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From NPR News, this is ALL THINGS CONSIDERED. I'm Michele Norris.

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And I'm Melissa Block.

The federal government says a very simple mistake was to blame for the death of a woman a year ago in Boston's Big Dig tunnel. She was killed by a falling slab of concrete. And according to a report from the National Transportation Safety Commission, the bolts that held that slab up were tested for their short-term strength, but officials didn't consider how they would hold up in the long term. Big Dig contractors are facing a lawsuit from the victim's family and possible criminal charges.

NPR's Tovia Smith reports.

TOVIA SMITH: The report details a series of missteps and missed opportunities that led up to July 10th of last year, when 39-year-old Milena Del Valle ended up in the wrong place at the wrong time. Del Valle, a mother of three, was killed instantly when 26 tons of concrete fell from the tunnel ceiling onto her car. Her husband, who was driving, escaped with minor injuries. Investigators have spent the past year trying to figure out what went wrong.

Mr. MARK ROSENKER (Chairman, National Transportation Safety Board): Simply stated: what should people have known, when should they have known it and who should have known it.

SMITH: NTSB Chairman Mark Rosenker questioned his investigators today about their finding that no one in design, installation or inspection really considered how the epoxy used to secure ceiling bolts would deteriorate over the long term. Here's director of the Office of Highway Safety, Bruce Magladry.

Mr. BRUCE MAGLADRY (Director, Office of Highway Safety): Anywhere along that chain, somebody could have pointed out, you know, this stuff really shouldn't be used in overhead situations...

Mr. ROSENKER: Could have or should have?

Mr. MAGLADRY: Probably, should have, but in general terms, I don't think - they didn't know what they didn't know.

SMITH: The NTSB report traces an almost perfect storm leading up to the accident. There were decisions made to use much heavier concrete ceiling tiles, but also cut the number of bolts holding the tiles up. Then a decision to use a fast-set epoxy, weaker than regular glue, and to apply it bottom-up in the ceiling, which causes air bubbles and weakens the hold. On top of that, government officials failed to do necessary testing and when they did find trouble spots, they assumed they were isolated problems.

Mr. JEFFREY DENNER (Lawyer): That amazing saga of shame, and it's unbelievable what they knew, when they knew it, what they should have known and how little they did about it.

SMITH: Jeffrey Denner is attorney for Del Valle's family. He says the report bolsters the lawsuit that he's filed against a slew of companies as well as government agencies responsible for overseeing the Big Dig.

Mr. DENNER: From the time they opened to the public in 2003 to the time of the accident in July of 2006, not one inspection was done by Mass Turnpike Authority to even see how the anchor bolts were holding. It is absolutely unbelievable, and it only redoubles our efforts to make sure that Milena's death is not in vain.

SMITH: The company that oversaw the Big Dig, Bechtel/Parsons Brinckerhoff, called the report thorough, but declined to comment further, as did the other companies involved. Governor Deval Patrick, who took office after the accident, says the report confirms his disappointment with those who managed and engineered the project. His transportation secretary, today, conceded some state responsibility for inadequate inspections. Jack Lemley is an expert in tunnel building who was hired by the Turnpike Authority to investigate problems with the Big Dig, including a massive water leak. He says the biggest problem was lack of state oversight of the 15 billion dollar project and he doesn't buy the NTSB's conclusion that the Big Dig contractors didn't know enough about the epoxy they were using.

Mr. JACK LEMLEY (Tunnel-building expert): I think it's an outrageous statement particularly by worldwide organizations with enormous experience with all of these materials. Those are things that were very well recognized by the industry decades ago.

SMITH: In hopes of preventing a similar tragedy, the NTSB has recommended a series of steps, ranging from better warning labels on the epoxy that was used to expanded federal inspections of all tunnels and stricter standards on when and how epoxy can be used. Other tunnels from New York to Virginia use a similar suspension system, but carry a much lighter load and they also have backup supports in case the bolts start to fail - Boston's tunnel does not. It's a point likely to weigh in the minds of federal and state prosecutors who are considering criminal charges.

Tovia Smith, NPR News, Boston.

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