An independent review of an outage of Optus’ emergency call network in September suggested shifting call centre operations outside of Australia contributed to delays in responding to failures in its backend system, with the operator considering firing staff over the incident.

The 40-page report stated: “The real tragedy here was the duration of the Triple Zero call outage and the failure of Optus and its contractors to deal immediately with the warning signals they received. At Optus and Nokia, the necessary processes were in place, but their requirements were not performed properly.”

Optus chair John Arthur detailed in a response to the report: “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 added sharing the report “underscores our commitment to being open” about what occurred, and it will assist the broader industry in tackling the challenges facing the sector.

The report highlighted a number of key issues. The first was “the very poor management and performance within networks [department] and its contractor Nokia. Process was not followed, and incorrect procedures were selected. Checks were inadequate, controls avoided and alerts given insufficient attention.”

It noted “there appeared to be reticence in seeking more experienced advice within networks and a focus on speed and getting the task done, rather than an emphasis on doing things properly. This behaviour must be rectified to ensure that such mistakes are not repeated.”

The second problem was at the call centre. “Instructions to operators did not recognise that they may be the first alert channel for Triple Zero difficulties.”

The review acknowledged Optus is moving part of its call centre back to Australia and operating that service locally 24/7, which it noted will improve call centre response.

The internal investigation was ordered following a failure of its emergency call network on 18 September that was linked to two deaths.