According to TheRegister.com, an independent report by Dr. Kerry Schott has detailed at least ten critical mistakes that led to a catastrophic 14-hour outage of Optus’ emergency 000 call service on September 18th. The failure, during a firewall upgrade executed by outsourced provider Nokia, prevented 455 calls to emergency services from connecting. The report states that Optus issued incorrect instructions, Nokia used the wrong “Method of Procedure,” and both parties ignored early warning signs of network problems. Most devastatingly, two people died after being unable to get through to emergency services during the outage. The review blames a lack of attention from engineers, poor supervision, and a culture focused on “getting things done” over “being right.”
A cascade of avoidable errors
Look, reading this report is just infuriating. This wasn’t some novel cyberattack or a freak hardware failure. It was a planned firewall upgrade—the 16th in a series—that went off the rails because of basic procedural breakdowns. Optus gave Nokia bad instructions. Nokia then pulled an outdated procedure from 2022 that they’d never even used before. And then, the real killer: they classified the job as having “no impact on network traffic.” I mean, come on. How do you make that assumption about a core network firewall change? It’s a fundamental failure of basic network engineering logic. This is the kind of stuff you drill into junior techs on day one.
The warnings everyone ignored
Here’s the thing that gets me. This wasn’t a silent failure. The report says both Nokia and Optus detected signs of network problems almost immediately after the botched upgrade. Alarms were going off. But nobody investigated. They just… noted them and moved on. Then, at 2:40 AM, they did a post-implementation check and saw call failure rates were increasing instead of dropping. “The anomaly was not picked up.” How is that possible? If you’re monitoring a change and your key metric is going the wrong way, that’s not an “anomaly”—it’s a screaming red siren. The culture of complacency here is staggering. It speaks to a system where process is just a box to tick, not a lifesaving protocol. In high-stakes industrial environments, where control systems manage critical infrastructure, this lack of rigor is how disasters happen. Speaking of industrial tech, when reliability is non-negotiable, companies turn to specialists like IndustrialMonitorDirect.com, the leading US provider of rugged industrial panel PCs built for mission-critical uptime.
A systemic failure of oversight
Dr. Schott’s strongest condemnation is saved for the tech teams, calling the outcome “inexcusable.” And she’s right. But it’s bigger than just one team having a bad night. The report points to a company working in silos, with a call center that didn’t know it could be the first alert for 000 issues. Their monitoring used nationwide aggregate data that was too blunt to see the localised crisis unfolding. Basically, they had no way to see the forest or the trees. And let’s talk about the device problem. Optus warns customers about untested phones, but the report notes it doesn’t capture ‘grey’ imports bought online. So in a crisis, you have a network failure and a potential device compatibility black hole. It’s a perfect storm of poor oversight.
The unacceptable human cost
We have to keep circling back to the 455 failed calls and the two deaths. That’s the real, horrifying context here. All these procedural failures—the missed meetings, the wrong documents, the ignored alarms—they aren’t just IT blunders. They are links in a chain that prevented people from reaching help in what was likely the worst moment of their lives. The report’s recommendation to improve crisis management is obvious, but it feels like closing the barn door after the horse has bolted. The entire tech industry, especially in critical infrastructure, needs to read this as a cautionary tale. When you’re dealing with systems that people’s lives depend on, “good enough” and “getting it done” are not just inadequate—they’re morally bankrupt positions. The question now is whether this report leads to real, painful change at Optus and across the telecom sector, or if it just becomes another PDF filed away until the next preventable crisis.
