A broken fence two “train surfers” used to get onto tracks before they were electrocuted went unrepaired for two and a half years.
Ben Haddon-Cave, 27, and Patrick "Paddy" Bolster, 26, died after climbing on top of a freight train between Hackney Wick Station and Stratford in the early hours of March 21.
The pair reached the train through the damaged barrier leading onto the tracks, St Pancras Coroner's Court's Mary Hassell heard during the inquest into their deaths.
The hearing revealed the broken fence was checked in October 2016, but Network Rail staff missed the gap because it was hidden behind dense vegetation during inspections in 2017 and 2018.
In a prevention of future deaths report, Ms Hassell states: "[R]easonable endeavours had not been made to inspect (and repair) the fence."
The inspectors also didn't check it from the other side - which they "could easily have done" - or make a paper copy of their report.
Without that copy, a track engineer and internal auditors couldn't see evidence of the failure or challenge the inspection, the report states.
Network Rail's original investigation following the deaths was "inadequate" with system failures only discovered during August's inquest, the report says.
Ms Hassell has written to Andrew Haines, Network Rail's chief executive, slamming the railway infrastructure owner for not knowing if its nationwide system of fencing inspection is a failure.
The report says: "Network Rail had been operating on the basis this was a localised problem. Yet the reality is that [it] does not know if it has a national system failure of fencing inspection.
"Paddy and Ben were adults who had responsibility for their own actions, but the fence gap was accessible to children and appeared to be worn."
Ms Hassell adds there was no evidence the two planned to go onto the tracks: "A determined effort can be difficult to thwart, but an impulsive action (with judgement and motor skills impaired through alcohol) might well be avoided if the route to danger is not so very easily taken."
Mark Budden, Network Rail Anglia's route director, said: "'We are deeply sorry two people lost their lives on the railway and my thoughts are with their family and friends at this difficult time.
"We take incidents of this nature extremely seriously and are carefully considering the coroner's recommendations."
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