Two internal reviews found a ticket inspector who slammed a teenage girl on her back over a $2.50 fare evasion did nothing wrong.
But a Victorian Ombudsman's report found the officer used excessive force to bring down the 15-year-old girl at Flinders St Station in July 2013.
The girl was tackled after going through a gate, thrown on her back and held down by three men for more than eight minutes.
"(He) picked me up and he threw me on the ground and virtually nearly broke my back," the girl said, according to the report.
"I couldn't breathe. I couldn't move. I was screaming."
Victorian Transport Minister Jacinta Allan has demanded to know why two previous ombudsman's reports into ticket inspectors using excessive force have been mostly ignored.
"It's distressing to see the sort of footage that accompanies this ombudsman's report today and we want to see improvements into the future," Ms Allan told reporters on Thursday.
She also asked the department why an internal review exonerated the officers, despite not interviewing the girl or independent witnesses.
A second internal review again gave the officers involved a free pass.
"It is disappointing that the use of force by authorised officers continues to be a issue despite two previous investigations and repeated recommendations," Ombudsman Deborah Glass' report said.
She recommended Public Transport Victoria take over recruitment and training of ticket inspectors, which PTV has agreed to do.
The ombudsman said ticket inspectors only received half a day of practical training in how to use force.
Two of the officers involved said they picked up restraint techniques on an ad hoc basis.
Ms Glass found excessive force was used by one inspector, and the girl's human rights were "degraded".
Greens leader Greg Barber said ticket inspectors should sell tickets or become regular station staff.
"They have already been given the equipment to take payments for fines on public transport, so should be able to help people buy tickets," Mr Barber said.
Ms Allan said most ticket inspectors did a good job in difficult circumstances, but they needed appropriate training.
She could not confirm if the officer was still working, or if girl had received an apology.
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