A QANTAS jet and an Emirates jumbo with a total of 443 people on board were on a collision course over Mildura when warning systems failed.
The Qantas 737 was heading from Sydney to Adelaide while the Emirates jumbo left Melbourne for Singapore.
They were flying at the same altitude and their flight paths were due to intersect when a warning system sounded at air traffic control in Melbourne.
But a newly trained controller's two calls to the Emirates 777 to change course were "not clear".
The controller also failed to focus enough attention on the potential disaster as the aircraft continued on their courses.
The air traffic controller eventually directed the Qantas 737 pilot to climb in altitude and turn away to avoid collision.
By that time, the distance between the two planes was just 6.7km - below the minimum 9.3km required.
The Qantas jet took evasive action almost two minutes after the conflict alert in the air traffic control centre was activated.
The near miss on September 3 last year was investigated by the Air Transport Safety Bureau.
Investigators found the controller had been confused by another traffic management issue earlier that day.
He was not clear enough in his calls to the 777 and did not place enough urgency on resolving the conflict, the report found.
The controller was stood down and ordered to have more training.
"The controller's de-confliction instructions were not heard by the crew of the 777. The audio replay indicated that the controller's transmission of the call sign of the 777 was not clear and distinct," the report found.
"The controller engaged in routine co-ordination with another controller regarding less critical traffic and did not assign priority to the aircraft in conflict."
The Qantas crew later reported they heard the controller attempting to call the Emirates jet and saw the convergence of flight paths on their plane's traffic alert.
Airservices Australia has amended part of its training to reinforce response requirements when flight path conflicts arise.
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