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One was "incompetent". Another was "completely detached". A third was "in an ivory tower". 

The public inquiry into Jean Paul Sofia's construction site death in December 2022 did not mince its words when it came to naming and shaming individuals and entities for their lack of action or failings.

These are the report's biggest targets, and the subjects of its most scathing remarks:

The State

Not a single entity was responsible for overseeing the Corradino construction site that collapsed with Sofia and five other workers inside it.

For the board of inquiry, the blame for that lay solely with the state. 

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

Even worse, the inquiry observed, not a single state entity felt responsible for doing something to avoid the tragedy, or others like it.

"The main argument of almost every chair and CEO was essentially identical - a litany of 'we don't have anything to do with this case'," the report noted.

"Nobody - and we emphasise - nobody assumed the slightest responsibility for what happened. As far as the board is concerned, nobody even asked 'why didn't we inspect this site?'"

David Xuereb - OHSA chairman

The inquiry's clearest call to resign was directed towards the Occupational Health and Safety Authority (OHSA) chair, architect David Xuereb. The board explicitly advised him to step down.

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

On Wednesday afternoon Xuereb confirmed to Times of Malta that he would resign.

Malta Enterprise

The board was clear - Malta Enterprise should have never approved the project.

It did not make business sense and therefore would not have employed the number of workers it promised it would.

Malta Enterprise is the state-run entity responsible for encouraging investment and industry through various support measures.

It accepted whatever was handed to it in the application without question, the board said.

Malta Enterprise assessors did not examine proposed building plans and did not even know how many storeys the projects they approved would rise to, the report said. 

"In its totality, this case exposed the problems at Malta Enterprise and revealed the urgent need for it to audit its operations, realising more than ever before what a huge responsibility it has towards the country and its citizens, and that it cannot and shouldn't accept poor behaviour from its public officials," the report said.

"The way events turned out should be enough to oblige Malta Enterprise to look inwardly and reconsider its operations."

Kevin Camilleri - Malta Enterprise micro-enterprise unit head

Kevin Camilleri, who was the Malta Enterprise official who assessed the developers' application, was found to have "totally failed in his responsibilities".

The board observed how company directors Kurt Buhagiar and Matthew Schembri had only been working together in the furniture industry for five months before they applied to be given government land to develop the factory.

They had only amassed €45,000 worth of furniture orders before applying to be given "a free public factory in an industrial zone", the board said. 

Yet Camilleri moved the application forward when he should have advised against its approval.

"You don't have to be a stellar expert to understand that the furniture manufacturing sector has been in crisis for years through globalisation. Small carpenters unfortunately shut down and the big ones transformed their business to importing furniture instead of manufacturing it," the report said.

"Whatever they say at Malta Enterprise, this is the reality on the streets that anyone with a knowledge of the industry knows.

"Therefore, handing out government land for the construction of a supposed furniture factory should have been ruled out."

Camilleri went on to present the developers' proposal to Malta Enterprise's investment committee, which also came in for an inquiry hiding. 

Malta Enterprise Investment Committee 

Malta Enterprise's Investment Committee is tasked with assessing smaller-scale industry proposals made to the state entity.

In this case, its five members were the ones to decide whether the project developers would be given free public land in Corradino, to turn into a furniture factory.

The inquiry concluded that the committee did a poor job of scrutinising the proposal and lacked transparency in its decision-making process. Instead of questioning the proposal, it tackled it in a "superficial" manner. 

The committee was led by Malta Enterprise deputy chair Peter Borg, who on Wednesday told Times of Malta he had tendered his resignation. 

Fellow committee and Malta Enterprise board members Victor Carachi also confirmed his resignation on Thursday afternoon but insisted he was not present for the controversial decision. 

Paul Abela is also expected to resign in the coming days. 

Carachi is the President of the General Workers Union (GWU) and Paul Abela is the President of the Malta Chamber of SMEs (former GRTU). Dana Farrugia and Frank Farrugia, who also formed part of the committee at the time of the Corradino decision, are no longer on the board.

INDIS

The board had equally scathing words for INDIS - the government entity responsible for administering state-owned industrial parks.

It should have ensured the conditions of the allocation were advantageous and in the interest of the government, being the land owner.

"INDIS failed this primary duty," the report said.

INDIS's enforcement was in the hands of two or three people who were tasked with covering the whole country, meaning enforcement was "almost inexistent".

"In this case nobody observed anything. Surveillance was so poor that had there not been a tragedy, INDIS would not have known anything."

"It should have never been the collapse of a building, the injury of workers and the death of a worker (who should have never been there) that triggered INDIS to seek revocation of the land contract."

Despite a contractual obligation that bound investors to finish the project by October 2021, Malta Enterprise and INDIS never inspected the site. Had one of them taken steps to revoke the agreement based on the contract breach - as they then did in July 2023 - Jean-Paul Sofia would not have died, the board concluded.

OHSA

The inquiry was critical of the way the Occupational Health and Safety Authority (OHSA) perceived its role.

The OHSA is responsible for workplace health and safety, but when testifying, its former boss Mark Gauci had said that even if OHSA officials had inspected the Corradino building, they would not have 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.

The board slammed most entities for inadequate enforcement and the lack of quantity and quality of inspectors.

Some of them blamed the Finance Ministry for not giving them enough money, but the board found that the Building and Construction Authority and the OHSA had between one and two million euro each accumulated in their bank accounts.

"These funds could have surely been used to employ more inspectors had this been truly a priority for them," it said.

"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." 

Mark Gauci - former OHSA CEO

Mark Gauci, now retired, spent more than two decades at the helm of the OHSA.

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

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

The board also recommended data be collected on near misses and dangerous occurrences in workplaces.

Gauci said the OHSA has no such statistics and that no other country keeps records of such incidents. 

The board, however, found that the UK does so, through a regulation that obliges the reporting of "dangerous occurrences, which are near misses that could have resulted in serious injury or harm".

"It would be good to introduce such a regulation in our country because it would improve prevention and put everyone on the alert."

While it acknowledged Gauci's expertise and significant work within the sector, it also said it was not a good sign when a state entity maintains the same CEO for as long as he led the OHSA. 

The Building and Construction Authority 

The construction sector's regulator, the Building and Construction Authority (BCA), did next to nothing to amend its processes in the wake of the collapse, the inquiry found.

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.

Damningly, the inquiry concluded that BCA bosses both past and present appear to be uncertain of the authority's precise remit, especially when it comes to free-standing structures like that in Corradino.

The board said such structures should be included within the BCA's remit as soon as possible.

Oliver Magro - Planning Authority CEO

The board said it was "so disappointed" that Planning Authority CEO Oliver Magro "seriously failed" to disclose that the PA had enforcement powers on the Corradino site.

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.

This was one of the problems flagged by legal academic Kurt Xerri in what the inquiry described as a "comedy of errors" within Maltese legislation regulating the construction sector. 

Karl Azzopardi - former BCA, INDIS boss

At the time when INDIS "rubber stamped" Malta Enterprise's approval of the Corradino project, the state entity was led by Karl Azzopardi. 

Azzopardi went on to lead the newly created construction regulator, the BCA, when it was set up in 2021. He spent roughly one year in that job before exiting in somewhat acrimonious circumstances.

The BCA was an effectively toothless entity in many ways, the inquiry concluded, and the Planning Authority was empowered to enforce laws that should technically have been the BCA's remit long after the latter was set up.  

The board was convinced the PA was not enforcing anyway, which was "a total lack of good governance".

It also noted that despite having set up the BCA as the construction sector's regulator, the government seemed concerned about rocking the boat. 

There was little appetite to introduce radical reform and rogue individuals were therefore able to continue doing what they were doing, the report said.

The inquiry also criticised Azzopardi for having left the BCA with a head count of 70 staff members when he himself admitted it required 300 people to operate effectively.

Helga Pizzuto - MCCAA chair

The board implied that the chair of the Malta Competition and Consumer Affairs Authority (MCCAA), Helga Pizzuto, was poorly prepared for her testimony.

It contrasted Pizzuto's poorly prepared remarks to those of the State Advocate, who clearly explained regulations pertaining to the sector.

Pizzuto told the board that as of November 3, 2023 - 11 months after the tragedy - the MCCAA had yet to take brick samples from the site of the collapse for testing. 

Similarly, the MCCAA did nothing to change its procedures to avoid tragedies like this happening again.

The board concluded the entity should be given more power and responsibility to be more effective.

Jobsplus

Jobsplus does not compile a list of active construction sites from contractors, meaning it is unable to carry out spot checks on the workers, the board noted.

Had it been otherwise, Jobsplus could have inspected the Corradino site and realised Jean Paul Sofia was not registered with the contractor.

It also noted the employment agency had more board members (16) than it had inspectors (11).

Former BCA chairperson Maria Schembri Grima

Schembri Grima, a practising architect, served as the BCA's first chairperson. 

That posed clear conflict of interest concerns and the Sofia inquiry said that she "should never have accepted the role". 

It took a dim view to her claims that she had nothing to do with the authority's day-to-day affairs and said her assurances that she acted in an upstanding manner throughout were no substitute for proper good governance. 

The inquiry also said Schembri Grima fell short as a policymaker when she failed to warn the minister responsible for the BCA that the regulator had no oversight of free standing structures. 

Schembri Grima resigned as BCA chairperson in February 2023 over an unrelated issue.