only the 

beginning of the efforts and activities to make NIST’s safety culture robust, lasting, and integrated into 

everything. 

For more information, see Dr. Locascio’s presentation. 

Discussion. NIST Safety Commission members were encouraged by the informative presentation and 

positive changes being made. They discussed the following topics:

• Role of external consultants to focus on safety culture and benchmarking against other 

organizations. 

• Value of coaching for the senior leadership team and professional development for OSHE staff.

• Engaging national laboratories and connecting at multiple levels of the organization, including the 

Directors. 

• Ensuring consistent safety approaches across Organizational Units. 

• Importance of change management to ensure a systematic approach; considering both cognitive 

and physical human factors affecting usability; focusing on details that will make a measurable 

difference; establishing tight timeline (e.g., two years from now)

Report of the Subcommittee 4 on its Review of the National Fire Research 

Laboratory Incident Investigation Report

Dr. Joseph Kolly presented the approach, observations, and draft recommendations for the

Subcommittee to Review Final National Fire Research Laboratory (NFRL) Incident Investigation Report. 

Subcommittee members appointed by the NIST Director include Dr. Kolly, Dr. James Bagian, and Dr. 

Darryl Hill. Dr. Kolly reviewed the NIST Director’s charge for the Subcommittee, which was established to 

conduct an independent review of the written final NIST investigation report on the death of an 

experienced NIST staff member in September 2022, in a fall from an elevated height when part of a 

research structure collapsed. This Subcommittee’s written report of this independent review and any 

recommendations for additional corrective and preventive actions will be incorporated as a standalone 

appendix in the Commission’s final report. 

NIST provided the Subcommittee with the NIST Internal Investigation Report (Director’s Message and 

Executive Summary and Full Report) and OSHA notices of violation. The Subcommittee held two 

preparatory meetings to be briefed on the NIST report and proposed corrective actions, a meeting with 

the lead investigator on the report’s scope, methodology, and findings, and a meeting with the NIST Chief 

Safety Officer on the Corrective Actions in response to the NIST investigation report. 

Dr. Kolly presented the Subcommittee’s observations on the of NFRL Incident Investigation Report. He 

noted the correct identification of proximate cause of the accident and that the investigation was 

sufficiently thorough to find proximate cause, but that root causes (and causal factors) as written are more 

accurately described as proximate causes, so true root causes had not been identified. Dr. Kolly 

described illustrative examples of proximate causes and the need to ask additional questions to explore 

further back into the causal chain to derive root causes. He noted that the Commission’s

recommendations provided in the NIST Safety Commission Interim Final Report address some of the root 

causes. The corrective actions as written address the proximate causes, so additional corrective actions 

that address true root causes, once identified, are needed. Identifying appropriate corrective actions for 

true root causes is important for making long-lasting change. The Subcommittee also identified additional 

corrective actions that address OSHA recommended practices for safety and heath programs for both 

general industry and the construction industry, along with corrective actions that should be identified that 

cover planning, set-up, experiment, tear down, and disposal. 
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Commissioners added comments during the presentation, reiterating the importance of defining true root 

causes, building upon the Commission’s and this subcommittee’s recommendations in the executive 

action plan, the value of a quality assurance system as part of safety, and behavioral change. 

Based on the observations, the Subcommittee proposed two draft recommendations: 

• Recommendation 1: OSHE take the time afforded by the NIST Director to further develop the 

proximate causes they have already identified and go back further into the causal chain, to arrive 

at organizational and systemic level root causes and contributing factors. 

• Recommendation 2: Upon reaching the root causes mentioned in Recommendation 1 above, 

derive corrective actions that address the deeper elements of the causal chain focusing systemic 

mitigations for actions taken at the organizational level.

For more information, see the Subcommittee presentation. 

Discussion. NIST Safety Commission members discussed the following topics:

• Confirmed that interim recommendations by NIST Safety Commission are applicable to what 

Subcommittee overserved in review of the NFRL Incident Investigation Report; do not anticipate 

changes to initial recommendations for final report. 

Working Session

NIST Safety Commission Vice-Chair, Dr. Craig Merlic, led a discussion with Commission members to 

review the draft final report. Commissioners reviewed each section of the report together, shared input, 

comments, and questions, and discussed the structure of the report and its appendices. The 

Commission determined the schedule to revise and produce the final version for submittal to the NIST 

Director by June 30, 2023.

Adjournment

The meeting was adjourned at 4:33 PM.

I hereby certify that to the best of my knowledge; the forgoing minutes are accurate and complete.

Dr. Sivaraj Shyam-Sunder, Designated Federal Officer, NIST Safety Commission 

Dr. Mark Peters, Chair, NIST Safety Commission