VCAT October 2023

Safety Briefing

Dr. Laurie Locascio

Under Secretary of Commerce 

for Standards and Technology 

and Director of NIST

Dr. Elizabeth Mackey

Chief Safety Officer and 

Director of Office of Safety, 

Health and Environment
 Listen and Learn 

 Vision for Safety

 Focus on Culture

 Action Plans 

 Safety Metrics

Agenda

Chief Safety Officer, Dr. Liz Mackey

NIST Director, Dr. Laurie Locascio
FY23: Learn from the Experts and DOE Peers
Fundamental Changes in Safety at NIST

New Vision: Safety Excellence

Structural Changes: 

• Safety Management System

• Roles and Responsibilities

• Enterprise Level Integration

Foundational Change: Safety Culture

Audits & Assessments

Education & Training

Hazard Review

Investigate Incidents

Inspections

Safety Culture
Renewed Focus on Culture 

Change our Culture: 

Integrate safety into 

how we think and 

what we do

Develop a culture that values 

safety excellence on a par with 

excellence in our work – our 

science, standards, and services

Everyone accepts personal 

responsibility for safety. We hold each 

other accountable, and our actions 

and decisions reflect our values.

Personal Responsibility

Accountability

Actions
Incident Investigation: 41 Corrective Actions

Safety Commission: 17 Recommendations 

Benchmarking with DOE Labs: 3 Improvement Actions

Safety Culture Improvement Plan: 9 Improvement Actions

Corrective and Improvement Actions
FY23: Respond and Investigate

NIST Director Response Initiatives

 All staff safety stand-down day

 Stop work for the project

 Listening sessions with staff

 FY23 initiative re-assess and observe 

hazardous work, include safety SME

Internal Investigation

 Determine what happened

 Why it happened

 How we can prevent incidents due to similar 

causes
Investigation Team Corrective Action Areas 

(26 Actions: workgroup, OU, NIST SMS level) 

• Strengthen requirements for and improve 

implementation of the NIST Hazard Review 

Program

• Improve line management oversight of 

hazardous work, and accountability with 

respect to safety 

• Address gaps in NIST’s safety management 

system in the areas of:

– Overhead cranes and rigging; and

– Audits and assessments (Contracted)

65% complete

Incident Investigation Action Plan

Additional ESC Subcommittee Corrective Action Areas 

(15 Actions: NIST level deeper root causes) 

• Strengthen and add to hazard review program 

requirements (Revised version under review)

• Additional Safety Management System Gaps

- Construction Safety (Contracted)

- Corrective and Preventive Action Program (Draft)

• Safety Program Implementation Insufficiencies 

- Fall hazard mitigation (Contracted assessment)

- Require refresher safety training (Assessing courses)

• Safety Culture Insufficiencies (50% completed)

 NIST Director communicates safety expectations

 Specify supervisor performance requirements 

 Review all safety-related R2As, OSHE staff R2A2s

- Improve communication of lessons learned from 

incident investigations (partially completed)
Role of Chief Safety Officer:

 Accountability to NIST Director (CSO named Special Assistant for Safety to NIST Director)

 Voting Member of Enterprise Risk Management Council (Charter Revision)

Roles and Responsibilities of OSHE staff:

 Lead role in workplace inspection, verification of corrective action (program revision)

 Participate in hazard reviews and incident investigations (program revisions) 

Structure of OSHE:

 Contractor to assess OSHE position within NIST (FY24)

 Contractor to assess OSHE expertise, staffing, organizational structure (FY24)

Staffing Levels: Ratio of Staff/Safety staff at two DOE labs is 40; at NIST, 160

 Approval for 12 new staff (includes 6 embedded safety staff)

Service Delivery Model: DOE best practice, embedded safety staff

 One embed positioned at NCNR; 5 more planned for FY24 

Strengthen OSHE Structure, Roles and Responsibilities
Hazard Review: 

 Risk assessment matrix revised to include probability timeframe

 OSHE staff participate in risk assessments to improve consistency

 Require observation of work for approval

Workplace Inspections: 

 OSHE staff lead inspections and verify deficiency abatement

 Improve risk-based prioritization of deficiencies

 Improve and enforce timeframe for abatement 

Incident Investigations:

 Improve ease of reporting

 Improve sharing of lessons learned

 Improve root cause analysis

Training: 

 Require refresher training 

 Improve relevancy of safety training with case studies

Fundamental Improvements to Basic Safety 

Practices 

Management Observation Process:

 Training for managers on how to 

conduct meaningful 

conversations about and 

observations of hazardous work 

(consultants, Nov; Jan/Feb)
Change Management Process

 Program drafted in 2022, implementation planned for FY24

 Human Resource components developed (safety exit from duty checklist; 

safety hiring questions for new managers)

External Audits and Assessments:

 External audit to ISO 45001 standard (Contracted, FY24)

 External audit will be a requirement of new Audits and Assessment Program 

(FY24)

Benchmarking:

- Routine benchmarking of SMS (not just individual safety programs)

Improved Tools:

- Build safety metrics dashboard (partially completed)

 Establish Review Panel: Review COTS products and assess in-house soft-ware, 

make improvements as needed

SMS Continuous Improvement
Facilities Improvements ($9M)

• Fall hazard assessment for all buildings on both campuses

• Roof rail installation for all buildings where rooftop work occurs

Safety Staffing ($2.5M)

• Approval for 12 new safety staff

Safety Consultant Services ($1M)

• Assess OSHE staffing and recommend changes as needed

• Perform ISO 45001 Audit

• Work with OSHE to complete safety program development

• Evaluate improvement action plan and timeline

Resource Commitments
Leadership in Engaged and Sets Clear Expectations

 NIST Director held listening sessions focused on staff concerns

 NIST Director communicated expectations for Safety at NIST Town Hall

 Workshop on Safety Leadership, Incident Prevention for NIST Leadership 

Board

 Safety Culture goals discussed at all staff Town Halls

 Strategic Communication Plan for FY24

Accountability

 NIST performance agreements include safety element and required 

activities for supervisors, rolled out in FY24

 Annual Safety Rules of Behavior for all employees and associates clearly list 

basic rights and responsibilities, will be pushed out next week

Safety Culture Program

 Formal requirement for safety culture assessments, goals, action plan with 

employee engagement, recognition programs

 Update NIST General safety and Leadership Safety training modules

Sustained Safety Culture Focus
Safety Culture Improvement: Survey

 Conduct survey National Safety 

Council’s Safety Barometer

 Share the results, responses, how we 

compare to others with NIST staff

 Multi-OU, multi-level teams, from 

each campus studied survey results 

and developed action plan to 

address low scoring items

 Representatives from each team will 

present action ideas to NIST 

executives at a Safety Town Hall 

(tomorrow)
Safety Culture Survey: NSC Safety Barometer

2078 Federal Employees; about 66%

178 Non-Federal Staff; <10%

NIST scored in top 30% of 156 similar organizations; 

top 36% of 1,530 companies in the NSC database
Safety Culture Action Plan– Cross OU, 

Multi-level Teams

Survey Question Score Improvement Idea

The same basic precautions are used by employees 

who deal with hazardous materials

5.9% Introduce an annual training requirement of NIST staff.

Medical resources are sufficient for treating the 

injuries that occur.

12% 

(Boulder)

Establish equitable and unencumbered access to the Boulder Health Unit to meet 

NIST’s, NOAA’s, and NTIA’s needs

Management has published a written policy

that expresses their attitude about safety

36% Create an accurate, succinct, emphatic statement to express the value of safety at NIST. 

Update NIST policy to back it up.

Management has provided adequate staff to manage 

and support its safety program

36% Conduct an assessment to determine what constitutes adequate safety staffing levels 

in OSHE and the OUs, making additional safety hires based on the results.

Job performance standards for production/work 

output are higher than safety performance standards

36% Raise awareness of opportunities for NIST scientists (students through directors) to 

engage with OSHE on effective hazard review SOP development, approval. 

Develop safety objectives in all performance plans that are measurable and specific 

to each role.

The work of committees like the ESC, SAC, and OU 

Safety Councils improve safety conditions

25% Create, execute an enhanced strategic comms plan, building upon the results of an 

analysis of current communications plans for the ESC and SAC

Safety office has high status at NIST; safety reps 

(e.g., SPC, DSR) have high status at NIST

53% NIST

25% Boulder

Require demonstration of safety leadership as a prerequisite for promotion to 

leadership positions. 

The hazard review or JHA (job hazard analysis) 

process reduces risk associated with my work

7% negative; 53% 

agree; 40% neutral

Optimize hazard review process across NIST Labs for usability, safety benefit, and 

time invested.
Incident Data
FY23 Incidents: 166 Reports

Notes

1. Of 38 OSHA Recordable Cases, 27 were DART (Days Away, Restricted or Transferred), 7 non-COVID, 20 COVID

2. COVID: 31 of 33 Illness Cases were Covid-19; 23 of which were recordable

3. Of 25 recordable illnesses, there were 23 were COVID cases; one hearing loss case; one altitude sickness case

Type Number of Cases # of Affected Staff OSHA Recordable 

Cases

Injury 45 46 13

Illness 33 41 25

Near Miss 49 0

Property Damage 12

Contamination by Radioactivity 6 8 0

Spill/Release 10

Exposure 5 4 0

Other 6 0 0

Total Cases FYTD 166 38
10-y Trend in Total Reports

Total number of events reported 

has almost returned to pre-COVID 

numbers reported, but still lower

FY19, n=150 cases

FY23, n=135 (non-COVID) cases

0

50

100

150

200

250

FY13 FY14 FY15 FY16 FY17 FY18 FY19 FY20 FY21 FY22 FY23

IRIS Cases FY13 - FY23

Incidents COVID-19
Trends by Incident Type

Near Miss reports (n=49) 

similar to pre-COVID levels

Injuries (n=45) are still well 

below pre-covid levels 

(typically about 70)

Property damage reports 

(n=12) are lower than most 

pre-covid years

Non-COVID illnesses 

typically <10, FY23, n=2 0

10

20

30

40

50

60

70

80

90

FY13 FY14 FY15 FY16 FY17 FY18 FY19 FY20 FY21 FY22 FY23

Incident Type Trends, FY13-23

Injury Cases Illness Cases

Exposure Near Misses

Property Damage Spill / Release

Contamination by Radioactivity Other
0

10

20

30

40

50

OSHA Recordables 

Including COVID 

RC

DART

Fiscal Year

Number of cases

OSHA Recordable Cases with and without 

COVID cases

0

10

20

30

40

50 OSHA Recordables

– Not Incl. COVID

RC

DART

Fiscal Year

Number of cases
FY23 NIST-Assessed High Risk Cases 

Case Number

(*DART Case) Title Type

23-IG-0084 Unsafe Activity on Roof Due to Lack of Fall Hazard Mitigation Near Miss

23-IB-0022 Underground Power Line Struck and Damaged by Construction Equipment Property Damage

23-IC-0002 Over-pressurization of Bulk Nitrogen Storage Tank Near Miss

23-IG-0072 Fire in Lab During Testing of In-House Built Oven Property Damage

23-IG-0069 Occupational Hearing Loss Illness

23-IB-0017 Electrical Equipment Struck and Damaged by Paving Equipment Property Damage

23-IB-0016 Near Miss from Trip on Deteriorated Steps Near Miss

23-IB-0015 Utility Line Strike Property Damage

23-IB-0009 Electrical Near Miss in Cleanroom Near Miss

23-IG-0048* Employee Injured When Personnel Lift Falls of Truck Liftgate Injury

23-IG-0021 Employee’s Fingers Injured During Delivery of Pallet of Drums Injury

23-IB-0005 Diffuse Scattering During Laser Alignment Results in Extended Visual Interference Injury

23-IG-0008* Employee Strains Back While Removing Burner Barrel from Boiler Injury

22-IB-0011 Hazardous Gas Leak in Microfabrication Facility Spill / Release

High Risk is defined as: - Incidents with serious or catastrophic severity (actual or potential), with a likelihood of recurrence.
32

31

18

15

14

8

8

7

5

4

4

0 5 10 15 20 25 30 35

HAZARD REVIEW

COVID-19 HEALTH AND SAFETY PROGRAM

CHEMICAL MANAGEMENT PROGRAM

PERSONAL PROTECTIVE EQUIPMENT (PPE)

WALKING/WORKING SURFACE PROGRAM

MATERIAL HANDLING PROGRAM

RADIOACTIVE MATERIALS AT NIST 

GAITHERSBURG

ELECTRICAL SAFETY PROGRAM

NON R&D CONTRACTOR SAFETY PROGRAM

FIRE PROTECTION AND PREVENTION PROGRAM

CRYOGEN SAFETY PROGRAM

FY23: Top 10 Most Frequently Tagged Safety 

Programs

Incident Data Analysis by Safety Program

Hazard Review is a commonly cited program,

We find that many incidents could have been 

prevented by following requirements of an 

adequate hazard review. (up from 23 in FY22).

NOTE: In 7 Insights for Safety Leadership, the 

Krause Bell Group noted that insufficient hazard 

review is a common root cause of incidents. 

Chemical Management– 8 Spills, 3 Exposures

Walking/working surfaces– 10 STFs

Personal Protective Equipment – 8 Injuries, 3 

Contamination