This paper presents unique data on how occupational safety and health management, which is internationally mandatory, is implemented in practice in Sweden. The results are based on a research review of some 270 (mainly case) studies of how Swedish employers manage risks at work and thereby how they implement the provisions of systematic work environment management. The requirements of systematic work environment management are structured on three levels: procedures (what should be done), empowering actors (how to do it) and management control (doing the right thing). Implementation in practice is found to be best at the first level. Failure to ensure that there are capable actors (the second level) is widespread, and effective management control (the third level), such that systematic work environment management is effective against all risks at work, is rare. In practice, more systematic procedures have improved the prevention of technical risks, while poor management control has made it hard to tackle the widespread organisational risks of stress and musculoskeletal disorders. Finally, the paper discusses how the background of Sweden’s labour market and work environment system may at least partly explain this half-empty/half-full implementation of systematic work environment management reform.