A recent investigation into the Optus Triple-Zero outage in September, which was connected to two fatalities, has uncovered significant problems and a general “lack of care” regarding the errors that caused the disruption. The findings highlight the severity of the incident and the need for improved emergency response systems.

The inquiry focused on the 14-hour service disruption on September 18, during which 605 individuals in South Australia, Western Australia, the Northern Territory, and parts of New South Wales were unable to reach the emergency line. This failure underscored the critical nature of maintaining reliable communication channels during emergencies.

According to the review, Optus provided their contractor, Nokia, with incorrect instructions for a routine system upgrade, resulting in at least ten critical errors. This miscommunication played a pivotal role in the ensuing chaos and demonstrated a significant oversight in operational protocols.

Alarmingly, both Optus and Nokia were oblivious to the ongoing issue for 13 hours. Reports from five callers about malfunctioning Triple Zero calls were not escalated by the call center, further exacerbating the situation. This delay in recognizing and responding to the problem highlighted serious deficiencies in the companies’ crisis management strategies.

The report also pointed out internal shortcomings, such as inadequate information flow and siloed organizational structures, which contributed to the failure to properly assess and address the outage’s severity. These gaps emphasize the urgent need for a more cohesive and responsive approach to handling such critical system failures in the future.

“The lack of care and work discipline evident in all the mistakes that were the cause of this incident is more difficult to address,” the report said.

The other major issue was that the Triple Zero calls did not latch onto other networks as they should have, which the report stated was “puzzling”.

“This raises issues about how well the Triple Zero system is operating and whether it can be improved,” the report said.

The Optus review handed down 21 recommendations, including encouraging staff to escalate issues outside their immediate group, considering whether Optus should contract its complex and essential services, and shifting the siloed nature of work.

At a meeting earlier this week, the board accepted all the recommendations and agreed to implement them quickly.

The board will also fine or fire the employees personally accountable for the failures.

Optus chairman John Arthur said the report was a “sobering read”.

“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.

“We recognise the scale of the challenge and will act decisively to make the necessary changes to strengthen the business and rebuild trust.”

Optus chief executive Stephen Rue said some of the key reforms needed were already under way, and the company will regularly report its progress.

“Our commitment is not just about compliance, it’s about setting a new standard for our performance as a critical infrastructure provider of essential services and serving the community,” he said.

“Australia deserves world-class emergency call services.

“We are working closely with government, regulators, and the wider telecommunications sector to enhance the reliability of the Triple Zero service for our customers.”