Updated 6.40pm

Jean Paul Sofia died in an essentially unregulated construction site and the state must bear responsibility for that, a public inquiry has concluded.

In a 484-page report published on Wednesday, the inquiry went to considerable lengths flagging multiple failings in various state authorities. Key officials within some of them should "consider their positions", the inquiry said. 

But it also noted that the broader government apparatus was to blame for having allowed a legislative mess to develop over the years.  

What it described as a “comedy of errors” within construction site legislation meant the Corradino building which collapsed on the 20-year-old Sofia and five others in December 2022 essentially fell through regulatory cracks.

“Jean Paul Sofia died at a site which was not overseen by any regulatory authority,” the board concluded, noting that not a single inspector from any of the various state entities involved had ever visited the site.

“Somebody must assume responsibility for these big mistakes. This must be the state, which failed to keep a close eye on messes at executive level, where everyone worked on their own steam without reporting to anyone.” 

The inquiry board said officials at Malta Enterprise, INDIS and the OHSA should "consider their positions". In his first reactions, Prime Minister Robert Abela said he expected resignations by 4.30pm. 

Sofia's mother, Isabelle Bonnici, said she now wanted to see action to fix the issues raised.

"I will not allow this report to be shelved, after having worked so hard for the inquiry," she said.

What does the Sofia inquiry recommend?

The inquiry advised the government to introduce legislation regulating free-standing buildings like the Corradino one with immediate effect, and to consider merging all regulatory oversight for the industry into a single authority.

Among its other recommendations are for skills cards for construction workers to be made mandatory and for industrial estate sites to no longer get a fast-tracked Development Notification Order route through the planning process.  

It also argued that splitting the Malta Development Corporation into what are today Malta Enterprise and INDIS had failed. 

What did the Sofia inquiry investigate?

The inquiry, which began its work last August and stopped hearing testimonies in November, was tasked with looking into the way public land for the furniture factory was allocated to the project’s two developers. Kurt Buhagiar and Matthew Schembri, and whether that allocation had anything to do with the collapse.

Led by retired judge Joseph Zammit McKeon, the inquiry was also asked to take a closer look at rules and policies related to planning, development and construction and to assess whether any state entity had failed in its duties.

The prime minister received a copy of the inquiry report on Wednesday morning and his office immediately distributed digital copies to the media. A copy was also presented to Sofia's family and will be tabled in parliament for MPs to discuss when the House convenes on Wednesday afternoon.

 

Abela said that a sub-committee led by his head of secretariat Glenn Micallef will be tasked with implementing the report’s recommendations, some of which are already in the process of being introduced into law.

Opposition leader Bernard Grech called for Abela and three of his ministers - Stefan Zrinzo Azzopardi, Silvio Schembri and Miriam Dalli - to resign. 

You are to blame because you allowed this culture of impunity, so you should go,” Grech said in parliament. 

Malta Enterprise and INDIS

Malta Enterprise and INDIS should never have allowed land in Corradino to be allocated to the developers whose faulty building killed Jean Paul Sofia, the report concluded.

The developers wanted to build a five-storey furniture factory at the site and applied for land at the Corradino Industrial Estate to do so. 

Malta Enterprise approved the project in May 2019 and INDIS signed over the site to the developers in February 2020. 

The developers’ proposal was “objectively lacking in every respect”, the board of inquiry concluded as it said officials at both Malta Enterprise and INDIS should “consider their positions” in light of the findings.

Malta Enterprise is the state-run entity responsible for encouraging investment and industry through various support measures. INDIS is tasked with overseeing industrial estates. In the past, the two entities were combined into what was known as the Malta Development Corporation. 

At the time when the Corradino project was assessed and approved, Malta Enterprise was led by Mario Galea while INDIS was the responsibility of Karl Azzopardi. 

Galea subsequently retired while Azzopardi went on to serve as CEO of the construction regulator, the BCA. 

The report concluded that the Lands Authority did not bear any responsibility in the way the parcel of land was allocated, as the Corradino site was not under its control.

Despite the many failings in the way land was allocated to the Corradino developers, the board of inquiry said the land allocation process itself could not be directly linked to the December 2022 collapse.

In scathing remarks, the inquiry found that Malta Enterprise was “irregular, disrespectful of the law and incompetent” in the way it assessed the proposal to build a timber factory, presented to it by the developers.

Their proposal should never have made it past the assessment stage. But instead it was passed on to Malta Enterprise’s investment committee, which approved it in a “superficial” manner, and then “rubber stamped” by INDIS.

While the inquiry found multiple instances in which the two entities had failed to adequately assess the project in question, it stopped short of saying the project was approved due to bribery or corruption.

In neither Malta Enterprise or INDIS’ case was there enough evidence to conclude that the approval was granted with the intent of helping anyone make personal gain, the board said.

Just five months of experience

Among other things, the inquiry noted that Malta Enterprise does not look at building plans of proposals, meaning its evaluators have no idea what sort of building they are being asked to allocate land and funding to.  

Nor does the state entity request audited accounts of applicants, check whether people working on the project are employed by the applicant or whether the business plan presented justifies the allocation.

In this particular case, Malta Enterprise went ahead and issued a letter of intent for the Corradino project shortly after the company responsible, AllPlus Ltd, made extensive changes to its business plan. The board considered this "a very strange fact".

The company’s two directors, Buhagiar and Schembri, had just five months of experience in the furniture sector when they applied to be given government land to develop the factory.

They applied to get "a free public factory in an industrial zone", based on €45,000 worth of furniture orders, the board said.

Malta Enterprise's expectation that the five-storey factory would cost €112,000 to build "did not make sense", the inquiry also noted. 

Jobsplus: more board members than inspectors

Other state entities and ministries also came in for criticism.

Many – from INDIS to the OHSA and BCA - had sought to wash their hands of the case, the inquiry noted. 

Not a single authority head had acknowledged failings or assumed any responsibility for what had happened. 

Representatives of all those entities testified that they were under-resourced and working in a broadly unregulated sector, and this was not down to a lack of money.

Both the BCA and OHSA, for instance, had well over €1 million in their respective bank accounts, which they could have used to hire more inspectors if they truly believed that was needed.

Both those entities, the inquiry noted, have almost as many directors on their boards as they have inspectors. The situation is even more skewed at Jobsplus, which has 16 board members but just 11 inspectors.

OHSA: In an ivory tower

The inquiry was critical of the way the Occupational Health and Safety Authority (OHSA) and its former boss, Mark Gauci, perceived its role.

The OHSA is responsible for workplace health and safety. 

When testifying, Gauci had said even if OHSA officials had inspected the Corradino building, they would not identified problems with the way it was being constructed. 

But the board had none of it.

"If OHSA inspectors aren't able to identify when people on a construction site are in danger, then we honestly don't know what the scope of these inspections is," it concluded.

It also expressed a measure of impatience at the somewhat academic arguments presented to it by Gauci.  

"The OHSA needs to climb down from the ivory tower it has built itself and start treating incidents not as numbers, but as tragedies that destroy families." 

It said that despite Gauci's claims, the entity appears to be a reactive, rather than proactive one. 

OHSA chairman to resign

The report was also damning for Gauci's boss, OHSA chairman David Xuereb. 

Xuereb appeared to be "completely detached from the authority's day-to-day realities" and made various factually incorrect statements in his testimony, the board said. 

It explicitly called for Xuereb to "consider his position" as OHSA chairman, saying authorities could not turn a blind eye to it. 

Xuereb told Times of Malta later on Wednesday that he was preparing his resignation.

The construction sector's regulator, the Building and Construction Authority (BCA), had done next to nothing to amend its processes in the wake of the collapse, the inquiry concluded. And aside from having a desperately low number of inspectors - 17 - its penalties are ineffective.  

More than 90 per cent of fines BCA inspectors issued to developers and contractors between February and August 2023 were of an average €506, the board noted - far too low to serve as deterrents. 

A legislative 'comedy of errors'

Arguably the most damning conclusions for the government relate to what the inquiry heard about legislative problems related to the construction sector. 

Legal academic Kurt Xerri provided the inquiry with an overview of legislation related to the sector, and flagged multiple instances where different laws contradicted each other. 

Among the problems flagged in what the inquiry described as a "comedy of errors":

• No laws to regulate free standing buildings like the Corradino one. 
• At the time of the collapse, two separate laws regulated construction.
• Enforcing construction site regulations was technically the Planning Authority's job, but it was not doing that due to a ministerial order tasking the BRO (later BCA) with that.

The mess was entirely the state's fault, the inquiry said, as it had allowed ministers to forge ahead in their own separate directions, with no sort of coordination or oversight. 

Enforcement: poor and inadequate

Even where laws exist, enforcement remains lacking, the inquiry noted. 

"The problem is not writing laws and passing them through parliament, especially when the executive has a solid majority. What's difficult is enforcing those laws. For this to happen, there must be clear political will," the report said.

The construction sector evidently lacks inspectors in both quantity and quality, it said.

A months-long inquiry

The public inquiry board was comprised of former judge Zammit McKeon, Auditor General Charles Deguara and architect Mario Cassar.

Contacted hours before she was handed a copy of the hefty probe into her son’s death, Isabelle Bonnici said she does not expect all the recommendations to be implemented at once, but all of them must be implemented at some point.

The report marks a significant milestone in a months-long fight for an overhaul of the construction sector. 

Sofia, 20, died when the building collapsed during roofing works, with CCTV footage indicating it collapsed in just two seconds.

Following the tragedy, his mother Isabelle Bonnici spent months campaigning for the government to order a public inquiry into her son’s death. The government staunchly resisted those calls for months and even voted against a parliamentary motion to appoint such an inquiry.

But faced with mounting public outrage and a massive protest outside Castille, Prime Minister Robert Abela changed tack just days after that parliamentary vote and agreed to order a public inquiry into the case. 

Five people involved in the Corradino project - developers Kurt Buhagiar and Matthew Schembri, architect Adriana Zammit and contracting firm directors Milomir Jovicevic and Dijana Jovicevic - stand accused of having involuntarily killed Sofia.

They are all pleading not guilty in criminal proceedings, which are separate to the public inquiry.