The review into September's Optus triple zero outages, during which multiple Australians died, has been released to the public with 21 recommendations to fix the company's culture.
The review into September's Optus triple zero outages, during which multiple Australians died, has been released to the public with 21 recommendations to fix the company's culture.
The review was led by former NBN Co boss Dr Kerry Schott and investigated the outages across South Australia, Western Australia, the Northern Territory and parts of New South Wales.
The report found failures in process, accountability, and escalation and information protocols it said needed urgent attention, and highlighted a challenging culture within the company, which it said impacted decision-making and response times.
It also confirmed the exact details of the September 18 outages; including that the outages lasted almost 14 hours, during which some 605 triple zero calls were made using the Optus network.
Of those who called, only 150 successfully connected.
In the days following the outages, four deaths were linked to failed calls.
In the report, however, it is claimed only two fatalities had been related to the unconnected emergency calls.
It begins by identifying ten mistakes made between Optus and contractor Nokia in the lead-up to the outages.
First, instructions provided to Nokia by Optus were incorrect resulting in a locked gateway at its exchange facilities in Regency Park, South Australia which blocked both voice and emergency calls.
In that instance, it took Optus and Nokia around 13 hours to become aware of the problem.
During those 13 hours, five calls were made to the Optus call centre to notify them of the issues; in each case the call centre attempted to diagnose issues with the callers handheld device and did not escalate the issue further.
The report found the 150 callers who did successfully make emergency calls were due to the 'camp-on' feature, which reroutes call traffic via alternate networks.
But calls would only camp-on after around 40-60 seconds, the report found, which many people in emergency situations are unlikely to wait on hold for.
The report found reporting mechanisms, both internal and external, could be improved with the Optus executive and government bodies not notified of the outage until the morning of September 19.
Incorrect contact details - both typos in emails and out-of-date information - contributed to the delayed notification to external stakeholders.
In concluding her report, Dr Schott said it must be noted Optus was already in the midst of a five-year reform and transformation program after chief executive Stephen Rue was appointed in November 2024.
"This degree of change does take time to filter through a large company," Dr Schott said.
"The triple zero incident provides the opportunity to hasten the transformation and changes needed.
"Calls to replace the current chief executive are not helpful at the start of this large program of change and will not help develop the more competitive and reliable telecommunications company needed in Australia.
"The incident certainly highlights significant problems at Optus that have been evident for some time. Major efforts are now being made to address them."
Optus chief executive Stephen Rue said the report underlined the importance of accelerating key reforms and confirmed Optus would move to implement all 21 recommendations.
"The Schott Review makes an important contribution to support the work underway to reform Optus. When I started as chief executive last year, we launched a company-wide program of change, underpinned by a long-term strategic plan which would transform the company over the coming years," he said.
"Many actions and improvements are already underway, and we have a clear program to complete the remaining priorities.
"In line with our commitment to be open about the events of September 18, we will regularly report our progress to restore confidence in Optus and our network.
"Australia deserved 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."
Optus chair John Arthur said the company was deeply sorry for the outages.
"We understand it is crucial for the community to always have access to triple zero services," he said.
"The board wanted an independent and forthright assessment of what went wrong and what needs to change, and the Schott Review has delivered on that in a candid and succinct analysis. The report is a sobering read for everyone at Optus.
"While the Schott Review acknowledges the work undertaken before the incident to build a better company, it is clear there is much more to do."
Mr Arthur then revealed the company would be putting a microscope on those involved in the failures.
"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," he said.
"Sharing this report underscores our commitment to being open with Australians about what occurred, and it will assist the broader industry tackle the challenges facing the telecommunications sector."
