A review concerning road tunnel fire safety and risk is presented. In particular different perspectives and methods on safety and risk are discussed. Road tunnel fire safety usually involves high uncertainty and high-stakes decisions. Thus, a wider group of stakeholders and different types of knowledge should be included in the fire safety analysis and evaluation, than what is required by technical risk analyses. It is argued that the decision process should not be separated from the design and safety evaluation as they are strongly dependent and iterative processes. Decision theory can guide the design and decision process in negotiation with stakeholders. Key parameters for the decision can be analysed through a combination of functional requirements, societal and political values, safety engineering, safety factors and systems theory. By taking an organisational viewpoint, potential latent and active errors can be analysed and a good safety culture can be engineered. In order to improve the safety culture of truck companies, regulation ensuring proper maintenance, training and quality management may be necessary in a competitive global economy.