Cases14 cases

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1. IL-0192 A Crossplane composition merge-policy change for a TLS policy update switched Kubernetes Services from LoadBalancer to ClusterIP and deleted the load balancers behind about 25% of Grafana Cloud services

   Grafana Labs2025

   Symptoms

   At 08:41 UTC on 18 February 2025, several Grafana Labs application teams noticed that some of their endpoints were no longer available. The investigation quickly found that the load balancers for those endpoints were gone.

   Service outageResources deleted

   Trigger

   A change to the merge policy of a Crossplane composition, made so that the default TLS policy of the load balancers could be overridden, was applied to development, staging and production at the same time.

   Root cause

   Configuration change

   Component

   Configuration templatingCloud load balancer

   Contributing factor

   Unverified assumptionNo staged rolloutExcessive blast radiusNo safeguard on destructive change

   Detection

   Application teams noticed at 08:41 UTC that some of their endpoints were no longer available.

   Remediation

   • rolled back the Crossplane composition change
   • recreated the affected Kubernetes Services so that Kubernetes recreated their load balancers

   Action items

   • Add a CI check that blocks a deployment to more than one wave, so any exception to the dev, staging, canary, production order is caught
   • Give higher priority to a more sophisticated wave design that was already under discussion
   • Enable deletion protection on the load balancers, one layer below Crossplane
   • Enable deletion protection on other critical cloud provider resources
   • Develop the Crossplane Managed Resources exporter for change validation and visibility, now in beta testing within Platform engineering; simulated against the change that caused this outage, it shows a clear diff
   • Complete and test support for reconfiguring the TLS policy so application teams can deploy it

   Lessons

   A change that looked small and low-risk had a side effect that only a full end-to-end test through Crossplane and the cloud provider's load balancer controller would have shown; seeing the intended override work was not that test. Staged rollout and blast-radius limits that exist only as process can be skipped, so Grafana Labs moved to enforce waves in CI and to add deletion protection on the load balancers themselves, beneath the Crossplane layer.

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2. IL-0145 A power sag and chiller failure in one Australia East availability zone took down the AKS control plane's compute and its non-zone-redundant SQL Database operation queue, blocking AKS create, update and delete operations in Australia East and Australia Southeast

   Microsoft Azure2023

   Symptoms

   From about 10:30 UTC on 30 August 2023, customers had trouble accessing or using Azure, Microsoft 365 and Power Platform services in Australia East. The affected Azure services included Azure Kubernetes Service (AKS) along with storage, SQL Database, Cosmos DB, virtual machines and Azure Resource Manager.

   Control plane unresponsiveHigh error rateService outage

   Trigger

   At 08:41 UTC a lightning strike on electrical infrastructure about 18 miles away caused a utility voltage sag that shut down the cooling chillers of datacenters in one Australia East availability zone; 13 chillers failed to restart automatically and five could not be restarted, so two data halls overheated and their infrastructure was shut down.

   Root cause

   Cloud provider outage

   Component

   AKS control planeApplication database

   Contributing factor

   Single point of failureExcessive blast radius

   Detection

   Cosmos DB impact was detected by monitoring at 10:47 UTC, first automated communications went to Azure Service Health at 10:48 UTC, the public Azure Status page was updated at 11:30 UTC, and all subscriptions in Australia East were sent portal communications at 11:36 UTC.

   Remediation

   • shut down the remaining networking, compute and storage in the two affected data halls so the chilled water loop could cool down
   • restarted the five chillers manually at 12:12 UTC
   • restored power to all hardware by 15:10 UTC and brought infrastructure back in phases
   • restored AKS operations through the recovery of the SQL Database operation queue, with no other mitigation

   Action items

   • AKS: convert all operation queue SQL Database databases to be zone redundant (estimated September 2023)
   • AKS: replace all cross-region SQL Database queue usage with zone-redundant Service Bus queues (estimated September 2023)
   • Change the control timing logic of the Chiller Management System so chillers do not fail to restart after voltage fluctuations
   • Change the emergency procedure for manual restarts of simultaneous chiller failures from an adjacent sequence to a load-based sequence per data hall
   • Increase technician staffing at the datacenter as a temporary measure for manual chiller restarts
   • Storage: optimise the large-scale recovery process and update troubleshooting guides (estimated December 2023)
   • Azure Service Fabric: improve reliability of SQL Database tenant ring recovery (estimated December 2023)
   • SQL Database: review the trigger criteria of auto-failover groups (estimated October 2023)
   • SQL Database: upgrade internal tooling to enable mass migration of databases (estimated December 2023)
   • Cosmos DB: optimise Service Managed Failover for single-region-write accounts (estimated November 2023)
   • ARM: complete the migration of its storage layer to the zonally redundant architecture (estimated December 2023)
   • Incident management: harden readiness, process and playbook for power-down scenarios (estimated October 2023)

   Lessons

   A control plane spread across availability zones still fails with a zone when one of its dependencies, here the SQL Database operation queue, is not zone redundant. When a second region uses the same database, the failure crosses into that region as well. Workloads already running were not expected to be affected; what stopped was everything that needs the managed service's control plane, such as scaling and cluster changes.

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3. IL-0091 Changing the worker node instance type through Terraform recycled all nodes at once and deleted users' production pods together

   UK Ministry of Justice2023

   Symptoms

   At 10:23 on 6 June 2023 a user of the Cloud Platform reported that all of their production pods had been deleted at the same moment. Several users received Pingdom alerts that their applications were down for a few minutes.

   Service outage

   Trigger

   The team changed the instance type of the cluster's worker nodes through Terraform.

   Root cause

   Configuration change

   Component

   Node poolTerraform

   Contributing factor

   Excessive blast radiusNo runbook

   Detection

   Users reported that their production pods had been deleted at once and that Pingdom alerts showed their applications down; the incident was declared at 11:00.

   Action items

   • Ask AWS, through a support ticket, for the steps to change the node instance type without an outage
   • Plan how to make instance type changes through Terraform without downtime and add a runbook with the steps for changing the node instance type

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4. IL-0132 A faulty resource cleanup process marked Vertex AI prediction endpoints as deleted worldwide, undeploying customers' models and failing predictions for 4 hours 20 minutes

   Google Cloud2022

   Symptoms

   From 10:10 US/Pacific on 2 June 2022, Vertex AI Online Prediction returned errors for 30% up to 100% of requests per region, depending on how each customer used the service.

   High error rateResources deletedService outage

   Trigger

   A faulty resource cleanup process marked Vertex Prediction Endpoints as deleted, globally.

   Root cause

   Software defect

   Component

   Model request routing

   Contributing factor

   Automation amplificationExcessive blast radius

   Detection

   The first public status update was posted at 13:58 US/Pacific and gave the start as 10:20 US/Pacific; the later mini incident report gives 10:10.

   Remediation

   • restored the Vertex Prediction Endpoints that had been marked as deleted

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5. IL-0106 A malformed Traefik IngressRoute triggered a Traefik v2 bug once a node rollover restarted every Traefik pod, and all Kubernetes services returned 404

   DFDS2021

   Symptoms

   At 08:00 UTC on 2021-09-06 every service in DFDS's Kubernetes cluster answered with 404. Investigation started five minutes later.

   Service outageHigh error rateProbe failures

   Trigger

   The automated Kubernetes node rollover on 2021-09-06 restarted all the Traefik v2 pods, five days after a malformed IngressRoute manifest had been applied.

   Root cause

   Software defect

   Component

   Ingress controllerCloud load balancer

   Contributing factor

   Change with a delayed effectNo configuration testsExcessive blast radius

   Detection

   All services returned 404 from 08:00 UTC and root cause investigation started at 08:05. Time to detection was 5 minutes.

   Remediation

   • changed the ALB health check path, which made the targets healthy but did not stop the 404s
   • rolled back by hand to Traefik v1 as the main ingress controller
   • deleted the malformed IngressRoute by hand and confirmed the Traefik v2 bug
   • applied the changes upstream

   Action items

   • Upgrade Traefik to v2.5, where the bug is fixed, and verify that it removes the bug
   • Change the Traefik v2 health check path to something more robust
   • Set up an external liveness probe on the ingress controller
   • Consider workload segmentation to limit the blast zone
   • Look into monitoring the Traefik v2 API for rapid changes
   • Look into smoke testing during and after node rollover

   Lessons

   A malformed IngressRoute did nothing visible for five days and then took down all ingress when every Traefik v2 pod had restarted during a node rollover. Because Traefik v2 failed gracefully, the first signals pointed at the ALB health checks instead of at Traefik. On incident handling, the team concluded that appointing an incident manager could have helped, that the war room meeting should be recorded and a log book kept, that people not involved should only make suggestions in writing, and that a short first round of sharing thoughts and gut feelings is useful.

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