The London Fire Brigade breached national guidelines by failing to adequately prepare for the Grenfell Tower fire, a damning report has concluded.
Seventy-two people died in the fire that engulfed the west London tower block in June 2017.
Inquiry chairman Martin Moore-Bick said the LFB's preparation for an incident such as Grenfell was "gravely inadequate", and the absence of a plan to evacuate the tower was a "major omission".
However, because there was no attempt to carry out a managed evacuation of the tower, the lack of a contingency plan was less significant than the absence of training to help incident commanders recognise when this might be necessary, he said.
Some of the 46 recommendations he has made require "urgent action" from the British government and others with responsibility for the "oversight and direction" of the emergency services, he said in a letter to Prime Minister Boris Johnson.
One of the groups representing bereaved and survivors, Grenfell United, welcomed the "strong" findings, which "give us some confidence that our journey towards truth has finally begun".
The report concludes that fewer people would have died had residents been evacuated during the blaze while it was still possible and if "serious shortcomings" had not plagued the fire service's response.
It also accuses the brigade's commissioner, Dany Cotton, of "remarkable insensitivity" after she said she would not have done anything differently on the night.
Ms Cotton told the inquiry that preparing for Grenfell would have been akin to preparing for landing a spaceship on the Shard.
But Mr Moore-Brick said her evidence "only serves to demonstrate that the LFB is an institution at risk of not learning the lessons of the Grenfell Tower fire".
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Ms Cotton expressed her "deepest sorrow at not being able to save all those who died in the Grenfell Tower fire" and said the brigade was "disappointed at some of the criticism of individual staff members" in the inquiry report.
She said: "We will now carefully and fully consider all of Sir Martin Moore-Bick's Phase 1 report and take every action we can to improve public safety.
"Many of the recommendations are welcome and will need to be fully understood not only by London Fire Brigade, but by government, every fire and rescue service and every residential building owner and manager across the country.
"The report is focused on our response and it is right for our actions to be fully examined by the inquiry.
"We welcome the chairman's recognition of the courage, commitment and bravery of firefighters on the night, 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.
"On the evacuation of Grenfell Tower we note the chairman states he has received no expert evidence to guide him on reaching his conclusion and that a qualitative judgment on the brigade's approach might be better reserved for Phase 2."
A report has concluded that London Fire Brigade breached national guidelines by failing to adequately prepare for the Grenfell Tower fire | Read more: https://t.co/QzhL7d3v2i pic.twitter.com/D4p72uN4PI— RTÉ News (@rtenews) October 30, 2019
Mayor of London Sadiq Khan said: "The Inquiry report shows that our firefighters and other emergency services showed incredible courage and bravery, working in the most challenging of conditions, in what was a catastrophic building failure.
"The firefighters that attended that night, and those in the control room at London Fire Brigade, were overwhelmed by the unprecedented nature of the fire. None of them had ever experienced a fire of this nature and scale. It wasn't their fault that a building designed for people to safely 'stay put' in their homes was so fatally compromised."
He added: "The report is clear there are significant lessons to learn for London Fire Brigade. While institutional failures meant that the overall response to the disaster was not good enough, every single person who attended that night did so to save lives.
"I personally will do everything within my power to ensure that the inquiry's recommendations are implemented, and I will be relentless in holding to account those responsible for implementing the remaining recommendations."
Grenfell United said senior firefighters had failed to learn the lessons from the blaze and called on them to "stop hiding behind the bravery of their frontline firefighters".
The group said: "While nothing can ever bring back our loved ones that passed away in the fire, this is a strong report with a forensic examination of the events of the night and clear recommendations that if implemented will save lives. The Government cannot afford to repeat the mistakes of Lakanal and ignore them.
"Justice means different things for all of us but the truth needs to be at the heart of our collective healing. 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. We now need to urgently see responsibility and action from this report, not excuses."
The inquiry chairman also criticised the London Fire Brigade for its "stay-put" strategy when residents were told to remain in their flats by firefighters and 999 operators for nearly two hours after the blaze broke out just before 1am.
The strategy was rescinded at 2.47am.
He said: "That decision could and should have been made between 1.30am and 1.50am and would be likely to have resulted in fewer fatalities.
Cladding 'principal' reason for fire's rapid spread - Report
The Grenfell Tower cladding did not comply with building regulations and was the "principal" reason for the fire's rapid and "profoundly shocking" spread, the inquiry report said.
Once the fire had taken hold of the building's exterior, it was "inevitable" that it would find its way inside, the inquiry's author Martin Moore-Bick said.
The judge said he still found the rapid engulfment of the tower block in London in 2017 by flames "profoundly shocking" despite having viewed footage many times over.
He concluded that the "principal reason" the flames shot up the building at such speed was the combustible aluminium composite material (ACM) cladding with polyethylene cores which acted as a "source of fuel".
The decorative crown then furthered its spread, he said.
Corporations involved with the refurbishment of the tower, in which the panels were added, previously urged the public inquiry not to make "premature" findings on the compliance of the building.
They also said the evidence heard in phase one was too provisional and insufficient for the judge to reach any firm conclusions for the spread of fire on the exterior of the building.
Arconic, which supplied the cladding on the outside of the block, said a "confluence of unfortunate circumstances" rather than the "mere presence" of the panels had caused the spread of the west London fire.
Stephen Hockman QC, representing the company, argued that any conclusion on compliance would "plainly" be premature.
But Judge Moore-Brick said he saw "no good reason for deferring to a later report what is no more than a self-evident conclusion".
No blame for man who lived in flat where blaze started
The man who lived in the flat where the Grenfell Tower fire started has been cleared of any blame by the inquiry into the disaster.
Survivors had previously urged Judge Moore-Bick to formally exonerate Behailu Kebede, who was offered police protection after false reports of his culpability circulated online.
The judge said the resident, who lived in flat 16, bore no blame for the fire, which he found started in a faulty fridge-freezer in his home.
"I consider the cause and origin of the fire and find that it was started by an electrical fault in a large fridge-freezer in the kitchen of Flat 16, for which Behailu Kebede bears no blame," he wrote.
"None of those who examined the large fridge-freezer, or the kitchen of Flat 16 more generally, found any evidence to suggest that the fire had been started deliberately or that it had been caused by an improvised or inexpert attempt to repair a defect in the appliance.
"Whatever the origin of the initial fire, the evidence indicates that it was accidental. Mr Kebede in particular bears no blame for what occurred in his flat, much less for the catastrophic events that followed.
"On the contrary, he did exactly what a responsible person might be expected to do in the circumstances and his presence of mind in switching off the electricity as he left the flat enabled important evidence to be gathered about the origin of the fire."
Grenfell United, a group which represents some of the victims of the fire, welcomed the findings.
A spokeswoman said: "We are glad to read this report totally exonerates our neighbour in flat 16.
"The Whirlpool fridge started the fire and our neighbour did everything he could do try to stop it and raise the alarm.
"He is long overdue an apology from media and corporates that tried to scapegoat him."