EHS Spotlight: Lessons Learned

Sep 25, 2019, 19:47 PM
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September/October 2019

ISRI’s new near miss reporting system allows members to learn from each other when they share their close calls and how they changed their operations in response.

Lessons LearnedNear misses in a scrap recycling facility are a gift, says John Day, ISRI’s EHS manager. They’re unexpected. You didn’t pay for them. And they can be of great value—if you know what to do with them.

Day defines a near miss as an “unplanned, unwanted event that disrupts work and could have damaged equipment or people.” Whatever happened “could have been a catastrophic event,” but it was not. Investigate near misses to the level of their potential, he says. Get to the root cause of the near miss, address what you learn, and prevent it from happening again. “Use it as a teaching moment, and share it widely within your organization and with ISRI,” he says.

Earlier this year, the ISRI environmental health and safety staff added a near miss reporting form to the ISRI website to facilitate that information-sharing, even if the sender wishes to remain anonymous. Contributors can also upload photos, video, or documents that provide more details. The EHS staff reviews submissions and posts them on a members-only part of the site ( Here’s a look at the dozen incidents reported as of mid-August (edited for clarity) and the corrective actions the members reported taking after each one. The key below indicates where the reporting company has uploaded supplemental material others can use for training and discussion.

Confined space

Incident: A torch operator cutting a 3-foot-diameter steel tube crawled inside the tube—without notifying anyone else—to cut it from the inside. Doing so created a confined space with a danger of smoke inhalation and burns from sparks and slag. Also, his location was unknown to others in the area, including material handler operators who could have lifted and moved the tube.

Corrective action: A nearby material hander operator reported the torch operator to management for safety violations. The supervisor met with the torch operator, explained the safety implications of his actions, and suspended him without pay for three days per company policy. The material handler operator suggested having all employees who are working around machines in the yard wear [special] safety-colored helmets to improve their visibility around scrap metal.

Emphasize that communication among the workforce is paramount. All employees must be empowered to “see something and say something” because it can prevent injury and/or save a life.


Incident: A shopping cart brought in as scrap had batteries in its wheels. These batteries caused a small fire that posed no risk but could have had major consequences had it made it into the scrap pile.

Corrective action: Educate employees and create awareness of this new hazard in this type of scrap.

Incident: A truck with an 80-cubic-yard trailer containing baled light iron was pulling off of the truck scale. An employee in the area reported on the yard radio that he smelled something burning. Just as the truck was nearing the exit gate of the facility, another employee noticed smoke rising from the trailer and radioed the driver to tell him to stop. Other employees reported to the scene with fire extinguishers. We cleared customers from the area and immediately dumped the load as the smoke intensified. A material handler operator segregated the light iron bale that was on fire from the rest of the load. Employees used fire extinguishers to put out the fire in the bale. The fire company arrived moments later and soaked the remainder of the load with water to prevent further smoldering. The fire originated from a battery attached to a motorized power chair.

Corrective action: Review the safe handling and packaging procedures of batteries of all varieties and review this report with all employees.

Incident: An employee emptied a Gaylord box of electric motors received from the company’s satellite facility into a bin and used a skid-steer loader to push the motors into a pile. The employee noticed that the pile began to smoke. Acting quickly, the employee began to remove materials from the pile with the skid-steer loader and noticed that the pile contained two lithium-ion power tool batteries. One of the batteries was melting and smoldering. The employee pushed the small pile containing these batteries into an open area where a fire extinguisher was available. Another employee in the work area put out the fire with the fire extinguisher.

Corrective action: Review the safe handling and packaging procedures of batteries of all varieties and review this report with all employees.

People-machine interface

Incident: Two customers were unloading a truck in the peddlers area. One customer, in the bed of the truck, handed a bicycle to the second customer, on the ground. The second customer proceeded to mount the bike and ride around the yard near the unloading area. The customer rode the bike in front of a loader that was turning to go to the south area of the yard. The loader operator had to immediately stop.

Root cause: Inadequate control of visitors to the yard.

Corrective action: Additional training to inspectors to make them aware of this unusual possibility with customers.

Incident: An employee was driving a forklift down the ramp into the nonferrous warehouse from the inventory scale area. The forklift was moving in reverse down the ramp into the building with nothing on the fork attachments. The operator began to raise the forks roughly 4-5 feet in the air while descending the ramp. As the mast extended to this height, the secondary cylinders for lifting began to engage, exposing the top portion of the fork mounting above the mast. As the employee attempted to drive through the doorway, this portion of the fork mounting hit the building. The impact dislodged a steel I-beam from across the top of the doorway, which subsequently dislodged the roll-down door from its mounting in a cinderblock wall. Pieces of cinderblock struck the forklift, but, luckily, not the operator. The impact caused damage to the dashboard and LED screen of the forklift.  

Corrective action: Safety stand down and retraining for all mobile equipment operators. 

Incident: A forklift operator was loading a trailer at a nonferrous warehouse loading dock. While the forklift was backing out of the trailer, three employees crossed behind it on foot while walking to the time clock and lunchroom. One employee was almost run over by the forklift.  

Root cause: There was no defined walkway to the time clock for employees. The area was a shared space for walking and driving. The forklift was backing out of the trailer and the driver did not see the employees.

Corrective action: We consulted employees for their needs and ideas. We controlled the hazard by designating a walkway and installing a protective barrier for pedestrians walking to the time clock and restrooms.

Incident: A forklift operator started the machine without performing an inspection. The operator parked the machine on a sloped loading dock plate that was not returned to its cradle. The forklift’s emergency brake was faulty, and the forklift rolled off the loading dock and flipped over, striking the ground.

Corrective action: Emphasize that pre-trip and post-trip inspections are mandatory. Create a method of checks and balances to ensure compliance. Review inspection policies with employees. Review equipment p.m. maintenance with staff. Be certain all safety equipment is fully functional.


Incident: A loader operator was offloading a large piece of scrap from a flatbed truck. His attempt to lift the item caused the loader’s back tires to rise off the ground. The flatbed truck driver pulled away, causing the weight of the scrap to tip the loader all the way forward and drop the load, at which point the loader slammed back down on its rear tires. The operator was uninjured, but a serious musculoskeletal injury could have occurred.  

Corrective action: The company has reiterated that the failure to follow the clearly established procedures during heavy lifts has the potential to result in serious incidents.

Incident: A truck dumping a load of scrap pulled away from the unloading area with its dump bed in the raised position. The front part of the load was stuck in the truck bed and did not unload. The container fell off the side of the trailer, spilling the remainder of the load and narrowly missing an employee nearby.  

Corrective action: Loading was moved to a less congested and flatter area. The safe distance for the spotter was changed to 75 feet from the vehicle. 

Incident: A forklift operator attempted to remove a Gaylord box of cans from a storage rack. The forks did not extend far enough into the pallet to pick up the load securely. The load caught on the storage rack and nearly pulled down the entire rack. Lack of personal protective equipment could have resulted in injury.  

Corrective action: Secure the rack to the floor. Instruct all to stop and contact supervisor when load becomes unstable. Use proper PPE.

Incident: A tractor-trailer was parked in preparation to dump its load. The yard jockey radioed for the driver to move the tractor-trailer to make way for another trailer coming off the scale. He learned that the driver was in the maintenance office. 

Noticing that the load to be dumped was still covered with netting, the yard jockey decided to remove the netting while waiting for the driver to come back. When the netting got caught on the trailer, the yard jockey climbed on the trailer. 

The driver returned to his truck and started moving it, not realizing the yard jockey was on top of the trailer. The truck moved approximately 20 feet before the driver realized there was a person on his trailer. He immediately stopped, put the truck in park, and assisted the yard jockey in uncovering the load and getting down from trailer.

Corrective action: No one should have been on top of the trailer. Temporary netting is designed to be cut and pulled off of the trailer from the ground or to break away in the course of dumping. Operators should do a 360-degree walk-around of their equipment to inspect it for safety hazards before operating it. The yard jockey should have locked out the truck by removing the keys from the ignition and putting them in his pocket if he absolutely needed to climb on the trailer.

ISRI’s new near miss reporting system allows members to describe close calls and share how they changed their operations in response.

  • 2019
  • Sep_Oct

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