‘Unacceptable’: Optus Admits Process Breakdowns After 000 Outage Linked to Multiple Deaths

A report has found poor communications and a lack of escalation of concerns contributed to emergency call outages.

A Optus service message is displayed on a phone outside an Optus store in Sydney, Australia, on Oct. 5, 2022. Brendon Thorne/Getty Images

Optus has publicly released the report from Dr. Kerry Schott’s independent review into a Sept. 18 outage that resulted in the emergency phone number 000 being inaccessible in parts of South Australia, Western Australia and the Northern Territory.

The 14-hour outage, which impacted 75 percent of emergency calls, was prompted by a network firewall upgrade.

At least four people died after not being able to reach emergency services for help.

A Senate Estimates hearing in Oct. found the government had received two emails regarding the outages on Sept. 18, but hadn’t noticed them until around 3.30 p.m. the next day.

The review, released by Optus on Dec. 18, made 21 recommendations after revealing there were gaps in process and accountability.

It further revealed that escalation and information protocols needed to be improved.

In a statement, Optus Chairman John Arthur apologised.

“We are deeply sorry for the 18 September outage that impacted Triple Zero services and the consequences for any Australians who were trying to reach emergency services,” he said in a statement.

“We understand it is crucial for the community to always have access to Triple Zero services.”

“I have made it clear the Optus failures were unacceptable.

“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.”

Arthur said sharing the findings was part of ensuring openness with customers.

The report found that around 10 major mistakes were made around the time of the firewall upgrade and subsequent outage issues, including five warning calls from customers about Triple Zero issues not being escalated.

During this time, incorrect information had been relayed between parties, resulting in a “gateway”—a network between systems—being isolated without emergency calls being diverted.

That meant people could call other numbers but most were unable to reach the emergency line.

The report reveals that engineers had doubts about the processes being used, but these were also not escalated.

The report also noted delays in crisis management due to the failure not being fully understood until about 13 hours later—only then did welfare checks begin.

Recommendations

Recommendations from the report include developing improvements to the “camping on” system which allows failed calls to be diverted to alternative networks.

According to the report, that system had not worked sufficiently and callers would benefit from being informed that it could take up to a minute to be transferred to another network.

The report also recommends the establishment of a Triple Zero custodian with oversight of and overarching responsibility for the efficient functioning of the Triple Zero system.

Industry agreements should also be formed in order for multiple telcos to collaborate on outage responses, the report says.

Optus has also committed to overhauling change management processes, improving internal communications and ensuring better testing of systems.

The outages remain under the scrutiny of both a Senate inquiry and the Australian Communications and Media Authority.

In a separate incident last month, Optus was ordered to pay a $826,320 penalty for failing to comply with anti-scam rules, leading to some customers experiencing financial loss and identity theft.