Victims say the blaze was a failure of an austerity-driven society, and hundreds more apartment blocks are at risk.

London, United Kingdom – A public inquiry into the Grenfell Tower fire in which 72 people died published its long-awaited report on the first phase of its probe on Wednesday.

The June 2017 fire that broke out in the 24-storey apartment block in Kensington, west London, was the deadliest incident to take place in the capital since the second world war. Eighteen of the victims were children.

The 935-page report reconstructs events as they took place on the night of the fire on June 14, with hundreds of testimonies from survivors, firefighters, emergency services and local authorities. It also relies on records of 999 calls and a range of fire and engineering experts to piece together how the fire started from a flat on the fourth floor and quickly spread to the whole building.

The report finds that the external walls of the Grenfell Tower failed to comply with building regulations. In particular, the building’s cladding and decorative features added as part of a refurbishment that took place between 2012 and 2016 were responsible for the rapid spread of the fire. This is likely to call into question the decision-making ahead of and during the $11m refurbishment – which will be the focus of the second phase of the inquiry, due to begin in early 2020 and report in 2021, four years after the fire.

While recognising the work of the firefighters who risked their lives on the night of the fire, and of the control room workers who had to deal with a high volume of distressing calls both from inside and outside the building, the report harshly criticises the response of the London Fire Brigade (LFB), which it says showed “significant systemic failings”.

The narrative starts from about 1am when Behailu Kebede, who lived in the flat where the fire broke out, called the emergency services. It describes how it took 15 minutes for the fire to reach the cladding, and just another 15 for the flames to reach the roof and other flats. The last survivor was evacuated just after 8am.

Institutional and corporate responsibility

In the first part of the report, inquiry chairman Sir Martin Moore-Bick says the “principal reason” why the flames spread so quickly was the presence of highly combustible material in the rainscreen panels that covered the building, which the report says “acted as a source of fuel”.

“The external walls of the building did not comply with the Building Regulations because they did not adequately resist the spread of the fire over them. On the contrary, they promoted it,” said Moore-Bick in a statement on Wednesday.

The architectural crown, a decorative feature added as part of the refurbishment, was also found to play a “significant role in enabling the fire to spread around the building”.

The report also confirms that the fire started because of an “electrical fault” in a large Hotpoint fridge-freezer in Kebede’s flat, but exonerates him from any responsibility – which is likely to prop up a multimillion-dollar lawsuit against the manufacturer, Whirlpool.

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Emergency response

In a damning reconstruction of the response of the LFB to the fire, Moore-Bick concludes that many lives could have been saved had the service revoked its “stay put” policy – advising occupants to remain in their flats until the arrival of emergency services – earlier.

The report finds that first incident commanders were of relatively junior rank and that they failed to identify the need for mass evacuation while it was still possible.

“Those who were liable to be called upon to act as incident commanders were not trained to recognise a fire in the external wall of a high-rise building, nor were they trained in how to respond to it,” Moore-Bick said.

“There was no contingency plan for evacuation of the tower and the LFB failed to revoke the ‘stay put’ advice at a time when the stairs remained passable.”

London Fire Commissioner Dany Cotton responded to the report in a statement: “Many of the recommendations are welcome and will need to be fully understood not only by the London Fire Brigade, but by government, every fire and rescue service and every residential building owner and manager across the country.

“But we are disappointed at some of the criticism of individual staff members who were placed in completely unprecedented circumstances and faced the most unimaginable conditions while trying to save the lives of others.”

Still awaiting justice

“Justice means different things for all of us but the truth needs to be at the heart of our collective healing,” the group Grenfell United, which represents hundreds of survivors and bereaved families, said in a statement on Wednesday.

“We have been waiting a long time for this report. Today’s findings give us some confidence that our journey towards truth has finally begun.”

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The group welcomed criticism of the LFB leadership, saying: “It is heartbreaking to read that more of our loved ones could have been saved that night if the building was evacuated earlier.” The group pointed out, however, that – contrary to media headlines following a leak before the official publication – the report says firefighters were “let down by their training, procedures, equipment and leadership”.

“One of the most worrying findings is Sir Martin Moore-Bick’s view that the LFB are currently an institution at risk of not learning the lessons from Grenfell,” said the group.

Hearings for this phase of the inquiry took place between May and December 2018, while its publication, originally due last spring, was pushed back – to the frustration of former residents and the victims’ families.

The report’s publication date – just ahead of a key Brexit deadline – was also criticised as an attempt to bury its findings.

The second phase of the inquiry will delve deeper into the issue of the building’s cladding, the certification of the materials used, as well as – crucially – the role of central and local government. The LFB will also be subject to further scrutiny.

The police are conducting their own, separate investigation, but said the public inquiry should conclude before charges can be filed.

The report makes a series of recommendations in relation to improving fire safety measures in high-rise buildings, communication and training of firefighters and support teams, as well as the testing and certification of materials.

Trade union Unite, which represents approximately 70 families affected by the tragedy, criticised the inquiry for being “back to front” – arguing it should have started by probing the events that led to the fire and its causes.

“It’s a terrible place to start,” Howard Beckett, Unite’s assistant general secretary for political and legal affairs, told Al Jazeera, adding the inquiry should move to its second phase “as quickly as possible”.

“We have over 400 buildings in this country that are still wrapped in exactly the same cladding,” Beckett said. “We’re almost three years on now, and if this inquiry had put that at the forefront, then the pressure could have been brought to bear to remove that cladding from other buildings before we have another catastrophe on our hands.”

In addition to assisting families in personal injury cases, rehousing and benefits, Unite is involved in legal action against US companies that provide materials such as those used in the Grenfell cladding to ban their export to the UK.

Beckett said that although former Prime Minister Theresa May set up the inquiry with the intention of triggering an immediate institutional response, this has not happened.

“And that’s a failure of government. It was a failure of an austerity-driven society that resulted in Grenfell in the first place, where greedy corporate companies, hand in hand with Tory councils, were able to get away with cutting the safety nets that were needed in a building such as this, putting up this cheap cladding that created an inferno,” Beckett said.

INQUEST, a charity that focuses on the issue of state-related deaths, has pointed out that recommendations on reviewing the “stay-put” policy and building regulations had been made following another high-rise fire back in 2009, when six people died at Lakanal House in south London.

“Families want to get to the truth of what happened, but they also want to make sure it doesn’t happen to anyone else,” Remy Mohamed, the charity’s Grenfell Project Coordinator, told Al Jazeera. The charity has called on the government to set up an independent public body to oversee, collate and monitor the implementation of any expert recommendations made after public inquiries or inquests.

“[They] are good methods if they’re run properly, making life-saving recommendations as they often do,” Mohamed said. “The problem is, these recommendations then sit on a shelf and gather dust.”