Cases2 cases

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1. IL-0400 Public sector sites across Wales lost connectivity for over 8 hours as a PE router wrongly advertised a default route

   PSBA2026

   Symptoms

   On 25 March 2026 from about 16:40, public sector organisations on the PSBA network across Wales lost connectivity at their sites. The Service Desk saw about 400 alerts at 16:58, when a Major Incident was declared, about 1,500 at 17:05 and about 5,000 across Wales at 17:08, while councils, a fire and rescue service and Natural Resources Wales phoned in to report sites down.

   Network unreachableIntermittent connection failuresLink flapping

   Trigger

   At 16:30 a route map change was applied, outside formal change control, on a PSBA core Provider Edge (PE) router to leak MPLS VPN routes, so that legacy Capita-operated UPS devices in a /16 subnet could be managed by BT/PSBA. The change was removed at 16:40.

   Root cause

   Configuration change

   Component

   BGP routing

   Contributing factor

   Ineffective rollbackMissed in reviewLimited debug accessOverlapping failures

   Detection

   At 16:57 Mid Wales Fire & Rescue Service phoned in a loss of connectivity at its Presteigne site, and at 16:58 a case was opened in Service Now for a group of about 400 alerts and a Major Incident was declared.

   Remediation

   • Removed the route map change from the PE router at 16:40
   • Changed QoS on the BGP to bring back the management links, after which alarms cleared
   • Cleared routes and reset inbound BGP advertisements, which did not stop the default route being advertised
   • Corrected the configuration issue affecting the internet learned route at 01:02
   • Performed a controlled reload of the affected router at 01:10, which restored customer services and management connectivity

   Action items

   • Reinforce change control requirements with an internal briefing on formal change submission, the risks of unplanned changes and roles during planned and emergency changes
   • Create a dedicated Microsoft Teams channel as the single real-time communication point for all live P1 and Major Incidents
   • Explore disaster recovery and business continuity test exercises for major or P1 incidents
   • During loss of management access, have all technical teams assess customer impact from what reporting organisations provide, captured and shared in real time by the Service Desk and Incident Management
   • Investigate a fixed link between Capital Quarter and the PSBA management racks in Vantage Data Centre at Newport, with dedicated management terminals and two-factor authentication for access outside the secure management platform
   • Improve initial triage with stronger probing questions when incidents are reported and keep reassessing and communicating impact throughout the incident
   • Review the P1 and Major Incident process so escalation criteria and timeframes are clearly defined, and train the Service Desk to recognise and escalate them early
   • Review the PSBA estate for legacy configuration, set processes and timeframes for removing it and add controls so it is not introduced again
   • Review email and SMS distribution lists and processes and reinforce Service Desk training on customer communications during P1 and Major Incidents

   Lessons

   The report names eight lessons: a change was made outside PSBA change control; internal communication during the Major Incident was slow and fragmented; the organisation was not ready for a network-wide incident; losing management access stopped the resolver groups from seeing the network state and customer impact; the resolver groups did not understand customer impact in enough detail, which delayed finding the root cause; escalation to PSBA management was slow; legacy configuration left in the network contributed; and email and SMS communications did not reach some customers in time.

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2. IL-0539 KT's internet service failed nationwide for about 89 minutes as wrong routes spread from one router in Busan

   KT2021

   Symptoms

   On 25 October 2021 from about 11:16, traffic to the DNS servers in KT's network rose sharply, and then KT's internet service failed across the whole country. KT recognised the internet outage at 11:20, and the outage lasted about 89 minutes until KT finished recovery at about 12:45.

   Network unreachableService outage

   Trigger

   During the replacement of an enterprise network router at KT's Busan office, worked on remotely from the Busan communication center, a worker entered a routing configuration script that lacked the 'exit' command that should have ended the IS-IS part of the configuration.

   Root cause

   Configuration change

   Component

   Interior routing (IGP)BGP routing

   Contributing factor

   Missed in reviewNo configuration testsChange during peak hoursExcessive blast radius

   Detection

   KT recognised the internet outage at 11:20, four minutes after DNS traffic began to surge at 11:16. The Ministry of Science and ICT saw the traffic increase in its own monitoring, and KT reported the outage to the ministry at 11:40.

   Remediation

   • Isolated the router where the faulty routing configuration was entered
   • Logged in to each regional router, deleted the faulty processes and restarted them

   Action items

   • Check the network management of major carriers, including their work procedures and the systems that stop technical errors from spreading
   • Consider having major carriers introduce simulation systems that diagnose errors from network work in advance
   • Have the NMS center and network operations center of each major carrier check technically that approved work plans are followed
   • Strengthen safeguards in routing work, such as limiting the number of route entries updated at once below a set level
   • Strengthen the monitoring of carriers' outages and develop technology, including AI-based preventive diagnosis, for network stability and resilience
   • Prepare structural measures for a stable network architecture and network survivability
   • Let carriers notify users of outages through SNS, text messages and other means, not only the website

   Lessons

   The investigation named management problems and technical problems. On the management side, work approved for the night was done during the day, partner company workers did the routing work without a work manager, and the work was done with the network still connected. On the technical side, the two pre-verification steps were people reading the script and missed the missing 'exit', there was no virtual testbed for trying the work on a disconnected network, and nothing stopped an error in one region from spreading to the whole country.

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