What new do we learn from the commission's report? As Hanger acknowledges, three earlier reports had already covered much of the same ground: Allan Hawke's review for the Department of the Prime Minister and Cabinet (April 2010); a report from the Senate's environment, communications and the arts committee (July 2010); and a report from the Auditor-General (October 2010-11). The commission, however, has had the advantage of further hindsight and the capacity to question witnesses, together with the freedom to go into considerable detail. It was also able to address directly the concerns of the families of the four young men who lost their lives, in an admirably compassionate and non-partisan manner.

In broad outline, the commission adds little to what was already clear from its predecessors. The root cause of the home insulation program's problems was the conflict between its two main objectives: the insulation of over two million homes and the need to stimulate the economy though speedy public expenditure. A massive insulation program called for careful planning and measured implementation, particularly if assigned to a department (the then Department of Environment, Water, Heritage and the Arts) with little experience in program delivery. Economic stimulus, on the other hand, required rapid outlays of funds without delay. The imperative for speed, driven by the Office of the Coordinator-General, within PM&C, continually overrode any need for caution as urged by the Environment Department. As was to be expected, PM&C, backed by the prime minister's authority, prevailed over a line department, particularly one relatively lowly in the APS pecking order.

Two critical decisions stand out as directly due to time pressure: the shift in delivery mode from contracting with experienced installers to direct funding of self-identifying installers, and the removal of the requirement that all installers have installation-specific training. Undue haste also lay behind other factors, such as the perfunctory risk assessment process and the compliance audit system that contributed to the high level of incompetent installations, including the deaths of the four young installers.

The story is not new but is told in a clear and trenchant style, without the soft edges typical of even the best official Canberra reviews. Hanger is not afraid to name names and to apportion shares of responsibility and blame. He is particularly scathing of the risk assessment process, facilitated by the consultants, Minter Ellison, which consistently overlooked the risk to installer safety, in spite of clear warnings from those more closely involved with the insulation industry. Risk assessment, it seems, has become a generic managerial practice of applying universal templates and ticking boxes, without needing to call on the specific skills and technical experience of experts in the field.

The Environment Department's reliance on management consultants at several key points underlines the deceptive sense of security that such advisors can provide. Consultants may sound expert and offer a plausible covering for exposed backsides. But their expertise is often no greater than that of departmental officials and may be much less. When things go wrong, responsibility falls not on the consultants but on the agencies that unwisely employed them.

Lack of technical knowledge within the APS is a recurring theme, along with an even more worrying lack of concern about the risks of such ignorance. For instance, in the assessment of risks, officials (and consultants) paid much more attention to more familiar general risks such as fraud and delay, than to specific issues of occupational health and safety, which required familiarity with the installation industry.

Significantly, the royal commission's report is the first to examine technical matters in considerable detail. It devotes a whole chapter to industry regulations, such as electricity standards and wiring rules. It also examines carefully the use of one particular insulation material, reflective foil laminate insulation, which contributed to the deaths, and should have been banned much earlier than it was. Whether anyone involved in designing and administering the program was fully aware of these issues remains an open question.

Another area the commission emphasises is the role played (or rather not played) by the states and territories. At the outset, state and territory governments could have been called on to administer the whole home insulation program or at least to help with the roll-out. However, the Rudd government decided quickly that it did not wish to involve the states and territories as partners in the program, which would have imposed further delays (the speed factor again) and deprived the commonwealth of the full kudos of what was expected to be a popular government handout.

However, regulation of insulation installation, including OH&S issues, remained within the jurisdiction of the states and territories, and the Commonwealth showed no interest in taking over these functions. At the very least, therefore, the Commonwealth should have consulted and cooperated fully with the relevant state and territory agencies and should have offered extra resources. After all, as the commission points out, the program ended up with a massive 15-fold expansion in the number of annual home insulations nationwide. On any reasonable assessment, such an increase would overwhelm existing regulation and inspections services. In the commission's view, the federal government's abdication of responsibility for OH&S and inspection, combined with its failure either to warn or to materially help the states and territories, is a major failure of responsibility. It is hard to disagree.

Hanger suggests that, in hindsight, the whole program might have been better devolved to the state and territory governments, like the "building the education revolution" that was part of the same economic stimulus package. Alternatively, it could have been outsourced to experienced private installers (as in the Environment Department's original plan). His report is likely to be used as ammunition to support the recent national commission of audit's view that the Commonwealth should devolve or outsource all service delivery.

But such an inference goes beyond the royal commission's careful conclusions. The fault lay in imposing a very risky program on an inexperienced department against that department's advice, and in an irresponsibly tight time frame. Over the years, many federal departments have proved themselves fully capable of delivering services at least as efficiently and effectively as state and territory governments or the private sector.

If there is a lesson for the commission of audit and its supporters from this report, it lies not in any general incompetence within the APS but in the importance of basic bureaucratic values that Hanger argues were ignored: a concern for process and regulations and a willingness to insist that superiors pay attention to advice that runs counter to ministers' enthusiasms. Not that the business community will listen. Its members will continue to deplore public service red tape and risk-aversion while referring to the botched home insulation program as a leading example of APS inefficiency.

If the Abbott government had hoped to sheet home full responsibility to Rudd or his ministers, it will be disappointed. At the time, in opposition, they concentrated their fire on the environment minister, Peter Garrett, as a potential ministerial scalp. Garrett, however, emerges as the least culpable of the ministers involved: not strong enough, perhaps, in standing up to the centre, but poorly advised by his officials and selflessly drawing fire away from his leader. The junior minister in PM&C, Mark Arbib, who had responsibility for coordinating the stimulus package, comes out worst. He helped to override many of the Environment Department's reservations and, when questioned by the commission, seemed anxious to minimise his own personal responsibility. At several points, Hanger casts doubts over the reliability of his testimony.

Most of the culpability, however, lies within the APS itself, particularly within PM&C and the other central agencies that were caught up in the drive to get money into circulation quickly and who were too ready to dismiss contrary advice as bureaucratic risk-aversion. For many years, APS leaders had stressed managerial virtues such as flexibility, innovation and agility. PM&C secretary Peter Shergold, in the later Howard governments, often quoted the rapid organisation of the government's response to the Indonesian Boxing Day tsunami as one of the greatest successes of his tenure.

As the Rudd government's stimulus package began to roll out, Shergold's successor, Terry Moran, extolled publicly the swiftness with which the several programs were being planned and implemented. Ambitious public servants could not fail to get the message. Speed and can-do flexibility were the prized qualities for high-flyers, while caution and risk-aversion were for also-rans. This was the broader culture within which the numerous individual public servants who feature in the commission's report made the various unwise decisions that contributed to collective recklessness and failure.

The home insulation program provides a sobering reminder that the public service should not go too far in trying to adopt private sector attitudes to risk. Members of the public have a much lower tolerance of government failure than of private sector mistakes, particularly when lives are lost as a consequence. Opposition parties and the media lie in wait to capitalise on such intolerance.

Governments should follow their own version of the Hippocratic dictum: first, do no harm. That is, make sure no one is seriously injured or killed through any government initiative. Public servants must keep reminding their superiors of this injunction. If that makes them appear unduly risk-averse, so be it. The public demand no less.

Richard Mulgan is an emeritus professor with the Crawford School of Public Policy at the Australian National University. richard.mulgan@anu.edu.au