London Fire Brigade has been criticised for "serious shortcomings" and "systematic" failures in its handling of the Grenfell Tower fire.
The findings are contained in the official report into the tragedy, which is due to be published on Wednesday but has been seen by a number of news organisations.
The report also accused LFB commissioner Dany Cotton of "remarkable insensitivity" after she said she would not have done anything differently on the night.
Inquiry chairman Sir Martin Moore-Bick said key decisions should have been made earlier, specifically mentioning the fire brigade's "stay put" strategy.
Residents were told to stay in their flats by firefighters and 999 operators for nearly two hours after the fire started just before 1am in June 2017.
It was not until 2.47am that the strategy was changed, according to the 1,000-page report.
Sir Martin described the "stay put" advice as an "article of faith within the LFB so powerful that to depart from it was to all intents and purposes unthinkable".
He added: "That decision (to reverse the advice) could and should have been made between 1.30am and 1.50am and would be likely to have resulted in fewer fatalities."
Sir Martin did, however, praise the "extraordinary courage and selfless devotion to duty" of firefighters and said "those in the control room and those deployed on the incident ground responded with great courage and dedication in the most harrowing of circumstances".
Regarding Ms Cotton's evidence, he said it demonstrated that "the LFB is an institution at risk of not learning the lessons of the Grenfell Tower fire".
He also said her evidence "betrayed an unwillingness to confront the fact that by 2017 the LFB knew (even if she personally did not) that there was a more than negligible risk of a serious fire in a high rise building with a cladding system".
Ms Cotton is to retire next year.
A London Fire Brigade spokesperson said: "The inquiry's findings are not being published until Wednesday morning and it would be inappropriate for us to comment on them until then."
The fire was started as a result of an "electrical fault in a large fridge-freezer" in a flat on the fourth floor of the west London building, the report said.
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