Several Optus workers face the sack after an independent review exposed a litany of failures behind September’s deadly Triple Zero outage, with the telco’s chairman calling the findings “a sobering read for everyone at Optus”.
The Schott Review, released on Thursday, found at least 10 separate mistakes by Optus engineers and contractor Nokia during what should have been a routine firewall upgrade on September 18 – failures that left 605 people unable to reach emergency services for almost 14 hours, and two people dead.
The review stopped short of calling for the dismissal of Optus chief executive Stephen Rue.Credit: Sitthixay Ditthavong
The review found that of the 605 callers who tried to dial Triple Zero across South Australia, Western Australia, the Northern Territory and parts of NSW on that September day, just 150 got through – a 75 per cent failure rate.
The Optus board accepted all 21 recommendations from the review, led by corporate veteran Dr Kerry Schott, at a meeting on Tuesday.
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“I have made it clear the Optus failures were unacceptable,” chairman John Arthur said. “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.”
The review recommends sweeping changes to Optus’ risk management, contract oversight and crisis response procedures. It calls for the operations centre to be moved onshore to Australia, for more robust Triple Zero testing, and for a cultural shift away from siloed working.
The withering findings of Dr Kerry Schott’s review into the Triple Zero outage add to a horror run for Optus.Credit: Oscar Colman
Schott stopped short of calling for chief executive Stephen Rue’s head, noting he had only started in the job in November 2024 and has been leading a five-year transformation program. “Calls to replace the current CEO are not helpful at the start of this large program of change,” the report states.
The 41-page report details a cascading series of errors that began when Optus engineers sent incorrect instructions to Nokia’s offshore operations centre for a firewall upgrade at the Regency Park exchange in Adelaide. Nokia then selected an outdated 2022 procedure that omitted a critical step: diverting call traffic before locking down equipment.
Despite three peer reviews at Nokia, nobody noticed the traffic diversion was missing. The work was incorrectly classified as “no impact” and “urgent”, allowing it to bypass senior engineering review and approval by the Change Advisory Board.
Optus chairman John Arthur: “I have made it clear the Optus failures were unacceptable.”Credit: SMH
When the gateway was locked just after midnight on September 18, regular voice calls quickly found alternative routes on the network, while emergency calls did not.
Two alerts triggered at the Network Operations Centre within 30 minutes of the work commencing were given “only cursory attention”, with staff dismissing them as related to the ongoing upgrade. Post-implementation checks at 2.40am showed call failure rates increasing, and not decreasing as expected. Again, nobody acted.
Meanwhile, five customers called Optus’ offshore call centre between 10am and 2pm to report they couldn’t reach Triple Zero. Each customer correctly spotted the problem, but none of their calls were escalated.
Optus initially told Communications Minister Anika Wells’ office that just 10 calls were affected.Credit: Alex Ellinghausen
“To have a standard firewall upgrade go so badly is inexcusable,” the review says. “Execution was poor, and seemed more focused on getting things done than on being right.”
The report found risk management within Optus was “materially deficient” across all three lines of defence, with the networks division operating in silos that prevented information flowing to senior executives. Rue was not informed of the fatalities until 8.13am the following day, more than 30 hours after the outage began.
Even then, Optus initially told Communications Minister Anika Wells’ office that just 10 calls were affected, a figure that ballooned to 600 by the time Rue faced cameras that Friday evening.
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“The Schott Review underlines the critical importance of this work and the need to accelerate and embed key reforms,” Rue said in a statement. “Our commitment is not just about compliance – it’s about setting a new standard for our performance as a critical infrastructure provider.”
The findings add to a horror run for Optus, which was fined $12 million after a nationwide outage in November 2023 left more than 2000 Australians unable to call Triple Zero. Just days before the September outage became public, the telco was ordered to pay $100 million for predatory sales practices.
The review also raised broader concerns about the emergency call system itself, noting some devices take 40 to 60 seconds to connect to Triple Zero.
A separate ACMA investigation into whether Optus breached emergency call regulations is ongoing, as does a broader Senate inquiry into the Triple Zero system.
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