Cases9 cases

1 to 5 of 9

1. IL-0095 An engineer deleted the prod namespace of the LEAP JupyterHub while believing the kubeconfig pointed at a new cluster, and the hub was down for about an hour

   2i2c2025

   Symptoms

   At 5:00 PM BST on 12 August 2025 a 2i2c engineer declared an incident. While deploying a new cluster called temple and running into NFS issues, the engineer had deleted the prod namespace; the deletion hung, and listing the pods showed many users from a different cluster. The engineer's first message suggested that the kubeconfig had somehow been mutated or corrupted and that some other cluster was being torn down.

   Resources deletedService outage

   Trigger

   While working around a bug in the NFS deployment process for a new hub, an engineer ran a delete of the prod namespace with the kubeconfig context pointing at the LEAP cluster.

   Root cause

   Operator error

   Component

   Persistent volumes and stateful setsJobs and CronJobsIngress controllerTerraform

   Contributing factor

   No safeguard on destructive changeNo runbook

   Detection

   The engineer who ran the deletion noticed when it hung and the pod list showed users of another cluster, and declared the incident at 5:00 PM BST, before the uptime check on leap.2i2c.cloud failed at 5:32 PM.

   Remediation

   • deleted the single remaining user pod in prod so the namespace deletion completed
   • killed the nfs-share-creator job that was blocking the deployment
   • redeployed the prod hub with the updated NFS server IP address
   • deleted the prod ingress during the deployment so that users could not start servers mid-deployment

   Action items

   • Write an incident report
   • Write a short incident response document for the case "I deleted prod, what next?"
   • Upgrade jupyterhub-home-nfs and remove the nfs-share-creator job
   • Add opt-in hardening against nested kubeconfig contexts to the deployer system
   • Change the engineer's shell configuration to show distinct kubeconfig contexts more clearly

   Lessons

   Provisioning persistent storage outside Kubernetes with Terraform meant a deleted namespace cost an hour of downtime and no data. The engineer had no visible cue for which kubeconfig context was active, which turned a workaround on a new cluster into a deletion on a production one. The engineer knew the fix but did not feel confident redeploying without first confirming with the tech lead, in another time zone, that there was no risk of losing persistent data, and reaching the tech lead took time.

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2. 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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3. IL-0244 A queued pull request destroyed the EKS subnet route table associations and Cloud Platform services went offline

   UK Ministry of Justice2024

   Symptoms

   On 20 September 2024 at 11:24 the Cloud Platform team received high priority Pingdom alerts for services on the live cluster, and from 11:26 teams reported in the #ask channel that services were unavailable. Users reported that services could not be resolved.

   Service outageNetwork unreachableResources deleted

   Trigger

   At 11:21 the infrastructure-vpc-live-1 pipeline was unpaused, and a pull request that had been waiting in its queue ran automatically.

   Root cause

   Operator error

   Component

   TerraformCI systemVPC route tables and firewall rules

   Contributing factor

   No safeguard on destructive change

   Detection

   High priority Pingdom alerts for live cluster services reached the Cloud Platform team at 11:24, and users reported that services could not be resolved.

   Remediation

   • Ran terraform apply locally to rebuild the subnet route table associations

   Action items

   • Review and update the process for pausing and resuming infrastructure pipelines so every team member knows its implications
   • Find a way to hold queued pull requests while manual infrastructure updates are under way
   • Find ways to isolate the plan and apply tasks of infrastructure pipelines better

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4. IL-0473 Jenkins infrastructure went fully down after a pod IP range fix deleted every AKS node pool and could not recreate them

   Jenkins project2023

   Symptoms

   On 7 July 2023 from 11:05 to 15:25 UTC many public Jenkins infrastructure services were completely down, including get.jenkins.io, plugins.jenkins.io, accounts.jenkins.io, javadoc.jenkins.io and incrementals.jenkins.io, while ci.jenkins.io, issues.jenkins.io, repo.jenkins-ci.org and www.jenkins.io were partly or completely disrupted.

   Network unreachableResources deletedCluster or node provisioning stallService outage

   Trigger

   After the upgrade to Kubernetes 1.25 changed the range of the pods' originating IP and LDAP access was blocked, a fix (Azure PR 431) deployed at 10:55 UTC to set a proper set of pod IP ranges removed all node pools of the cluster.

   Root cause

   Configuration change

   Component

   Node poolCNI pluginCloud load balancer

   Contributing factor

   Unverified assumptionNo staged rolloutNo safeguard on destructive change

   Detection

   After the upgrade, at 10:30 UTC, the team noticed that services inside the cluster, such as accounts.jenkins.io, could not reach the LDAP service.

   Remediation

   • Created the cluster again from scratch with a fixed network setup
   • Set a custom pod CIDR in a range separate from the virtual network
   • Moved the services and their DNS records to new public IPs
   • Pushed a pull request that recorded the manual rebuild, including the IP setup, in code

   Action items

   • Protect the public IPs from deletion with a Management Lock
   • Keep the public IPs in a separate resource group and point the Kubernetes-managed load balancers to it with the service.beta.kubernetes.io/azure-load-balancer-resource-group annotation
   • Improve network diagrams and documentation so possible overlaps are visible when preparing operations
   • Avoid changing the configuration of all AKS node pools at once

   Lessons

   The team said that changing one node pool at a time would have shown the problem after the first pool and avoided a full outage, and that the public IPs should change as little as possible because users behind corporate firewalls with allow-lists depend on them. The team also noted that it could rebuild, in under 4 hours, the cluster that hosts almost all public services.

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5. IL-0207 A routine task run from an engineer's local environment switched to production and deleted GitLab.com's Consul release, so Patroni lost Consul and GitLab.com returned 5xx errors to all traffic

   GitLab2022

   Symptoms

   GitLab's monitoring and alerting fired at once. One of the alerts reported a Patroni failover, and users of GitLab.com received 5XX errors; the CDN counted about 13 million requests answered with 503 during the outage.

   Service outageHigh error rateResources deleted

   Trigger

   An engineer ran a routine task with GitLab's tools in a local development environment; during a local deploy or rollback operation the tool's context changed from local development to production, and the change was applied to production.

   Root cause

   Operator error

   Component

   Database

   Contributing factor

   No safeguard on destructive change

   Detection

   GitLab's monitoring and alerting fired immediately; one of the alerts reported a Patroni failover.

   Remediation

   • re-applied the Consul release to the production Kubernetes cluster, with manual steps because the tooling did not support the redeploy directly

   Action items

   • Improve the Kubernetes deployment process to reduce the risk of running harmful deployment operations against production from local environments (https://gitlab.com/gitlab-com/gl-infra/reliability/-/issues/16875)
   • Integrate Teleport with the Kubernetes clusters, which could give SREs a read-only role by default (https://gitlab.com/gitlab-com/gl-infra/reliability/-/issues/16221)

   Lessons

   A tool that can switch its target from a local environment to production during a deploy or rollback turns routine local work into a production change. GitLab plans to improve its Kubernetes deployment process so that harmful deployment operations are less likely to be run against production from local environments, and to integrate Teleport with its clusters, which could give SREs a read-only role by default. Detection and diagnosis were fast because the alerts led straight from Patroni to its dependency, Consul. Bringing the deleted release back needed manual work, because the tooling did not make the redeploy straightforward, but it was still done relatively quickly.

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