Not enough was done to prevent Victoria's $100 million coalmine fire and residents should have been told earlier to get out of the town blanketed by toxic smoke and ash for 45 days, an inquiry says.
A report found the Hazelwood mine fire was foreseeable and could have been mitigated, if not prevented, if operator GDF Suez had taken better precautions.
"We know that GDF Suez didn't take as many precautions as they might have done to mitigate and reduce risk," board of inquiry member John Catford said on Tuesday.
"Whether those measures could have absolutely have avoided the fire taking hold in the mine is uncertain but certainly it could have mitigated the risks and perhaps it could have been brought under control faster."
The report said health authorities had enough information about the poor air quality to warn residents to relocate a week after the February 9 fire started, when the peak reading for a particular coal fire pollutant reached 28 times the advisory level.
"That first weekend was probably the weekend you could argue was a trigger for more active management and advice to consider relocating," Professor Catford said.
Vulnerable residents were not told to consider leaving until February 28 which the inquiry board said was too late.
The report said the basis for limiting advice to groups living south of Commercial Road was poorly explained and was perceived by the community as arbitrary and divisive.
"Empathy was also often lacking, particularly from some government spokespeople," it added.
The State Control Centre's request for advice and support from the Environment Protection Authority came too late and the agency was ill-equipped to respond rapidly, the report said.
Latrobe Valley Support Network president Simon Ellis said the recognition the health response was too slow was a vindication of residents' fears but the health department still wasn't moving quickly enough.
"They're still being slow on the preparing of the long-term health study, they're still being slow on testing the kids," Mr Ellis said.
The report said mine operator GDF Suez failed to take reasonable measures to eliminate or reduce the health and safety risks associated with a fire in the worked-out area of the mine.
It also failed to carry out a risk assessment that may have avoided or reduced the severity of the blaze.
GDF Suez said it has already undertaken a number of measures including removing vegetation and improving back-up power supply.
"We have identified a number of future actions from this incident and we are committed to working with all stakeholders to minimise the risk of a repeat of the unprecedented fire in the mine early this year," spokesman Jim Kouts said.
Voices of the Valley president Wendy Farmer said the government should have done a better job regulating the mine and the report didn't go far enough to address community concerns.
"The government has clearly failed in its duty of care to the community through a lack of oversight and regulation of the mine," Ms Farmer said.
"We need to know precisely what is being done to ensure that this disaster can never happen again."
Deputy Premier Peter Ryan said the report noted the government's emergency management changes generally functioned well during the fire.
"However, the government acknowledges that elements of the response could have been implemented more effectively," he said.
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