Optus has released a long-awaited review into September’s network outage which left hundreds of people unable to reach Triple Zero and was linked to two deaths.

The review, by Dr Kerry Schott, found there were widespread failures that contributed to the outage and prevented it being resolved faster.

The outage lasted for almost 14 hours and during that time 75 per cent of Triple Zero calls failed from a total of 605 attempts.

The report found a routine network upgrade was plagued by multiple failures by Optus and its contractor Nokia — with as many as 10 crucial mistakes made.

The Optus call centre then failed to escalate warnings from five callers who said Triple Zero calls were failing.

More Optus network triple-0 failures

A woman was unable to call triple-0 after robbers broke into her home while she was in the bedroom.

The review found Optus needed to overhaul its network operations which “clearly failed” and improve risk management and internal audit functions.

The report also raised broader issues about how well the Triple Zero system was operating and whether it could be improved.

The report identified a “lack of care and work discipline evident in all the mistakes,” and said there was a growing awareness of “siloed structures” which contributed to a lack of transparency within engineering groups.

At its meeting on Tuesday the Optus board accepted all the recommendations and agreed to move swiftly with their implementation. 

In a statement, Optus Chairman John Arthur said the company was, “deeply sorry for the September 18 outage that impacted Triple Zero services and the consequences for any Australians who were trying to reach emergency services”.

Growing crisis of confidence in Triple Zero network

There are growing questions about whether one of Australia’s largest telcos could have done more to ensure customers would be able to call Triple Zero.

He said it was clear there was “much more to do”.

“[Optus] will act decisively to make the necessary changes to strengthen the business and rebuild trust.”

Some of the key recommendations from the review included, “conducting incident exercises for staff to improve their judgement about when to escalate an incident to a more severe level” and to, “move the entire Optus Operations centre onshore more quickly”.

It also suggested implementing a system that could track caller details faster if Triple Zero outages occurred.

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