Singapore's rail authorities admitted a crucial failure in applying vital safety mechanisms led to the accident on the SMRT track near Pasir Ris last month that killed two maintenance workers.
SMRT said in a statement on Monday that a vital safety protection measure was not applied before the men stepped on to the track, eventually getting under the train that crushed them to death on march 22.
The public transport operator also said it is "comprehensively reviewing all its safety structures, processes and compliance" in the wake of the accident.
The report, which details the conclusions of the investigation into the accident, added that the "effectiveness of such protection before entry in to the work site was not ensured as required".
The crucial finding in the report is that the Signal team, led by the supervisor, stepped onto the track before protection measures were implemented on the fateful day.
SMRT said before a maintenance team is allowed on the tracks, certain basic safety measures need to be activated. These include setting the speed limit on the track to 0 km/h, barring entry of trains on automated mode and deploying watchmen to look for any approaching trains.
However, these measures failed on that day, leading to the fatal accident in which two workers -- Nasrulhudin and Muhammad Asyraf -- died.
"SMRT deeply regrets that the failure to apply a vital safety procedure led to the tragic accident on 22 March 2016," the statement said.
The men were part of a team comprising six signal staff and nine permanent way staff that was on duty to examine a signaling condition monitoring device which had deled a snag."The device had earlier registered a warning of a possible fault that could affect train service. The engineering team made their way to the device in single file along the maintenance walkway," the statement said.
While the supervisor narrowly avoided the oncoming train, his colleagues who were left on the track could not react in good time to save their lives, the statement added.