May 22, 2023

Subcommittee to Review Final National Fire Research 

Laboratory (NFRL) Incident Investigation Report

NIST Safety Commission

Dr. Joseph Kolly, Dr. James Bagian, and Dr. Darryl Hill

Review Subcommittee Members
Charge to the Review Subcommittee 

NIST Director’s Charge to the Review Subcommittee:

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.

The Subcommittee will assess:

• the quality and thoroughness of the incident investigation,

• the quality and thoroughness of the analysis of root causes and causal factors, and

• the applicability and robustness of the planned corrective actions. 

The Subcommittee’s written report of this independent review — and any 

recommendations for additional corrective and preventive actions for inclusion in the 

Commission’s final report — will be:

• discussed at the Commission’s third public meeting, and

• incorporated as a standalone appendix in the Commission’s final report. 
Review Subcommittee Members

James P. Bagian, M.D., P.E.

Professor of Industrial and Operations 

Engineering; Co-Director, Center for Risk 

Analysis Informed Decision Engineering

University of Michigan

Darryl C. Hill, Ph.D., MBA, CSP

Senior Vice President, Safety and Security

First Group America

Joseph M. Kolly, Ph.D.

(Subcommittee Chair)

Director, Transportation Innovation Center

MITRE Corporation

Subcommittee Members Appointed by NIST Director:
Approach and Progress

• NIST provided the Review Subcommittee with the following materials:

➢ NIST Internal Investigation Report: Director's Message and Executive Summary

➢ NIST Internal Investigation Report: Full Report

➢ OSHA Notices of Violation

• The Subcommittee held two preparatory meetings to be briefed on the report and 

proposed corrective actions:

➢ On April 21, the lead investigator for the NIST investigation report Dr. Steven Banovic 

briefed the Subcommittee on the report’s scope, methodology, and findings.

➢ On May 5, the NIST Chief Safety Officer Dr. Elizabeth Mackey briefed the Subcommittee 

on the Corrective Actions in response to the NIST investigation report.
Observations 

Investigation quality and thoroughness

• Correct proximate cause of the accident was identified

• Thoroughness of investigation sufficient to find proximate cause

• Additional topics should be addressed for completeness

• The investigation and report as a whole are a useful foundation for further 

development
Observations 

Quality and thoroughness of root causes and causal factors

• Root causes (and causal factors) as written are more accurately described as 

proximate causes 

• Causes as written are correct as proximate causes

• True root causes have not been identified
Observations:

Applicability and robustness 

of the planned corrective actions

• Corrective actions as written address the proximate causes

• The corrective actions as written are not sufficient in and of themselves. If not 

supplemented or superseded by additional corrective actions that address true root 

causes it is unlikely that effective and sustainable improvements will be 

accomplished.
Proposed Additional 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.