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In its 94-page report, the commission found that ``actions or inactions'' of the fire department and the building's management ``contributed to the loss of life and serious injuries.''
The department's mistakes included fighting the fire from the wrong stairwell, directing fleeing employees to the wrong place and failing to seize control of a public-address system, the report said.
The commission also cited missed 911 calls.
``It seemed like the 911 calls came in, they went into a black hole,'' said commission chairman Abner Mikva, a former U.S. Court of Appeals chief judge and congressman. ``They just never got followed up.''
The commission also criticized the building's management company _ 69 West Washington Management _ for failing to train its staff on building evacuation procedures.
The fire department had no immediate comment.
In addition to the six who died from smoke inhalation, several people were injured in the Oct. 17 fire at the 35-story Cook County Administration Building.
The report recommended requiring sprinklers in pre-1975 high-rises as well as requiring exit stairwells to have doors that either remain unlocked or automatically unlock when there is a fire.
The commission said the deaths and serious injuries ``would not have occurred'' if the high-rise had such protections.
The commission also found that in violation of its own policies, the department ``did not set up an initial search-and-rescue team upon arrival'' and focused on extinguishing the blaze rather than rescuing the building's occupants.
``This behavior and decision making is an example of poor training and a lack of appropriate prioritization,'' according to the report.
The report includes 20 recommendations for the fire department, including better coordination with the city's Office of Emergency Management and Communications, a physical-fitness training program, and top-to-bottom stairway searches during high-rise fires.
The commission also recommended an overhaul of the department's promotion policies, calling for ``competitive examinations'' for every job except those immediately below the fire commissioner.
That recommendation promises to get special attention in a department that has long been struggling with its hiring and promotion policies. For years, minorities and whites have attacked those policies, claiming they have been discriminated against.
Police have yet to rule on whether they believe the fire was arson.
The commission, made up of retired judges, held months of hearings, interviewing experts, engineers and fire officials.