An inquiry into Australia’s second-largest telecommunications provider Optus’s emergency services telephone number outage in Australia has now come up with its report, revealing a series of failures during a firewall upgrade that left hundreds of people unable to contact police, fire and ambulance services. The venture, owned by Singaporean firm Singtel, published the review, which found at least 10 mistakes during the routine network upgrade carried out after midnight on September 18.
The independent internal investigation revealed that Optus provided incorrect instructions to its contractor, Nokia. On top of that, the Finnish telecoms equipment maker selected and approved an incorrect method to proceed with the upgrade, which shut down key equipment but did not redirect calls. The error impacted both normal voice calls and the emergency number “Triple Zero,” but the consequences were different, said Kerry Schott, the report’s author and transport and infrastructure business executive.
“While voice calls found an alternate pathway and their service continued, Triple Zero calls failed,” the report noted.
The outage lasted for almost 14 hours, during which 605 callers sought “Triple Zero” emergency services and assistance of some kind. About 75% of these calls could not connect, with two of them resulting in fatalities.
“Three issues are clear during this incident. The first is the very poor management and performance within the networks and their contractor, Nokia. The process was not followed, and incorrect procedures were selected. Checks were inadequate, controls avoided, and alerts given insufficient attention,” the report remarked.
Apart from finding gaps in process, accountability, escalation, and information protocols, the report also highlighted “challenges in Optus’ organisational culture that have impacted decision-making and response times.”
The review has made 21 recommendations, with prominent among them being strengthening network change-management and escalation processes, improving incident detection and crisis response for emergency services outages.
On December 16, the Optus board conducted a meeting, where it accepted the recommendations and agreed to move swiftly with their implementation.
“The board is taking further action in relation to individual accountabilities flowing from the incident, which will extend from financial penalties through to termination in appropriate cases,” Optus Chairman John Arthur said.