• recommendation layers;
  • underlying cause;
  • top managers' attitude;
  • societal safety management


Trevor Kletz belongs to the pioneers in root cause analysis of accidents. This article summarizes Kletz's approach to accident investigations, and it points out that his approach has some gaps that sometimes need to be addressed. These gaps seem to be related to certain assumptions taken for granted by Kletz but not always fulfilled in the real world. In general, Kletz assumes that professionals and leaders are honest and responsible. In fact, Kletz deliberately strives to avoid “blaming.” Therefore, Kletz gives no guidance of what to do when leaders' negligence contributes to an accident.

This article expands the Kletz approach to include this aspect of process safety. Two acronyms are used to describe the difference between the Kletzian (more ideal) and non-Kletzian world. The engineering approach that follows Mr. Kletz's vision is depicted by the word RUDE, where R is for Reliable equipment—the need for engineers to provide R; U is for Understanding it—the need for engineers to understand the properties, hazards, and correct use of equipment; D is for Disciplined personnel—the need for leadership to select and support D, E is for Empathy—the need for leaders to recognize the deficiencies and incompetence of their employees.

An expanded approach is depicted by the word RUDENESS, where NE is for Navigators in Ethics—the need for the leaders of society to act as role models and stress ethic fundamentals of process safety, and SS is for a Safety-demanding Society—the need for both government and the governed to place a high priority on safety performance with appropriate laws and standards. © 2012 American Institute of Chemical Engineers Process Saf Prog, 2012