The 2025 Optus Triple-Zero Outage: Why Firing Leaders Only Silences Learning
- mikemason100
- Sep 29
- 5 min read
In September 2025, Optus experienced a catastrophic failure: during a routine firewall upgrade, around 600 emergency (000) calls failed across multiple states, and three fatalities were linked to the outage.
Public outcry was immediate. Calls for the CEO’s resignation, for stern accountability, and for someone to “pay the price” dominate headlines and social media. But when the stakes are life and death, do demands for dismissal help or hurt?
Somewhat ironically, the person at the top when a failure happened is often the one who learned the most from it. That person holds vital insight into what broke, what controls didn’t work, and how the failure propagated. This knowledge if lost, can doom future resilience.
If we default to sacking leaders or 'the last person to touch it' after every visible breakdown, we institutionalise fear, silence, and memory loss. We lose the chance to build systems that adapt and improve. In this post, I’ll explore why the reactive “fire them” instinct is dangerous, and how in the Optus case, and beyond, we’d be wiser to keep leaders close and push for learning instead.
Let’s unpack what happened (based on available evidence), then look to other high-stakes cases (Secret Service, healthcare), and draw business lessons we can apply in any high-performance organisation.
What We Know (and What We Don’t) About the Optus Outage
Because Optus’ affected infrastructure is older and much of the system data isn’t publicly available, much of what we know about the outage comes from statements, media reporting, and regulatory observations, not from hard black-box-type data.
Here’s how the failure unfolded (as far as is known):
The outage began during a scheduled firewall upgrade early on 18 September 2025.
Calls using the 000 (emergency) system were blocked or failed to route properly during the outage, even though regular phone calls were unaffected.
Around 600 emergency calls were not connected during that period.
At least three people died in circumstances linked to the outage: two in South Australia (one was an eight-week-old infant, though authorities later said the outage likely didn’t contribute to that case) and one in Western Australia.
Optus has admitted that some customer calls to 000 were not escalated or not relayed properly by its call centers, delaying awareness of the failure.
There is intense scrutiny on how Optus communicates to government and emergency services: many officials say they were not informed until after media announcements.
Optus has launched internal investigations, and federal and state agencies have initiated formal reviews.
Because crucial system logs and telemetry aren’t yet public, many causal links remain uncertain. But the conclusion in many public narratives is simple: someone must be held accountable, and often the CEO is the target.
Why Reactionary Firing Is a Poor Strategy
1. The Decision-Maker Holds the Most Insight
The Optus CEO and executive team were present at the moment decisions (or oversights) were made. They know what tests passed or failed, what rollback options were considered, how thresholds for “stop work” were set, and how escalation pathways were meant to function.
When leadership is replaced immediately, that institutional memory is lost. The successor must play catch-up, while the organisation loses direct access to the nuance of what went wrong. That gap becomes a blind spot in future resilience design.
2. Fear Kills Transparency
If boards and politicians make execution of failure synonymous with dismissal, then downward layers will interpret errors as existential risks. They’ll stop reporting near-misses, small anomalies, or “strange feels.” The very signals that could prevent catastrophe will go unspoken.
In the Optus case, some calls from customers did alert Optus to the failure, but those reports weren’t escalated. If culture punishes those who raise alarms, those voices disappear next time.
3. Failures Are Systemic, Not Just Personal
The Optus outage reportedly stemmed from a firewall upgrade that disabled emergency call routing. That implicates change management protocols, rollback strategies, monitoring, communication with emergency services, redundancy architecture, and the culture of testing vs. risk tolerance. All of those are systemic. Removing or punishing one person doesn’t fix any of them.
Supporting Cases That Bring the Lesson to Life
The Secret Service Breach
When the assassination attempt on Donald Trump occurred in 2024, critics immediately demanded the head of the Secret Service be removed. But that director and the on-duty team now hold first-hand insight into where a breach occurred, how protocols failed, and what went unnoticed. Firing them would simply expunge that knowledge. Even worse, now that the precedent is set, any future errors will be swept under the carpet for fear of punishment and the learning opportunities cease.
Nurses and Medication Mistakes
Across healthcare systems, there have been tragic cases where nurses making medication errors are sacked or prosecuted. Yet investigation often ignores contributing conditions: high workload, ambiguous labelling, inadequate supervision, or flawed handover protocols. Punishing the individual may feel just, but it drives a culture where mistakes are hidden and learning is stifled.
What Organisations Should Do Instead
Focus on “Why something happened” not “Who is to blame”. Ask: what conditions made this failure possible? Which controls were insufficient? What trade-offs were made under pressure? In Optus’s case: Why did escalation paths not detect the failure? Why did 000 routing depend on a single firewall upgrade?
Retain the Leader Through the Storm. The person in charge during a failure has what no one else does: direct experience. Work with them to lead investigations into causal factors, remediation, and communication, rather than immediately removing them.
Separate Accountability from Punishment. Accountability means transparency, owning the outcome, and driving improvement. Punishment means shutting down, scapegoating, and fear. Be clear about which you demand.
Institutionalise Learning. Build structures that capture lessons, system gaps, near-misses, and signal detection, and feed them into continuous improvement. Don’t let failure become a taboo.
Design Safe Error Reporting Channels. Encourage people to speak up early, surface anomalies, and escalate with confidence that admitting concerns won’t lead to career-ending consequences.
Business Takeaways
When a major product failure, data breach, or service outage occurs, be wary of calls to immediately replace leadership. The person in the hot seat often holds crucial insight.
Building a culture of psychological safety ensures staff surface issues before they become crises.
Focus your post-mortems on causes and system redesign, not scapegoats.
Maintain continuity across change — don’t throw out the person who knows where the walls are weak.
Final Thoughts
The 2025 Optus triple-zero outage is tragic and unacceptable. The technical failure and loss of life demand accountability. But replacing people isn’t the same as creating change.
If we demand firing over learning, we guarantee outcomes merely repeat. When leaders are removed, institutional memory evaporates. Fear takes root. Opportunities to prevent recurrence vanish.
Real accountability means keeping that leader in the room, not so they carry the blame, but so they lead the transformation. Because no one cares more deeply about a failure’s lessons than the person who had to live through them.
At On Target, we believe in holding systems accountable, not people. We believe that failure is fuel for growth, not fodder for scapegoats. And we help leaders navigate crisis, drive learning, and build cultures that never forget.
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Mike Mason and Sam Gladman are the co-founders of On Target, a leadership and team development company that brings elite fighter pilot expertise into the corporate world. With decades of combined experience in high-performance aviation, they specialise in translating critical skills such as communication, decision-making, and teamwork into practical tools for business. Through immersive training and cutting-edge simulation, Mike and Sam help teams build trust, improve performance, and thrive under pressure—just like the best flight crews in the world.
If you'd like to learn more about how On Target can help your team, contact Mike and Sam at info@ontargetteaming.com
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