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.

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2. IL-0078 Enabling EKS secrets encryption with KMS through Terraform removed worker node IAM permissions and took down all ZenML Pro workspaces

   ZenML2025

   Symptoms

   Between 12 AM and 8 AM CEST on 11 May 2025, every ZenML Pro workspace server was unreachable, so customers could not use workspace UIs or pipelines. The ZenML Pro dashboard was not affected.

   Service outage

   Trigger

   At 23:38 on 10 May, secrets encryption with AWS KMS was enabled through Terraform as part of the EKS module upgrade.

   Root cause

   Software defect

   Component

   TerraformNode pool

   Contributing factor

   Unrepresentative stagingDeferred upgrades

   Detection

   Engineers found the cluster degraded when they resumed the upgrade at 06:00.

   Remediation

   • deleted and recreated the EKS node group with the correct IAM permissions and configuration
   • restored service access across all affected ZenML Pro environments

   Action items

   • Upgrade all Terraform modules (EKS, VPC) to current supported versions
   • Complete the EKS cluster upgrades as planned
   • Review the strategy for periodic Kubernetes and infrastructure upgrades to prevent a recurrence

   Lessons

   A successful upgrade on a much smaller staging cluster understated the risk of the same change in production. Skipping Kubernetes and module versions let upgrade complexity build up until one upgrade carried many changes at once.

   View case
3. 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

   View case
4. IL-0109 A retried node rollover on a DFDS EKS cluster set the Auto Scaling group back to 15 instances, and the default termination policy removed every healthy worker node, leaving the cluster with no nodes

   DFDS2023sev1

   Symptoms

   At 09:33 UTC on 14 February 2023 end users told the platform team that Kubernetes logs were not arriving in CloudWatch as expected. The investigation went through fluentd and found that the nodes were running containerd as their container runtime instead of docker-shim. A scheduled node rollover the day before, at 07:30 UTC on 13 February, had set containerd as the default runtime by accident.

   Service outageResources deletedMonitoring outage

   Trigger

   A scheduled node rollover had accidentally made containerd the default container runtime, which stopped log shipping to CloudWatch; the unscheduled rollover to revert it timed out, and the pipeline run that followed reduced the Auto Scaling group from 30 to 15 instances.

   Root cause

   Configuration change

   Component

   Container runtimeNode launch templateNode poolTerraformTelemetry agent

   Contributing factor

   Automation amplificationUnreviewed defaultsUnrepresentative stagingNo configuration testsNo runbookHarmful manual action

   Detection

   End users reported the missing CloudWatch logs that started the work. The postmortem lists 2 minutes as the time to detection of the node failure.

   Remediation

   • ran the node rollover script to add new nodes, which failed on a timeout from Docker Hub
   • ran the node rollover script a second time, which added new nodes that the load balancer marked healthy at 11:01 UTC

   Action items

   • Document the rollover process, especially what can be done when it goes wrong
   • Investigate options for improving the rollover process
   • Add fluentd log collection to the QA test suite so logs are covered end to end
   • Add alarms for fluentd when too little or no log data is sent
   • Implement a staging environment
   • Implement guards against selecting an invalid container runtime

   Lessons

   When a change goes wrong, rolling back to a known working configuration is safer than rushing a fix, which can make the damage worse. Launching new worker nodes depends on the cloud-init script not failing in any way. The QA configuration differed from production, there was no staging environment, the QA tests did not cover fluentd log collection, and the rollover process had no documentation for when it fails.

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5. IL-0112 The daily node rollover put DFDS's EKS nodes on an AMI later recalled for a kernel issue, causing "PLEG is not healthy" NodeNotReady flaps and pod network timeouts

   DFDS2022

   Symptoms

   On 2022-10-31 a planned upgrade of the vpc-cni EKS add-on, started from the deployment pipeline at 13:45 UTC, timed out at 14:10. Only about 10 of the 45 aws-node pods had upgraded, 5 were stuck in Terminating and the other 30 had not been attempted.

   Node NotReadyUpgrade stallIntermittent timeoutsIntermittent connection failures

   Trigger

   At 07:30 UTC on 2022-10-31 the daily node rollover replaced the existing nodes with nodes built from AMI v20221027, the latest AWS EKS node AMI, released on 2022-10-29 and later recalled because of a kernel issue.

   Root cause

   Software defect

   Component

   Node operating system imageLinux kernelkubeletAWS VPC CNINode launch templateTerraform

   Contributing factor

   No staged rolloutAutomation amplificationOverlapping failuresMonitoring blind spotNo health probes

   Detection

   The team noticed nodes flapping between NodeNotReady and NodeReady ("KubeletNotReady PLEG is not healthy") at 14:30 UTC while watching the stalled vpc-cni upgrade, about seven hours after the rollover. Time to detection was 7 hours. Alerting did not catch the NodeNotReady events or the socket growth.

   Remediation

   • cordoned, drained and deleted 15 stuck nodes one at a time to complete the vpc-cni upgrade
   • changed the Terraform infrastructure-modules so a specific AMI could be set
   • rolled the EC2 Auto Scaling group launch configuration back to the previous known good AMI through the pipeline

   Action items

   • Reach out to teams with suggestions about readiness and liveness probes
   • Create a dashboard for readiness and liveness probe coverage
   • Write a wiki article on readiness and liveness probes and their usefulness
   • Modify infrastructure-modules to allow specifying a particular AMI
   • Schedule a discussion on whether to take the latest AMI immediately and how to test new AMIs before they are deployed
   • Implement alerting on abnormal NodeNotReady events and on increased socket use
   • Create a learning path for Kubernetes within the team
   • Collect logs from nodes centrally
   • Create a Prometheus exporter that retrieves the latest available AMI, with a dashboard and alerts

   Lessons

   When a new node AMI has just been rolled out, upgrading other cluster components on the same day makes it hard to tell which change is causing trouble; here the vpc-cni upgrade on the same day confused matters. Taking the latest AMI automatically with no way to pin one meant a rollback first needed a Terraform change. The team also concluded that it needs better communication paths with application teams during incidents.

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