The first report into the Grenfell Tower fire in London has concluded that fewer people would have died if the London Fire Brigade had evacuated people earlier.
The report praised the bravery of individual firefighters but criticised fire brigade management over the lack of a plan to evacuate the tower.
It noted that the organisation's "stay put" strategy meant that residents were told to stay in their flats by emergency services.
This meant residents were told to remain in their flats by firefighters and 999 operators for nearly two hours after the June 2017 blaze started.
Inquiry chairman Martin Moore-Bick said the organisation's preparation for a fire like the one that broke out in Grenfell was “gravely inadequate,” with the absence of an evacuation plan a “major omission.”
Survivors of the disaster welcomed the report as “strong and fair.”
Natasha Elcock, chair of Grenfell United survivors group, said she was happy with the findings of phase one.
“The report has been quite damning of the leadership of the LFB and quite rightly so,” she said.
“There were issues on the night with the fire brigade, definitely not those on the ground - I was rescued by them so I am eternally grateful that those firefighters risked their life.
“But it's definitely around the leadership. The higher up the chain.
“It's around the training and it's around this institution that believes that they can't do nothing wrong and it's about time that changes.”
The head of the London Fire Brigade said she will not resign despite the criticism.
Dany Cotton said that "it's important for me to continue to protect the people of London".
The report concluded fewer people would have died if residents had been evacuated while it was still possible - within an hour of the blaze starting - and if "serious shortcomings" had not plagued the fire service's response.
She said it was "very difficult to reach that conclusion without understanding fully how the building performed on that night".
Ms Cotton pointed out that over the last five years, there have been more than 5,000 high-rise fires in London and for virtually all of them "stay put" has been the "right policy and has protected the people in those buildings".
However with Grenfell she admitted she would do things differently now, knowing about the tower block's "highly flammable cladding and all the fire safety breaches", adding "we've got different steps in places".
The fire was started by an electrical fault in a large fridge-freezer in the kitchen of flat 16, for which the resident bears no blame, according to the report.
It said the "principal reason" the flames shot up, down and around the building so quickly was the combustible aluminium composite material cladding with polyethylene cores which acted as a "source of fuel".
And there was "compelling evidence" that the tower block's external walls did not comply with regulations.
The report accused Ms Cotton of "remarkable insensitivity" after she said at the inquiry she would not have done anything differently on the night.
Speaking on Wednesday, Ms Cotton said: "Clearly knowing what we know now about the building and about ACM cladding we would do things differently.
"But the one thing that I want to make clear is if I caused any additional hurt or upset to the people of Grenfell that was never my intention."
She added of her comments: "I regret they caused offence."
Mr Moore-bock said the testimony evidence “only serves to demonstrate that the LFB is an institution at risk of not learning the lessons of the Grenfell Tower fire.”
Ms Elcock said it was “disgusting” to hear Ms Cotton’s testimony after so many people died.
“You can't say there is nothing you wouldn't change,” she said. “There are clearly lots and lots of failings, including herself.
“For me, we need to question whether she should still be in that job.”
The second phase of the inquiry will examine the circumstances and causes of the disaster.