The "dysfunctional culture" of the Rudd government led to the botched home insulation scheme, Prime Minister Tony Abbott says.
Mr Abbott on Monday tabled the report of the insulation scheme royal commission, headed by barrister Ian Hanger.
"It details a litany of failures arising from a dysfunctional culture in the former administration," Mr Abbott said.
Mr Hanger was asked to examine how the Labor government assessed workplace health and safety risks of the program, which began in February 2009, and whether warnings were dealt with adequately.
Installers Matthew Fuller, Rueben Barnes, Marcus Wilson and Mitchell Sweeney died in 2009 and 2010, three by electrocution. The program was terminated on February 19, 2010.
The government is considering the findings and will initially report on its response by the end of the month.
"The report's findings are grave and its recommendations are detailed," Mr Abbott said.
Mr Hanger concludes in his report that the deaths were avoidable.
"In my view each death would, and should, not have occurred had the HIP (Home Insulation Program) been properly designed and implemented," the report said.
"The decision to permit the use of reflective foil sheeting as ceiling insulation was, in my view, fundamentally flawed."
He said the insulation industry at the time had been largely "unregulated" and to inject $2.7 billion into it so quickly and without proper planning was always going to carry "the risk of rorting and other unscrupulous behaviour".
The most critical issues had been the "inflexible" start date, the delivery model and the removal of the requirement for installers to have insulation-specific training.
However, Mr Hanger said it was not possible to isolate one error or failure that caused all of the problems with the scheme.
"Overall, it was poorly planned and poorly implemented."
A special cabinet committee comprising then prime minister Kevin Rudd and ministers Julia Gillard, Wayne Swan and Lindsay Tanner had taken an "unorthodox" approach because it was an emergency measure designed to combat the effects of the global financial crisis.
"What was contemplated was a fast and large-scale rollout," the report said of the body known as the strategic priorities and budget committee.
"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."
The report recommended that any future large-scale government programs include a "succinct and candid" assessment of the skills needed to implement them, undertaken by an agency head with advice from expert and experienced staff.
Mr Hanger also recommended a new False Claims Act to penalise companies that defraud government programs.
The inquiry received evidence that $24 million worth of fraudulent claims against the insulation program were written off by the government.
Opposition Leader Bill Shorten said he hadn't seen the report but what mattered to him was the tragedy of four people losing their lives.
"If there are lessons in this report which can improve safety so that other families never have to go through this again, then we will approach that appropriately," he told reporters.
"We are up for any improvements we can make to safety and the lessons. We are not up for a political blame game."
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