Cases7 cases

1 to 5 of 7

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.

   View case
2. IL-0018 A Docker Hub password rotation left EKS nodes and Concourse locked out of Docker Hub and unable to pull images

   UK Ministry of Justice2023

   Symptoms

   At 14:22 a Cloud Platform team member noticed failed Docker Hub logins. Fetching an image returned: failed to fetch manifest: Head "https://registry-1.docker.io/v2/ministryofjustice/cloud-platform-tools/manifests/2.1": toomanyrequests: too many failed login attempts for username or IP address

   Image pull failures

   Trigger

   The Docker Hub password was changed as part of LastPass remediation activities while the EKS cluster nodes and Concourse still logged in with the previous password.

   Root cause

   Operator error

   Component

   Container registry and its credentialsNode launch templateNode poolCI system

   Contributing factor

   Credential in configurationShared credential

   Detection

   A Cloud Platform team member saw the failed Docker Hub login error at 14:22. The Kuberhealthy daemonset check showed at 14:52 that the cluster could not pull images, and a user reported ErrImagePull in #ask-cloud-platform at 14:54.

   Remediation

   • Changed the Docker Hub password back to the previous value still used by the EKS cluster nodes and Concourse
   • Confirmed with the reporting user that the pod deployed and that cluster image pulls worked again

   Action items

   • Switch from the Docker Hub username and password to a Docker Hub token created specifically for Cloud Platform
   • Rotate the password cleanly out of hours with a graceful recycle of the nodes

   Lessons

   The write-up states no separate lessons. Its review action replaces the Docker Hub username and password with a Docker Hub token created specifically for Cloud Platform.

   View case
3. 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

   Application 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.

   View case
4. IL-0115 One of OpenAI's three production AKS clusters went offline through a human error, and rebuilding it took 10½ hours because an AKS Kubernetes upgrade broke the ingress and AKS cannot be downgraded

   OpenAI2022

   Symptoms

   At 18:56 PDT on 23 June 2022 (01:56 UTC on 24 June) several models went offline at once: some fine-tuned curie and davinci models, the Codex beta models code-davinci-001 and code-cushman-001, the legacy GPT models curie, babbage and ada, and all Embeddings models.

   Service outageHigh error rateIntermittent timeouts

   Trigger

   A destructive operation on one of the three production clusters, caused by human error that the existing safeguards did not catch, took the whole cluster offline.

   Root cause

   Operator error

   Component

   Ingress controllerModel hub

   Contributing factor

   No safeguard on destructive changeNo headroomDeferred upgradesOverlapping failures

   Remediation

   • re-allocated the models from the lost cluster to the remaining two clusters
   • rebuilt the VPN link with Azure support after losing the connection to AKS during cluster setup
   • built workarounds with Azure support after losing the connection to Azure Private Link
   • tore down the cluster and rebuilt it from scratch after the upgraded Kubernetes version broke the ingress
   • moved traffic back into the rebuilt cluster between 05:30 and 06:30 PDT

   Action items

   • Add checks and locks so that this and similar production-critical infrastructure cannot be modified by accident
   • Add better visibility into the operations being performed and make parts of the system more lexicographically distinct
   • Keep working with Azure on the AKS network connectivity issues so they do not disrupt new cluster operations
   • Update playbooks with the new cluster failure modes and change the setup steps for new clusters and infrastructure
   • Upgrade Kubernetes systematically and set aside time so the clusters do not fall behind again
   • Shard fine-tuned models across multiple clusters and work towards more automatic cross-cluster replication
   • Distribute and replicate Azure Blob Storage so fine-tuned models load faster and more reliably
   • Finish rolling out node-to-node caching to relieve Azure Blob Storage bottlenecks
   • Change how model weights are stored so they are more efficient and faster to load

   Lessons

   Losing one of three clusters exhausted the GPU headroom, and GPUs could not be added on short notice, so full recovery depended on bringing the same cluster back. Rebuilding it exposed a deferred Kubernetes upgrade: the newer version broke the ingress, and because AKS cannot downgrade there was no way back except a full rebuild. Recovering many large models at once is limited by the bandwidth of the storage they load from, and the caches that normally hide this do not help when everything moves to a different cluster.

   View case
5. IL-0197 Moving a three-node Elasticsearch StatefulSet to new persistent volumes split the cluster in two, because the Helm chart hardcoded cluster.initial_master_nodes to elasticsearch-0

   Palark2021

   Symptoms

   After the last old Elasticsearch pod, elasticsearch-0, was deleted and came back on a new, empty persistent volume, `_cat/nodes` run inside that pod listed a single node: elasticsearch-0 itself, marked as master. The same command run inside elasticsearch-1 listed the other five nodes, elasticsearch-1 to elasticsearch-5, with elasticsearch-2 as master.

   Split brain

   Trigger

   Deleting the elasticsearch-0 pod and its PVC so that it restarted on an empty volume of the new StorageClass.

   Root cause

   Operator error

   Component

   Elasticsearch or OpenSearchPersistent volumes and stateful setsHelm

   Contributing factor

   Unverified assumption

   Detection

   The engineer running the migration checked `_cat/nodes` after elasticsearch-0 restarted and saw it alone in a cluster of its own.

   Remediation

   • scaled the three deployments of workers writing to Elasticsearch down to zero
   • listed elasticsearch-0, elasticsearch-1 and elasticsearch-2 under initial_master_nodes in the elasticsearch ConfigMap and removed the cluster.initial_master_nodes environment variable from the StatefulSet
   • saved and deleted the elasticsearch discovery Service and deleted the PVC of elasticsearch-0 while the rolling update ran
   • set initial_master_nodes to elasticsearch-3, elasticsearch-4 and elasticsearch-5, created an empty PVC for elasticsearch-0 and deleted all six pods
   • recreated the discovery Service from the saved manifest, after which the six nodes formed one cluster with every index green

   Action items

   • Restore the original initial_master_nodes values in the ConfigMap and restart all pods again
   • Move all shards to nodes 0, 1 and 2 and scale the cluster down from six nodes to three
   • Commit all the manual changes to the repository

   Lessons

   A setting that only matters when a cluster first starts, such as Elasticsearch's cluster.initial_master_nodes, can sit in a Helm chart template rather than in the ConfigMap that was reviewed. When a pod named in it starts with an empty data directory, it can bootstrap a new cluster beside the existing one. The author's conclusion is that a migration plan like this one breaks on any surprise and needs a plan B ready. Before running it in a more important environment, rehearse it in a test environment configured like production, and either schedule downtime or move the load to another cluster: stop the writers, take a fresh backup, then move the data.

   View case

By root cause1