The James Lee Witt report, released Thursday, concluded that the six deaths could have been prevented if the high-rise had had sprinklers and unlocked stairwell doors and if firefighters had searched those stairwells and not let in smoke and heat. The victims were found more than hour after the fire broke out, trapped in a stairwell that had filled with smoke after firefighters opened a lower door.
``Properly addressing any one of the four key factors would have changed the outcome of this incident and prevented loss of life from occurring,'' the report said.
The investigation spread blame for the Oct. 17 fire among the Chicago Fire Department, Cook County, the state of Illinois, building security and building management.
Most of its major findings echoed a July report by another commission that had been appointed by Cook County to investigate.
Blagojevich had said when he ordered the independent investigation that he wanted Witt, former head of Federal Emergency Management Agency, to investigate because the county's team lacked expertise. The initial cost for Witt's investigation was $1 million, but officials said Thursday it would run the state nearly $2 million.
The report cited inadequate evacuation training of building staff and occupants; ineffective communication among fire and police emergency dispatchers as well as the city's emergency dispatchers and fire commanders on the scene; and the fire department's focus on fighting the blaze instead of searching for victims.
The 35-story county building had no sprinkler system above the ground floor, and its stairwell doors locked automatically when closed.
Even though the fire broke out in a 12th-floor storage room and was contained to that floor, all the victims died on upper floors of the high-rise, trapped inside a smoky stairwell.
The Witt report and the other investigations said fire officials had reports of people missing in the building and 911 calls suggesting people were trapped in the southeast stairwell, but the stairwells weren't immediately searched. The victims weren't found until 90 minutes after the fire broke out, after firefighters had brought it under control.
``Actions on the fireground indicate that the operations were focused on suppressing the fire rather than determining the level of life safety risk in the building,'' the Witt report said. ``Priority at every incident should always be on life safety of the occupants.''