Open Journal of Safety Science and Technology, 2012, 2, 16-24
http://dx.doi.org/10.4236/ojsst.2012.21003 Published Online March 2012 (http://www.SciRP.org/journal/ojsst)
Engineering Management Framework to Achieve Safety
of a Service of an Organization Based on
Yuichi Otsuka1*, Hiroshi Noguchi2
1Top Runner Incubation Center for Academia-Industry Fusion, Nagaoka University of Technology,
2Faculty of Mechanical Engineering, Kyushu University, Fukuoka, Japan
Received November 13, 2011; revised December 19, 2011; accepted December 28, 2012
We aim at a management framework of an organization in order to achieve its safety in a limited case for a system in-
volving the organization for the service, its users and the surrounding society. The proposed framework is possible to
allow safety managers to specify tasks involving safety measures based on the concept of “a study of safety”. In the
beginning, we discuss the definitions of safety and acceptance, which will be the target of safety management. Next,
problems in which the hierarchy of components in the safety systems involves are noted. We then propose the following
details of the management framework to achieve the safety of the service of the organization based on acceptance by the
surrounding society. Applications of the components in the proposed framework are effectively demonstrated. The
shown application can aid in visualizing a way of specification of the proposed concept in a target system.
Keywords: Safety Theory; System Management; Organizational Safety; Incident Report; Safety Rule; Hierarchy
The extents of accidents within systems have become
more serious according to the increases in complexities
of the systems . In a hierarchical structure composed
of humans, the structure amplifies the effect of human
errors by its complexity and finally results in an organiza-
tional accident. As a precaution to prevent a serious ac-
cident, the safety management involving a reduction in
the occurrence of errors and the detection of errors before
resulting in damage to the victims is indispensable. For
the former factor, the concepts of human factors and stan-
dard safety measures for them have been studied [2,3].
Regarding the concept of the human factors, human errors
emerge due to various causes in their workplace. A safety
management system should then be constructed on the basis
of the considerations for cognitive and physiological cha-
racteristics of humans. Considering the latter factor, the con-
cept of a man-machine system  to optimize the inter-
faces between the both has recently been investigated.
Furthermore, the concept of complexity adaptive system 
based on the theory of complexity  has been proposed.
This concept is applied to some cases in designing safety
systems for patient safety management . In other words,
the activity for establishing the constructing policy of
safety systems is in progress.
Murakami has proposed a “safety theory”  as the
universal concept of safety. He argued that safety itself is
a value and that the “safety theory” should become meta-
science integrating normal safety engineering and social
science. Axelrod  also showed the management frame-
work of a complex organization whose purpose is not
limited in achieving safety. On the other hand, Tominaga
 discussed his theory of structural variation in which
an observer within the system can organize the force of
structural variation. This point indicates the necessity of
including the interactions in workplaces (among workers
practicing safety rules) in the process of achieving safety
of the system. However, the framework in which the
view of utilizing this bottom-up interaction is involved
has not been established.
The concept of the “safety theory” normally includes
the following elements.
1) The design concept of reliability and safety engineer-
ing including fail-safe and foolproof characteristics [8,9,11].
2) Incident reporting [2,12].
3) The concept of safety climate [13,14].
4) Risk communication [8,15].
There are many examples of the elements such as safety
audits in nuclear plants  or marine plants , an
incident reporting system in aviation safety  and the
opyright © 2012 SciRes. OJSST
Y. OTSUKA ET AL. 17
investigation for cognitions of risks in nuclear plants .
An integrating framework of these elements to establish a
safety management system is necessary in the case where
someone applies the above concept to a practical organiza-
Horii et al.  have reported a concept of social tech-
niques for safety involving visualization technique to the
structure of the problems and handling the situations of
society in order to take countermeasures for the problems
and evaluate those effects. Their study targets involved
various fields, and they reported remarkable results in
handling the complex structure, such as the structure of
emerging anxiety in humans due to the risks of nuclear
plants . Their major target was to enclose the problem
and unfortunately the management framework for the
systems as risk sources was little considered. If the in-
tegrating concept based on the above elements to specify
the framework of the “safety theory” under limited con-
ditions is established, it is possible to construct an effective
and applicable framework for safety management systems
in practical fields. However, to the author’s knowledge,
no investigation has been reported for an integrating
This paper describes an engineering management frame-
work for safety systems based on social acceptance for
the limited target including an organization providing ser-
vice, service users and the surrounding society. The pro-
posed framework allows the specification of the safety
management system in one application to become easier.
All of the elements in the proposed framework are pro-
vided as examples, in order to refer to the examples in
applications for other systems. Finally, we discuss the con-
sequence of our proposal for safety system management.
2. Definitions of Safety and Acceptance
At first, definitions for conditions of safety and accep-
tance are discussed using the simplest case shown in
These conditions emerge from the relationship between
two subjects in the figure.
Service subject: A subject who creates a service and
serves it for users.
User object: A subject who purchases the service or
considers utilization of it.
In the case where the service is one product, the service
subject is the designer of service and the user object is
regarded as a customer.
The service includes both its quality  and risk. The
involved risk may determine the expected damage to the
users. This relation can determine the condition for safety
Safety: The extent of the risks involved in the service
remains lower than the target level (Dtarget in Figure 1).
Figure 1. Definition of safety of service and acceptance.
The definition is based on the assumption that risk can
be calculated by the function of probability of an occurrence
and the extent of damage .
On the other hand, Slovic revealed that the subjective
risk that people perceive is different from the value of
objective risk calculated by statistical data . This fact
requires that the target of safety is also lower than the
value people accept. Consequently. the definition of accep-
tance is shown as follows.
Acceptance: The extent of the risks involved in the
service remains lower than the level acceptable to the
user objects (Dsub in Figure 1).
“Sense of security” has meaning similar to that of
“acceptance”. However, this term may lead people to
misunderstand that no risk is involved, which cannot be
achieved by any activities. The term “acceptance” is pre-
ferably used because it means that the user objects auto-
nomously judge the acceptability of a service by con-
sidering both its quality and its risk. The term “active
security” is also proposed ; however, it may have the
same meaning as “acceptance”.
The service subject provides a service to the user ob-
jects under the constraint condition Dtarget ≤ Dsub. To
specify the values in the equation, a proactive risk com-
munication must be practiced.
3. Considerable Aspects Emerge from the
Hierarchies of Subjects to Achieve
Safety in Social Acceptance
The service subject becomes a hierarchical organization
when he produces and provides a complex service .
This hierarchy may produce considerable new aspects as
shown in Figure 2 on the process to achieving safety.
3.1. Aspects Produced by the Hierarchy of
an Organization Creating a Service
We discuss the problems in a safety management process
using a simple hierarchical structure of an organization,
such as Safety manager-section manager-worker, shown
in Figure 2. The organization involves the following pro-
blems in safety management activities.
Copyright © 2012 SciRes. OJSST
Y. OTSUKA ET AL.
Figure 2. Considera ble pr oblems produc ed by the hierar chy
of the service subject and the user object.
3.1.1. Problems Involved in the Relationship
between a Section Manager and Workers
1) A section manager has difficulty in observing a de-
tailed (complex) condition in his workplace. He/she often
misunderstands that problems in his workplace are sim-
ply caused by errors of the workers. Furthermore, the sec-
tion manager also orders the workers to obey current safety
rules which have not properly adapted to the working
situations. These safety rules may be a significant work-
load for the workers, and the ambivalent relation between
safety and efficiency then becomes a considerable pro-
2) Workers often hesitate to report their errors to a
safety management section. This problem forces the safety
manager to handle the real tendency of errors occurring
in the workplaces and to analyze the causes of the errors.
This also damages the effectiveness or the acceptability
of safety measures proposed by the safety manager. Namely,
safety measures determined based on insufficient infor-
mation may involve difficulty in their practical efficiency in
real workplace. The safety rules may increase their load in
practice and produce many more errors or violations.
3.1.2. Problems Involved in the Relationship
Workers are unable to judge whether their workplaces
are objectively safe, because they have no target for com-
parison. This problem misleads workers into confusing
which practices in the workplace are really effective for
process safety. Furthermore, even if they collect numer-
ous error reports, they cannot perceive them as an alarm
that tell them the necessity of taking safety measures.
Because the errors are a usual event for them without
objective data. To make matters worse, these reports in-
cluding real errors by workers are often hidden by a sec-
tion manager, because he she may consider that these
reports are not very useful for neighboring sections.
3.2. Aspects Produced by the Hierarchy of User
Objects: As a Social Group
an evaluation. The constraint condition for safety-accep-
tance is then determined by his individual evaluation.
However, a social group, composed of various persons, is
a target as customers of the organization. The social group
has no autonomous subjectivity other than a set of indi-
vidual ones among its members. The organization then
has the problem.
A user object in Figure 1 has a single personal view of
3.3. Policies of Treatments for the
In sent should be neces-
ucting an improvement process for safety
4. Management Framework to Achieve
Fi ed management framework to
l structure by Safety Mana-
ety of persons who in-
ummary, the following treatm
sarily investigated in order to achieve safety of a service
based on social acceptance, as illustrated in Figure 2.
1) Establishment of a predicting method for a target
cial acceptance (if possible, a quantitative prediction is
les using incidents or occurrence reports.
3) Constructing an improvement method
ility of safety rules by treatment of worker’s percep-
tion to lessen the ambivalent relation between the safety
of service and the efficiency of the service.
Safety of a Service on the Basis of
gure 3 shows the propos
achieve the safety of a service of an organization based
on social acceptance. The proposed framework includes
the following participants.
r-Supervisor-Worker to provide a service for users.
Users group: A set of persons who have accepted
ality of the service and use it.
Surrounding society: A soci
uding both the organization and the users group. A
competitive organization providing the same services can
also be existed.
Figure 3. Management Framework to achieve the safety of a
service by an organization based on acceptance by a society.
Copyright © 2012 SciRes. OJSST
Y. OTSUKA ET AL. 19
We now discuss the procedure of operating the pro-
posed framework as the follows.
1) Communicating the quality of a service to the sur-
2) Determining the acceptance limit for the quality of
service by a society and transforming it into an organiza-
nal safety target. (Reliability and safety design, manu-
facturing and provision of a service under the safety tar-
3) Establishing a system for collecting failure informa-
ncidents or adverse events) inside the organization.
tions in the workplace by comparing
Limit for the
Thee of an organization
The ined by
4) Visualizing the problems in the safety systems based
on the collected incidents.
5) Introducing the safety measures for the problem by
a safety manager.
6) Improving the contents of the safety rules to optimize
the complex situa
the execution method among sections
4.1. Determining the Acceptance
Quality of Service by a Society
(Processes 1-2 in Figure 3)
attitude of a person for a servic
is determined by a judgment based on service informa-
tion, as shown in Figure 4. We simply assume that the
status of persons involves only two conditions, accepting
or rejecting. The status of persons can be changed by the
interactions (discussions) among persons . However,
if a target set for the quality of service is lower than one
characteristic value in the organization, the ratio of ac-
cepting person among total persons can be stable after a
sufficient number of interactions [23,24]. This value is the
acceptance limit of the society for the quality of the ser-
vice. The organization should determine its safety target
in order to satisfy the acceptance limit. This service should
be continuously accepted by the society to earn a suffi-
cient profit; otherwise the organization will be bankrupt.
4.2. Organizational Learning from the Collected
Incidents (Processes 3-6 in Figure 3)
process of achieving the safety target determ
the society is shown in Figure 5. Firstly, a collecting system
for failures in the workplaces must be established. Inci-
dent reports [2,18] are normally collected. In the intro-
duction stage of the incident report system, it should be
necessary to evaluate the usability of the system in order
for users to accept comfortably . Next, the collected
data must be analyzed to investigate the cause and deter-
mine the problem in the organization. The kinds of pro-
blems are considered such as human factors as well as
technical and management problems . Among these
three types of problems, the organization should take
measures for the management problem (especially relating
the safety rule and the management systems) because this
Figure 4. Determination of safety target of service by the
predicted acceptance limit of the surrounding group.
tendencies involved in the determined problems can be
wn measures or
ework of Learning
the ey decrease the occurrences of errors.
causes technical and human errors to occur. The repo
used to visualize the potential problems in the management
systems. If no measures have been introduced, the safety
manager should call the experts to analyze the cause and
take safety measures in the workplaces.
In introducing the safety measures, there are two cases
to be considered, such as the case of kno
w measures. The new measure should have no diffi-
culty in execution. In the latter case, the already practiced
measures were probably insufficient. To improve the meas-
ure’s effectiveness, the details in the measure should in-
clude consideration of them to the complexity in the work-
place. It is possible to improve the contents of the safety
measures in order to adapt for the complexity by collect-
ing practices in the workplaces and extracting its “good”
heuristics. In this process, by introducing the practices of
the safety rules, the details of the safety rules can be im-
proved sufficiently to attain both work efficiency and the
worker’s acceptance. These continuous treatments enable
a safety manager to establish the effective management
framework in which occurrences of human errors can be
reduced and damage to victims may also be prevented by
the certain detecting the errors.
4.3. On Evaluating the Fram
The evaluation of safety measures can be quantified by
xtent to which the
However, the evaluation cannot be avoided based on the
failure information that workers voluntarily report. The
case in which the change in the number of reports does
not correspond to the change in the practical number of
error occurrences is naturally predicted. If the safety mana-
ger decides that a lower number of reports is good for
organizational safety, the workers will more hesitate to
report, because the activity of not reporting will obtain
“good” evaluation by the manager. In this case, the differ-
Copyright © 2012 SciRes. OJSST
Y. OTSUKA ET AL.
ence between the number of reports and that of the
practical occurrences should be extended, and effective-
ness of the evaluation based on the number of reports
will be lost. Therefore, an indicator which can encourage
reporting by workers and express the decrease in damage
due to errors is necessary.
Continuously introducing safety measures in the work-
place may yield difficulty in determining the effect of
oncept of Acceptable
ordeworker’s acceptance, consideration for
dividual measures. However, it is not really necessary
to identify the effect of one safety rule or measure. Entire
evaluation of the whole framework shown in Figure 5
can be performed using the indicator mentioned above.
Furthermore, in the process of introducing safety meas-
ures, the supervisors in one workplace probably partici-
pate. Their judgment based on experiences in a complex
situation in the workplace can prevent bad measures
from being introduced.
4.4. Introducing the C
The contents of safety rules must be kept by work
r to obtain the
increasing the conscious effort to keep the rule is neces-
sary. Rule violating action is affected by both individual
factors and organizational factors. In Figure 5, the objec-
tive analysis by experts and practical heuristics of work-
ers can improve the contents of safety rules to become
acceptable and safe. By participating workers themselves
into the improvement process, the improved rule can be
better acceptable by the workers because of explicitly con-
sidering both the factors for rule violating actions .
The flow of the work above mentioned is continuously
practiced up to achieving the target of safety. It should
ted that the target itself may be changed according to a
change in the situation of a society. This point will re-
quire a safety manager to update the safety target in a
5. Case Studies for Elements in the
Figure 5. Safety management system to achieve safety and
accepted rule s.
safety the proposed framework
We provide example cases in engineering and
fields for each element in
to support specification of the proposed framework.
5.1. Quantification of the Target Quality of
Service: Prediction of the Acceptance
ka et al.  reported that the state of acceptance
a social group is that the ratio of accepting person for one
service can be maintained after sufficient interaction (dis-
cussion) among persons. An acceptance limit cost is also
defined as the maximum cost of the acceptance. Fur-
thermore, the prediction method for the value of the ac-
ceptance limit by combining simulations using cellular
automata and experiment with real persons to determine
the value of control parameters in the simulation. For exam-
ple, the prediction of airplane fares shown in Figure 6 is
conducted. The predicted value is accepted for almost all
examinees at that time. Using the prediction method and
modeling the interaction process among humans for one
group can quantify the acceptance limit of a service. The
proposed method is also applicable to predict the extent
of acceptable safety by one society.
5.2. Development of Incident Re
System for Enthusiastic Reporting
A web-based incident reporting system has b
oped in the patient safety field . In the development
stage of the system, the results of usability tests by real
workers which indicate a better functionality of the sys-
tem than that of a previous one may be effective to allow
workers to use new system. After introducing the devel-
oped system, a number of reports increased more than
50% after two years, which indicates efficiency impro-
vement in collecting failure information. This research can
Figure 6. Case study of predicting acceptance limit; permissible
cost of airlines fares .
Copyright © 2012 SciRes. OJSST
Y. OTSUKA ET AL. 21
be a reference in establishin acceptable reporting
bothhe decrease in the extent
get value of the horizontal axis is
system for practical workers.
5.3. Pattern Indicator for the Damage
Distribution of Incidents for Evaluating
the Entire Framework
The pattern indicator for the damage distribution of
nts shown in Figure 7 was proposed in order to ex
the increase in reports and t
of damages . The proposed indicator is defined by
the ratio of the number of reports for unacceptable damage
among the total reports. Figure 7 illustrates a predicted
correlation relationship between the proposed indicator
and the average numbers of reports for unacceptable da-
mage in the workplaces. The predicted relationship can be
observed in the incident data from one university hospital
. Using Figure 7 allows the safety manager to quan-
titatively evaluate the effectiveness of the entire safety
management framework by the changes in the value of
the pattern indicator.
The vertical axis in Figure 8 can be regarded as the
indicator of safety. If the safety target in the vertical axis
is determined, the tar
so determined using the regression line. Therefore, Figure
7 can transform the safety target externally determined into
an internal reporting target for the management sections.
Figure 7. Determination for comparing sections by pattern
Figure 8. Example of acceptable safety rule; checking with
patient by communication .
5.4. Improving Procedure for the Contents of
Safety Rules Using Incident Reports
By the analysis of collected incidents, causes of the inci-
dents relating to fails in checking, work process and others
were determined . The safety manager decided to select
one of the causes, “the failure in checking the contents of
drugs in distributing to patients” as one target of im-
proving. Comparisons between sections using the pattern
indicator and interviewing supervisors in the sections
could lead to an acceptable safety rule based on practical
s the job training concept in a design re-
vi al. .
ucing his knowledge and
heuristics, as shown in Figure 8. The resulting rule in-
volves the following considerations in order to satisfy
upervisor: The contents of the check safety.
Worker: Communicating to patients to handle their
conditions at the same timeof checking for efficiency
Patient: Accepting for participation in the checking
process by active communications from workers.
The framework in Figure 8 can be regarded as one
target of safety rules to be achieved. Using the pattern
indicator and comparing an empirical method for prac-
ticing safety rules in sections can enable visualization of
those acceptable safety rules.
5.5. Job Training Concept in Design Review
Process; Example of Acceptable Safety
Rule in Engineering Management
Figure 9 show
ew process, which is named Design Review Based on
Failure Mode (DRBFM), proposed by Shimizu et
fety and acceptance by all participants can be achieved
by the following.
Manager: Establishing the process of DRBFM for
precautionary prevention (Safety).
Professional adviser: Introd
experience to designers in the design review pr
esigner: Determining his lack of knowledge th
iscussion with the adviser (Acceptance).
Figure 9. On-the-job training in design review based on failure
Copyright © 2012 SciRes. OJSST
Y. OTSUKA ET AL.
Copyright © 2012 SciRes. OJSST
The type of the framework shown in Figure 9 is ob-
viously the same as that in Figure 8. This similarity can
support the applicability of the concept of an “acceptable
safety rule” for workers not only for patient safety fields
but also for other fields such as engineering management.
Consequently, the target of the safety management frame-
work is to improve the contents of the safety rules to be-
come an “acceptable safety rule” for workers in order to
achieve safety target.
the correspondence between the elements
lues in the axes in Figure 8.
ent relation between safety and efficiency of
the work probably becomes a considerable problem, as
e 10 . Namely, a worker may judge
5.6. Applicability of the Entire Framework
Table 1 shows
the proposed framework and the explanatory examples.
All elements in Figure 3 can be specified in a practical
management system because all of the elements possess
the correspondent examples. The functionality of the entire
framework should be discussed. The difficulty in the con-
nection between the second element and the third element
in Figure 3 is concerned, because these elements were
applied to different fields. However, both processes are
controlled using the va
We can then integrate the considered connection suc
cessfully using Figure 8. This is because Figure 8 ca
observed in a practical subject and can be utilized effec-
tively for safety management. Therefore, the proposed
framework is totally effective for achieving one safety
target and possessing a sufficient applicability to practi-
Workers should always obey one safety rule, because they
Table 1. Relationships between elements of the propos
cannot predict when they take an error . In some situa-
tions, an ambival
Element of the proposed framework Application 1: Engineer
illustrated in Figur
whether he keeps one safety rule by comparing the loss
due to the work load with the benefit of preventing future
accident using the rule. It is very easy for all workers to
perceive the work load. Unfortunately, cognition of the
benefit due to the rule greatly varies according to the
subjectivity of the workers . The less cognizant the
person is of the benefit of a safety rule, the more likely
the person will not keep the rule. The ordinary treatment
for this assignment achieves only a not-specific result,
“recommendation for obtaining the consciousness of prior
thinking for safety”.
The proposed management system model is a kind of
specified adaptive complex system model [6,7,31] to achieve
safety of a service produced by the system. The roles of
agents (workers, a supervisor and a manager) are deter-
mined, subject to the respective hierarchy of the system
structure. Heuristic practices will be examined by the
safety management activity for the purpose of improving
safety, efficiency and the acceptability of the safety rules.
These bottom-up activities will change the internal (safety)
rules in the organization, which means that the structure
of the system will have been slightly changed . The
described model in Figure 10 integrates internal (heuris-
tic) experiences and external objective knowledge to achieve
the condition of acceptable safety. This concept also cor-
responds to the internal interaction model in normal sys-
tem theory . This coherence supports the applicability
of the proposed framework to other practical fields.
ment framework and applications in engineering safety and
Safety Application 2: Patient Safety
1. Service information Risk and time for an airplane 
2. Acceptance limit Airplane fare 
eb-Based report system 
actors in safety rules for checks or specific
Monthly report of the incidents to workers
ble measures n-the-job training in DRBFM processes  s  found by
using the pattern indicator 
(2’: Reliability and Safety design for manufacturing and serving)
3. Incident report W
4. Setting problems F
5. Safety measures
6.Learning acceptaOHeuristic practices in workplace
Y. OTSUKA ET AL. 23
Figure 10. Concept of changing trade-off relationship for ac-
ceptable safety work.
The elements in the proposed framework have undergone
empirical case study in the field of patient safety manage-
ment or engineering management, which indicates s
cient applicability of the proposal to practical tar ets.
ules, can be specified in both fiel
he contents of safety ru
fe for workers. We have provide
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We have proposed the concept of a management frame-
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based on acceptance by a society. The proposed concept
includes collecting failure information and learning from
failures in order to improve tles to
be acceptable and sa
examples for all e
These examples can be useful in the case of application
to other practical subjects.
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