Liz Mackey, Ph.D., Chief Safety Officer

Director, Office of Safety, Health & Environment

Safety Update for VCAT

February 2023
 Status of 9/26 Incident Investigations

 Interim Follow up Actions

 New NIST Safety Culture Program

 Performance Metrics

 IT Application Integration and Improvements

 Risks and Opportunities

Agenda
 OSHA investigation ongoing; final report 3/26

 OSHE Deputy CSO is leading NIST safety incident 

investigation and root cause analysis team

 Fact-finding phase

• Document incident site

• Review documents, files, and communications

• Perform interviews with relevant staff

• 3rd party finite element modeling and failure 

analysis of pertinent structural components

 Analyze circumstances of event to determine contributing 

factors, root cause(s)

 Develop corrective action plan 

 NIST Executives review corrective action plan to ensure 

depth, breadth, and sustainability

Incident Investigations of 9/26/22 Fatality, Update from Oct

Completed or In progress
Safety Stand-down (October 7, 2022)

- Recommit to the basic NIST philosophy and policy of taking personal responsibility 

for safety of oneself and others

- Pause to think about how to perform work safely

Focus on Re-Review of Hazardous Activities in FY23

Accelerate Safety Culture Survey Launch (survey launched12/12/22)

Engage external Safety Commission to review safety program 

implementation and safety culture (January 2023)

Engage Subcommittee of Safety Commission to review quality, thoroughness 

of NIST investigation into 9/26/22 fatality and robustness of planned 

corrective actions

NASEM Workshop to evaluate the effects of the post-pandemic, hybrid work 

on safety culture, practices, training, mentoring in a research lab 

environment. (February 2023)

NIST Interim Actions To Improve Safety

Objective Strategy

Actions Evaluate

NIST Director FY23 Initiatives 
Chief Safety Officer provides guidance 

• Focus on activities with RHI=3, and RHI=2 with 

catastrophic, severe potential severity

• Fresh eyes, not the PI, previous reviewers

• Include technical and safety expertise

• Observe work, as feasible

Associate Directors (AD) ensure accountability

Office and Laboratory Directors report to ADs on 

progress target completion in Q3 FY23

Re-review of Hazard Reviews 

Potential Severity

Catastrophic Severe Moderate Minor

Frequent RHI=4 RHI=4 RHI=3 RHI=2

Probable RHI=4 RHI=4 RHI=3 RHI=2

Occasional RHI=4 RHI=3 RHI=2 RHI=1

Remote RHI=3 RHI=2 RHI=2 RHI=1

Improbable RHI=2 RHI=1 RHI=1 RHI=0

Likelihood of Occurrence

NIST Director FY23 Initiative 

Relative Hazard Index Matrix Adapted from ANSI Z10
NIST Safety Culture Program Elements

1. Define Safety Culture Attributes

2. Conduct a survey to assess beliefs

3. Develop Action Plan

4. Assess actions and behaviors

5. Recognize and reward safety 

improvements

6. Encourage engagement and 

participation

7. Sustain and improve through learning 

environment and questioning attitudes

Safety Culture Program Implementation

1. Leaders demonstrate they value safety through their actions 

and engagement.

2. Leaders, managers and supervisors set clear expectations for 

safety and exercise accountability.

3. Everyone at NIST takes personal responsibility for their 

safety and the safety of others. (NIST P 7100)

4. Everyone, at every level, participates in safety activities that 

help maintain and improve safety.

5. Everyone at NIST is vigilant in helping to identify and 

mitigate workplace hazards.

6. Safety is routinely part of the conversation to keep our focus 

on workplace safety, reinforce safety requirements.

7. Learning to work safely and improve safety is part of 

professional development throughout one’s career.

8. Employee safety and wellbeing are valued and supported 

throughout the organization.

9. Continuous improvement of safety is integral to operations.
NIST Safety Culture Program Elements

1. Define Safety Culture Attributes

2. Conduct a survey to assess beliefs

3. Develop Action Plan

4. Assess actions and behaviors

5. Recognize and reward safety 

improvements

6. Encourage engagement and 

participation

7. Sustain and improve through learning 

environment and questioning attitudes

Safety Culture Program Implementation

Number of federal employees 3440; 61% participation

NIST Director FY23 Initiative : Enhanced timeline
 Safety Management System (82% complete)

 Communications Data (average 70% click rates, webpage views)

 Training Data (course completion)

 Safety Culture Survey Results (every three years, issue 2023)

 Workplace Inspection Data (inspections, 96% closed deficiencies)

 Incident Reporting and Investigation Data (see comparison with peers)

 Corrective Action Data (92% completed)

 Monitoring Measuring and Assessments (under development)

 Corrective and Preventive Actions (under development)

 Management Observation Visits (no data collected at the NIST level)

Performance Metrics and Continual Improvement

Leading Indicators

Lagging Indicators

Under Development
Safety Management System Directives, Update from Oct

Effective and Deployed

Safety Programs (46)

Programs Under 

Development (11)

Resources 

Posted (6)

FUNDAMENTAL SAFETY (Total, 15 programs)

- Safety Culture (Suborder approved; training planned for 

NIST General Safety and Leadership)

- Contractor Safety

- Monitoring Measurements and Assessments (FY24)

- Change Management (OSHE Draft)

- Corrective and Preventive Actions (OSHE Draft)

- Documents and Records (Approved, training TBD)

TECHNICAL OCCUPATIONAL SAFETY AND HEALTH (Total 24 

programs; 6 resource pages)

- Electrical Safety (Notice)

- Walking Working Surfaces (Resource)

ENVIRONMENTAL (Total 14 programs)

- Gaithersburg Wastewater

- Boulder Wastewater (OSHE Draft)

- Stormwater Management (OSHE Draft)

Status Update
Communications in FY23 to date (2/1/23)

• Weekly emails to NLB, Incident Summary

• NIST emails to notify staff of changes in COVID 

Community Levels and mask requirements

• Safety Culture Survey announcements, reminders

• Safety Standard Newsletter (Issued in November)

• Incident prevention: safe disposal of sharps

• Winter weather safety, and NIST Library – OSHE 

collaboration on winter safety equipment
NIST General Safety

Total current NIST staff with records of completion: 4,130

- FY23: 150 to date

- FY22: 314

Total current NIST staff with outstanding training: 1,064

NIST Safety Leadership

Total current NIST staff with records of completion: 509 

- FY23: 7 to date

- FY22: 10

Total current NIST staff with outstanding training: 16

Safety Education and Training Cumulative Data 

80%

97%

Data from Jan, 30 2023
Comparison with Industry Standard and DOE Labs:

Total Recordable Case and Days Away, Restricted or Transferred Rates

0

0.2

0.4

0.6

0.8

1

1.2

1.4

2016 2017 2018 2019 2020 2021

NIST TRC and DART Rates vs NAICS 

Category

NAICS TRC NIST TRC NAICS DART NIST DART

NIST RC and DART rates compared with Bureau of Labor Statistics industry category for Research and Development in the 

Physical, Engineering and Life Sciences, and Dept. of Energy laboratories with similar work environments
Incident Reports FY23, to date (2/1/23)

Incident and Near Miss Type Number of 

Cases

OSHA 

Recordable 

Cases (DART)

Injury 11 3 (2)

Illness 9 6 (6)

Near Miss 6

Property Damage 2

Contamination by Radioactivity 0 0

Spill/Release 2

Exposure 0 0

Other 2 NA

Total Cases FYTD 32 9

*All illnesses are work-related COVID cases

** 2 DART injuries; 6 DART illnesses Total reports includes all incident and near misses 
OSHA Recordable Cases and Subset that Represent

Days Away, Restricted or Transferred

Recordable Illnesses: n=6 cases* all travelrelated, COVID illnesses

Recordable Injuries (n=3 cases):

- *Slip/fall in restroom results in 

concussion possibly due to wet footwear. 

Corrective Action: email sent to staff on 

situational awareness for potential slip 

hazards; info on winter safety and 

slipping hazards.

- *Back and shoulder strain during removal 

of barrel from fuel oil burner in facilities 

(under investigation)

- Laser eye injury: diffuse scattering during 

laser alignment results in extended visual 

interference. Interim action: medical 

attention. (under investigation)

*DART
 NCNR Director and CSO co-chair NIST NCNR Enforcement Actions Support Team

 CSO ex officio position on the TR-5 Safety Evaluation Committee (SEC) by charter

 New: OSHE Radiation Safety Officer serves on the Reactor Restart Subcommittee of the SEC

 OSHE Radiation Safety staff embedded in NCNR, OSHE general safety embed position posted

 OSHE staff participates on SEC subcommittee for 

 Qualification and Training Review

 OSHE safety embed in NCNR, position posted

 Participation in committees formed to meet CO

 Safety Culture Program (CSO)

 Employee Concerns Program (DCSO)

Ongoing OSHE Support for NCNR, Update from Oct
IT Applications: Improve Integration among systems

1. Embed Safety Training System link in 

MML HRA system

2. Expand My Safety Dashboard 

Capabilities- link to data

3. Door-signs are linked to Chemical 

Inventory to update NFPA 

information

4. Single database for all supervisor 

actions: inspection deficiencies, 

incident and audit corrective and 

preventive actions

5. Improve workplace inspection 

application 
Safety-Related Risks and Opportunities: 30,000’ View

Risks Opportunities

Ageing infrastructure Prioritize funding to address facilities issues; 

collaboration between facilities and safety

Safety Management System is not fully integrated 

into operations

Strengthen partnerships and provide safety services 

in a manner that facilitates integration

Finalize and implement new Change Management 

Program 

No audit or assessment program in place to assess 

safety compliance

Develop and implement Monitoring, Measurements 

and Assessment Program

Safety complacency Create conditions to strengthen safety culture, NISTwide, at all levels
Questions or suggestions?