Rail operator SMRT Corp has admitted that a failure to follow safety measures before allowing a work team onto train tracks had "directly" caused an accident which killed two of its employees last month.
The lapses included allowing a train to ply in automatic mode while workers were on site, not deploying watchmen to look out for approaching trains, and failing to provide early warning to the work team.
SMRT released the findings of its investigations in a statement yesterday, 34 days after workers Nasrulhudin Najumudin, 26, and Muhammad Asyraf Ahmad Buhari, 24, were hit by a train near Pasir Ris MRT station when they were on the track to investigate a technical fault on the morning of March 22.
The Straits Times understands a number of personnel had failed to observe safety protocol that day, but SMRT said no one has been singled out for disciplinary action yet.
The transport operator said the findings were part of an internal investigation which was reviewed by its board of directors as well as an external panel of three experts.
The panel said though existing mechanisms were adequate, track access management controls, communication protocols and track vigilance must be improved.
"Before a work team is allowed onto the track, protection measures must be applied," SMRT said.
This includes "code setting the speed limit on the affected track sector to 0 kmh so that no train can enter on automated mode".
This procedure was not followed on the day of the accident, when six signalling workers and nine track workers were on a maintenance walkway near Pasir Ris station to check on a possible fault in a component. As they approached the device, the signalling team, led by a supervisor, stepped onto the track "before protection measures were implemented", SMRT said.
"The supervisor narrowly avoided being hit by the oncoming train, but Nasrulhudin and Muhammad Asyraf, who were second and third in line, were unable to react in time."
The two young men were just two months into the job.
SMRT did not say why the work crew did not seem to notice the train till the very last moment, why the train driver did not see the men earlier, or why the train changed tracks at the site. It said its investigation report has been submitted to the police, Manpower Ministry and Land Transport Authority to help with their investigations.
The police said they are investigating the "unnatural deaths" of the two men, and had started interviewing a number of SMRT employees.
Transport Minister Khaw Boon Wan has said there will be a coroner's inquiry "in due course", and that if SMRT staff were found not to have followed safety procedures, they would be taken to task.
National Safety Council of Singapore deputy president Fong Kim Choy said: "For critical jobs, a permit to work has to be granted. And the manager or managers granting that permit will have to ensure that all safety measures are in place before the work can be carried out."
Meanwhile, Mr Nasrifudin, 33, Mr Nasrulhudin's eldest brother, said: "Since SMRT has acknowledged the mistakes and given us full support from day one until now, we don't think we will be taking further action at the moment."
•Additional reporting by Seow Bei Yi