Three of the six elements of the DEGAS-circle are located mainly in the systems world, a virtual world, in which people analyze what happens and develop systems to ensure that everythng runs in the best possible way. The other three belong mainly to the physical wordl, the world of life, in which people actually do things. Line management connects these two worlds. The role of top management is to provide the space for becoming a Learning Organization by promoting a Just Culture.
The SHEQ-department (Safety, Health, Environment, Quality) does the analysis and develops rules and procedures that are tools. The toolkit they themselves use can contain items like Bow-Tie, TRIPOD, Lean Six-Sigma, and so on. But that is their toolkit and there is no need to bother actors in the first line, the people actually doing things in the physical world, with these. They just need the output: rules and procedures that work, that really help.
The first line actors need to have the necessary knowledge and skills, they need to report things that go wrong, they need to tell the story behind an occurence, and they need to ring the bell when rules and procedures developed in the systems world do not work as intended in the physical world.
Line management needs to make sure that the first line actors do have the necessary knowledge and skills and offer additional training when they don't, and they need to make sure the stories behind occurences and about unhelpful rules and procedures are told and reach the SHEQ-department for analysis.