Over the past decades, alongside advancing global industrialization, the modern HSE (Health, Safety and Environment) management system has evolved into a key governance tool for high-risk industries. A wide range of risk-based safety management frameworks have been established worldwide across sectors including oil and gas, offshore engineering, chemical engineering, power, shipping, aviation and nuclear industry. Typical examples include ISO 45001 for occupational health and safety management, the IMO ISM Code, API RP 75 Safety and Environmental Management Systems (SEMS), as well as long-standing safety best practices in the North Sea offshore sector. Thanks to these systems, modern safety management has gradually shifted from traditional post-incident response to systematic risk governance.

Nevertheless, a long-standing question remains largely unanswered: Why do accidents keep recurring in many enterprises with sound HSE systems in place?

Numerous companies that have suffered major accidents are not short of rules and regulations, nor do they lack risk awareness. On the contrary, many of them possess well-developed procedural documents, risk assessment mechanisms and internationally certified management systems. Even so, on-site violations still occur frequently, risk control measures often fail to work, and poor organizational execution has become a core bottleneck plaguing a great many enterprises.

The evolution of modern HSE systems is essentially a transition from experience-based safety to systematic safety.

In the early days, industrial safety relied largely on personal experience and passive rectification after accidents. With the advancement of international safety science, enterprises have gradually built systematic risk control frameworks via procedures, audits, risk assessments and standardized management systems. The adoption of numerous international standards has indeed boosted industrial safety performance worldwide.

Meanwhile, a prominent problem has emerged: Organizations attach growing importance to rule formulation, yet pay less attention to organizational behaviors themselves.

Many enterprises keep adding more procedures, forms, audits, inspections, KPIs and closed-loop management workflows. Safety management has become highly document-driven and process-oriented. Management tends to believe that sound regulations, frequent inspections and strict audits will inevitably lead to improved safety performance.

Reality tells a different story. Despite voluminous rules and documents, accidents keep occurring. In some cases, overly complicated systems become disconnected from on-site practices. Cumbersome procedures and impractical management logic leave frontline staff relying on personal experience rather than following established systems.

This has given rise to a typical dilemma in modern HSE management:

Organizations appear increasingly professional on paper, while on-site operations rely more on individual accountability.

Safety management in many enterprises has drifted into formalism.

Whether inspections are conducted, whether records are duly signed, and whether identified issues are closed out,

have become the primary metrics for evaluating safety work. Yet the core issue is often overlooked: whether the organization has developed consistent, stable and sustainable risk judgment capabilities.

In practice, managers, auditors and frontline supervisors often hold vastly different understandings of the same risk. A single hazard may be rated at different severity levels by different inspectors, and identical violations may receive disparate disciplinary outcomes across organizational tiers.

This indicates that despite extensive inspection mechanisms, organizations have failed to establish unified logic for safe work behaviors. This is the fundamental reason why HSE systems cannot be fully implemented in many companies. Safety management is never merely about what has been done; more importantly, it lies in:

A common misunderstanding prevailing in modern HSE management practices is that many enterprises equate compliance with safety. Consequently, organizations keep tightening audits, KPIs, procedures, records and closed-loop management, attempting to improve safety performance through stricter control.

The core problem, however, is that rules alone cannot drive people to consistently follow safe working practices. Without unified safety values embedded across the organization, all regulations will eventually become ineffective. When schedule, cost and production pressures mount, the organization will inevitably revert to its inherent value priorities.

This explains why many companies advocate "Safety First" on paper, yet still operate under the unspoken rule of "Production Comes First". Safety then turns into nothing more than an audit, compliance and administrative obligation, rather than a core value truly embraced by the organization.

A more concerning phenomenon is that most organizations still tend to penalize personnel directly responsible once accidents occur. Disciplining employees, tightening assessments and imposing harsher penalties have become the default management approaches.

Such practices usually lead to two negative outcomes.

First, employees start to conceal problems. Since the organization focuses more on identifying who is to blame than on discovering and resolving hazards, staff tend to cover up risks instead of reporting them proactively.

Second, inherent flaws within the organizational system remain hidden for a long time. If accidents are always attributed to individual mistakes, the organization will never conduct in-depth reflections on whether its rules are reasonable, training is effective, inspection criteria are consistent, management mechanisms are well-balanced, and the workplace culture genuinely underpins safety.

This is a major root cause of recurring accidents. The real goal of modern HSE management is not merely to reduce individual errors, but to build organizational mechanisms that foster sustained safe behaviors.

In this sense, an HSE system is essentially an organizational behavioral system, rather than a mere collection of documents. Safety performance is ultimately determined not by the number of regulations, but by whether the organization has established stable and consistent safety values and behavioral logic.

Advancements in modern safety science increasingly prove that all behaviors are ultimately shaped by organizational culture. It dictates the genuine choices an organization makes when faced with pressures related to cost, schedule and risks.

If an organization truly believes that personnel safety, health and dignity are non-negotiable, safe practices will gradually become the shared mindset of all members. By contrast, if the organization inherently prioritizes efficiency, no amount of regulations can foster long-term and consistent safe behaviors.

This explains why High Reliability Organizations (HROs) maintain an extremely low accident rate over time. Sectors such as aviation, nuclear power, deep-sea oil and gas, and aircraft carrier operations achieve high safety levels not merely by virtue of more rules, but by building robust capabilities for sustained safe performance across the entire organization.

Such capabilities rely not on individual regulations, but on organizational trust, effective leadership, unified risk perception, consistent conduct and cultural recognition.

From this perspective, the true value of the 2-4 Model extends far beyond accident analysis. It serves as a reminder to the industry: all accidents trace back to human behaviors, and all behaviors are rooted in organizational culture.

The evolution of modern HSE management does not diminish the importance of rules, procedures, audits and inspections. On the contrary, they remain indispensable foundations of a sound safety management system. Without regulations, an organization cannot maintain basic operational order; without standardized procedures, risks cannot be effectively identified and controlled; without audits and inspections, a fundamental risk management framework cannot be established. Therefore, the core issue is never whether rules are needed, but whether they are integrated into the organization's operational logic and translated into consistent and sustained safe behaviors among all personnel.

Many enterprises today are not troubled by the absence of management systems, but by a growing disconnect between established systems and actual organizational behaviors. On the surface, their HSE systems appear fully operational: inspections and audits are carried out on a regular basis, more forms are introduced, and procedures are further refined. Beneath the surface, however, employees fail to develop unified risk awareness and shared safety values. Consequently, safety management drifts into formalism: rules exist but are poorly followed; systems are in place yet supported by no genuine safety culture.

The 2-4 Model profoundly reveals the underlying logic behind such operational failures. Traditional safety management tends to address problems merely at the behavioral level. For instance, on-site violations lead to employee penalties, accidents trigger accountability investigations, and potential hazards result in more frequent inspections and assessments. The 2-4 Model, by contrast, clarifies that no behavior exists in isolation. Individual conduct stems from personal competency, which is shaped by management mechanisms, and all management activities are fundamentally governed by organizational culture and values.

Accordingly, effective safety management requires not a one-way control system, but a self-reinforcing and cyclical operational mechanism. If an organization prioritizes work progress and output above all else, such values will permeate management decisions, resource allocation, training investment and on-site risk tolerance, and eventually manifest as unsafe behaviors. On the contrary, when an organization embraces the consensus that life and safety are inviolable, this culture will guide rule formulation, management strategies, competency development and on-site implementation, fostering consistent and reliable safe work practices.

In this light, the 2-4 Model illustrates more than just how accidents occur. It uncovers the dynamic cycle that shapes and undermines organizational safety capabilities. Culture influences management, management shapes competency, competency determines behaviors, and the outcomes of behaviors in turn reinforce the prevailing culture and values. A vicious cycle will lead to recurring accidents, while a virtuous cycle helps safety capabilities become an inherent strength of the organization.

Therefore, the future of HSE management lies not only in improving regulatory frameworks, but also in building organizational recognition, unified risk perception, consistent conduct and continuous improvement capabilities behind the rules. Ultimately, an organization's safety performance depends not on how many regulations it has, but on its ability to maintain sound safety practices steadily and sustainably in the long run.