Issued to: All Network Rail line managers, safety professionals and accredited contractors
Ref: NRL25-04
Date of issue: 08/08/2025
Location: M40 Northbound (Junctions 12–13)
Incident Summary
At approximately 0245 on Wednesday 8 May 2024, two Vital Human Resources Limited (VHRL) employees were involved in a fatal RTC on the M40 Northbound. Returning home post-shift from Hemel
Hempstead, their vehicle collided with the rear of a Heavy Goods Vehicle (HGV). The driver sustained non life-threatening injuries. Tragically, the passenger later died. Both had chosen to forgo their pre-booked
hotel accommodation to return home for personal reasons. This incident underscores the critical risks posed by fatigue, policy non-adherence, and gaps in monitoring and assurance.
During the investigation, the parallel police investigation meant the driver could not be interviewed, and the hire vehicle lacked telematics to support post-incident reconstruction. However, the revised Fatigue
Risk Index (FRI) score of 39.7% indicated a high risk of microsleep. Given the early-morning timing following a night shift and being over 60 minutes into a 90-minute journey, it is reasonable to conclude
that the driver’s alertness was likely impaired due to fatigue, even if the exact cause - such as microsleep or loss of concentration - cannot be definitively confirmed.
Behavioural and systematic insights
• Personal responsibilities (childcare, appointments) motivated a decision to return home rather than
rest.
• Night driving following a shift increased fatigue risk, equivalent in impairment to alcohol.
• Vehicle lacked data-capturing systems, limiting post-incident reconstruction and assurance.
• Sentinel swipe protocol was bypassed, impairing fatigue and attendance data quality.
• Policy assumed rest would be taken if provided - no check was in place to verify.
Key lessons
• Fatigue must be treated as a live risk, even below FRI trigger points.
• Behavioural choices under pressure (e.g. returning home) can override planned controls.
• Short-term hire vehicles must meet baseline monitoring requirements.
• Sentinel compliance must be actively monitored, not assumed.
• Booking rest does not guarantee rest - assurance processes must verify usage.
Recommendations and Local Actions
Network Rail
• Confirm Sentinel swipe-in requirement in Scheme Rules v5 and brief accordingly.
• Explore feasibility of validating hotel room usage as part of fatigue assurance
VHRL
• Review process for inputting shift data into PeopleSoft to ensure FRI accuracy.
• Install geofencing and telematics in all fleet and hire vehicles.
• Deliver refresher driver training on fatigue, post-shift travel risk, and lifesaving rules.
• Brief all drivers on consequences of non-compliance with rest policy and Sentinel protocol.
Key Takeaway
This fatal incident was not the result of one failure, but a series of unverified assumptions. Behaviour,
fatigue, monitoring gaps, and policy execution all intersected. Preventing recurrence requires not only
policies but living, verifiable compliance and behavioural alignment under pressure.