The interim report of the Royal Commission into Australia's worst peacetime disaster has called for a radical overhaul of the bushfire warning system.
Major failings in the response of the emergency services meant that warnings were not passed on to the public.
The report recommends sirens to be used to alert residents to approaching fires, and a rethink of the controversial stay-or-go policy.
Though it stops short of recommending compulsory evacuations, it says the safest option was always to leave early and emphasised that not all homes were defendable.
During the inquiry it emerged that 113 people were killed sheltering in their houses, undermining the long-held belief that people save houses and houses save people.
The commission highlighted major problems at the incident control centre on 7 February, when it was not properly staffed and did not have a working fax machine or available computer.
This contributed to a failure to provide adequate and timely warnings to the public.
The day has become known as "Black Saturday" - the worst day of the bushfires that destroyed 2,000 properties in 78 communities, leaving 173 people dead.