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 Nokia then selected an outdated 2022 procedure that omitted a critical step: diverting call traffic before locking down equipment.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.”
Telecommunications analyst Paul Budde said the incident revealed a governance failure rather than a technical problem. “Ten separate failures don’t happen by accident. What failed at Optus was risk governance — the discipline that should protect essential services when routine work goes wrong,” he said.
“You can outsource operations, but you can’t outsource responsibility. If contractors and internal teams both miss obvious red flags, that points to a systemic failure of oversight, not human error.”
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.
Senator Sarah Hanson-Young, Greens communications spokesperson and chair of the Senate inquiry into the Triple Zero outage, called for a government review of Optus’ operating license.
“This is a damning report of the culture within Optus, their contractor Nokia and the entire Triple Zero system,” she said. “Optus’ failures were systematic and widespread. For too long, Optus has put profits ahead of safety and its customers. The company must face serious consequences for its failure.”
“The government must now review Optus’ licence and licence conditions. Going soft on the telco is not an option.” She said Optus and parent company Singtel representatives would be called back before the Senate inquiry in early 2026.
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 is a broader Senate inquiry into the Triple Zero system.
