Cases17 cases

2 to 6 of 17

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-0005 A new telemetry service overloaded the Kubernetes API servers of large clusters and broke DNS-based service discovery for all OpenAI services

   OpenAI2024

   Symptoms

   Alerts fired at 3:13 PM PST on 11 December 2024, and from 3:16 PM every OpenAI service was significantly degraded or completely unavailable, including ChatGPT, the API and Sora. The status page reported API calls returning errors and difficulties logging in to platform.openai.com and ChatGPT. Customer impact peaked at 3:40 PM.

   Service outageHigh error rateControl plane unresponsiveDNS resolution failures

   Trigger

   At 2:23 PM PST a change introducing a new telemetry service, which collects detailed Kubernetes control plane metrics, was merged and the deployment pipeline started. Between 2:51 PM and 3:20 PM the change was applied to all clusters.

   Root cause

   Configuration change

   Component

   Kubernetes API serverClient-side DNS resolver and cacheTelemetry agent

   Contributing factor

   Unrepresentative stagingNo staged rolloutCache-masked failureMonitoring blind spotLimited debug access

   Detection

   OpenAI's detection tools worked: alerts fired at 3:13 PM PST, a few minutes before customer impact began at 3:16 PM, and the root cause was identified at 3:16 PM.

   Remediation

   • Scaled clusters down to reduce the total Kubernetes API load
   • Blocked network access to the Kubernetes admin APIs so no new expensive requests arrived
   • Scaled up the Kubernetes API servers
   • Removed the telemetry service once enough control was back
   • Moved traffic from impacted clusters to healthy ones
   • Intervened manually in clusters where simultaneous resource downloads saturated resource limits

   Action items

   • Put every infrastructure configuration change through a phased rollout with continuous monitoring of both the service workloads and the clusters, including the Kubernetes control plane
   • Run fault injection tests in which the data plane runs without the control plane for longer, and tests that roll out bad changes on purpose to check detection and rollback
   • Build break-glass mechanisms so engineers can reach the Kubernetes API servers in any circumstances
   • Decouple the Kubernetes data plane from the control plane so that service discovery for critical workloads does not depend on the control plane
   • Speed up recovery with better caching and dynamic rate limiters for resources needed at cluster startup, and regular drills that rapidly replace an entire cluster

   Lessons

   Several systems and processes failed at once and interacted in unexpected ways: tests did not catch the change's effect on the Kubernetes control plane, DNS caching put a delay between the change and the failures, and being locked out of the control plane made remediation very slow. Because service discovery used Kubernetes DNS, the control plane was carrying load for product traffic even though the data plane was meant to be independent of it.

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3. IL-0114 An unpinned AWS VPC CNI plugin was updated automatically during a capacity expansion, leaving new pods Pending without IP addresses and stopping CoW Protocol settlements for about 3.5 hours

   CoW Protocol2024

   Symptoms

   At 16:40 UTC on 19 April 2024 CoW Protocol's mainnet production environment stopped producing settlements; the outage officially began then.

   Pods PendingIP address exhaustionPod evictionService outage

   Trigger

   During a cluster capacity expansion, the Infrastructure as Code automation updated the AWS VPC CNI plugin, because the CNI version was not hardcoded in the IaC and the IaC library version had recently changed.

   Root cause

   Configuration change

   Component

   AWS VPC CNINode pool

   Contributing factor

   Unpinned versionOverlapping failures

   Detection

   The CNI version mismatch was identified as the cause at 17:03 UTC, 23 minutes after settlements stopped.

   Remediation

   • upgraded the Kubernetes cluster
   • set up new node groups with a new version of the networking plugin

   Lessons

   Versions in IaC scripts should be specified explicitly so an automation run cannot update a component such as the CNI plugin unintentionally. Changes in production need change management that is easy to revert.

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4. IL-0153 DOKS worker nodes went NotReady at 06:00 UTC on three days because a systemd timer in the Debian image ran apt upgrade and killed it mid kernel upgrade, breaking node networking

   DigitalOcean2023

   Symptoms

   Customers of DigitalOcean Managed Kubernetes (DOKS) saw worker nodes go NotReady between 06:00 and 07:00 UTC and stay unavailable, taking down the services on them, until the nodes were replaced or rebooted; some nodes needed several replacements or reboots. The first sporadic reports on October 8 said replacing the node fixed it. The same thing happened again around 06:00 UTC on October 9, more widely and across many regions, and again on October 10. Only clusters on versions 1.27.6-do.0 and 1.28.2-do.0 were affected.

   Node NotReadyService outage

   Trigger

   A systemd timer in the DigitalOcean Debian image started apt upgrade daily at 06:00 UTC, with a random delay of up to 60 minutes.

   Root cause

   Configuration change

   Component

   Node operating system imageLinux kernelkubelet

   Contributing factor

   Unreviewed defaultsLimited debug accessChange with a delayed effect

   Detection

   Sporadic customer reports of failed worker nodes arrived at 07:43 UTC on October 8; internal incident response started at 07:10 UTC on October 9 after broader impact across regions.

   Remediation

   • Advised customers to replace or reboot affected worker nodes
   • Arranged SSH and console access to worker nodes while they were healthy, and live-debugged an affected node on October 10
   • Released a DaemonSet to all affected clusters that disables the apt upgrade systemd timer on every worker node
   • Released new node images without the auto-update process

   Action items

   • Disable the timer during node provisioning, then remove the DaemonSet from all clusters
   • Add a check to the internal conformance test suite for new cluster versions that the auto-upgrade process and other unwanted timers stay disabled
   • Support logging into worker nodes even when normal access paths are broken

   Lessons

   An operating system auto-update timer left enabled in a node image can change the kernel and systemd underneath Kubernetes, and a timeout that kills the upgrade half-way can leave a node without networking. Failures that start at the same time every day point to a scheduled job on the nodes, and systemd timers belong on that list next to cron jobs. When the failure takes out a node's network, an investigation that depends on logging into the node stalls; access paths that work while the node is broken shorten diagnosis.

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5. 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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