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The former government’s $2.7 billion Home Insulation Program (HIP) was “fundamentally flawed” and the deaths of four young men could have been prevented, according to the findings of a Royal Commission into the scheme which was tabled in parliament this week.

Commissioner Ian Hanger identified seven failings in the design and implementation of the program in a 360-page report which assessed workplace health and safety risks of the program which was introduced in February 2009.

The program was terminated on February 19, 2010 following the deaths of four young men, three who were electrocuted installing insulation and a fourth who died from heat exhaustion. In addition to the deaths, there were 224 house fires under the program.

Hangar said the decision to permit the use of reflective foil sheeting as ceiling insulation was “fundamentally flawed.”

“Reflective foil insulation - a dangerous and unsuitable product - should not have been used,” he said.

Even when problems with the use of metal staples to attach the foil emerged in October 2009, Hangar said nothing was done to stop the practice.

“The reality is that the Australian government conceived of, devised, designed and implemented a program that enabled very large numbers of inexperienced workers - often engaged by unscrupulous and avaricious employers or head contractors, who were themselves inexperienced in insulation installation - to undertake potentially dangerous work,” the Commissioner wrote.

“In my view each death would, and should, not have occurred had the HIP been properly designed and implemented.”

Despite electrical safety issues emerging after the first death, Hangar said insufficient action was taken to prevent further tragedies. He said planning was sacrificed for speedy stimulation of the economy with the government “unrealistically” adhering to a “practically unachievable” start date of July 1, 2009.

“This urgency seems to have infected the entire program and caused less than adequate attention and consideration to be given to questions of risk generally, of personal safety and compliance,” Hangar said.

The original aim of the program was to retrofit insulation into every Australian home, or about 2.2 million dwellings, in just 2.5 years.

Hangar said this was a dramatic escalation of the existing industry and the federal environment department was “ill-equipped” to deal with a program of such size and complexity.

He criticised the government’s decision to relax training and competency requirements. Without a robust compliance regime in place, large numbers of inexperienced and untrained workers were getting into dangerous roofs.

“The causes of failure of the HIP were multifactorial. Overall, it was poorly planned and implemented,” the Commissioner said.

Findings of the $20 million Royal Commission were tabled in parliament by the Prime Minister Tony Abbott who said the report details a litany of failures and highlights the dysfunction of the former government.

“The government’s response will focus on ensuring such a catastrophic policy failure never happens again,” Abbott said.

Opposition Leader Bill Shorten said the focus should be on lessons learnt from the report and improving safety, not engaging in a political blame game.

Recommendations at a glance

The Commissioner Ian Hangar has recommended that future large-scale government programs like the HIP should include a succinct and candid assessment of the skills needed for implementation including expert advice from experienced staff.

Hangar also recommended a new False Claims Act to penalise companies that defraud government programs.

The inquiry heard evidence that $24 million worth of fraudulent claims against the insulation program were written off by the government.

Other recommendations include: a new minimum standard of qualification for all workers in roof cavities; reflective foil laminates to be banned in retrofitting ceiling insulation; consideration should be given to taking action against public servants who failed to act with care and due diligence during the program rollout and; public servants to comprehensively brief ministers on risks and flaws of future programs.