The Swedish Accident Investigation Board (SHK)'s investigation leader, Eva-Lotta Högberg, concludes that safety deficiencies occurred at all stages - from planning to execution.
To carry out work at this location, it would have been necessary to close this track, she says, as an example.
The track was not closed.
SHK recommends that the Swedish Transport Agency supervise how the Swedish Transport Administration ensures risk control among hired contractors.
In April last year, two men checking inspection notes were hit by a passenger train. One, a man in his mid-20s, died, and the other, a man in his 30s, was seriously injured.
