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-0225 An IGP purge command made every Microsoft WAN router recompute routes, causing global latency, timeouts and packet loss

   Microsoft Azure2023

   Symptoms

   From 07:08 UTC on 25 January 2023, customers saw long network latency and timeouts when connecting to resources in Azure regions and to other Microsoft services such as Microsoft 365 and Power Platform. Microsoft's monitoring detected DNS and WAN issues from 07:11 UTC.

   High latencyIntermittent timeoutsIntermittent connection failuresPacket lossNetwork unreachable

   Trigger

   A network engineer adding capacity to the global WAN in Madrid ran a step of a recently changed standard operating procedure that purged the IGP database; on the router manufacturer involved, that command runs on all IGP-joined routers instead of only the local one.

   Root cause

   Configuration change

   Component

   Backbone network (WAN)Interior routing (IGP)BGP routing

   Contributing factor

   No configuration testsUnverified assumptionExcessive blast radiusHarmful manual action

   Detection

   Monitoring detected DNS and WAN issues from 07:11 UTC and alerted the on-call engineers within 5 minutes of the command being run. The team reviewed all recent changes and identified the command by 08:20 UTC. The engineer making the change was not informed of the alerts because of the unqualified changes to the SOP.

   Remediation

   • Restarted by hand the paused WAN health and traffic engineering systems, which ended the remaining packet loss

   Action items

   • Audit and block similar widespread-impact commands across all three vendors for all WAN router roles
   • Give on-call engineers real-time visibility of approved and unqualified activity on network devices
   • Run regular mandatory operational training and attestation of following all SOPs
   • Have the Change Advisory Board review all SOPs still pending qualification within 30 days

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