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Telstra's triple-0 outage on March 1 was the combination of a technical fault, an issue in the backup process and a communication error that occurred in the heat of the moment, Telstra CEO Vicki Brady has said.
The outage, during which a Victorian man died, took place at Telstra's triple-0 call centre at the start of the month and affected calls from five states and territories.
The issue resulted in Telstra operators being able to answer calls, but not redirect them to all triple-0 call centres.
Calls from Victoria, New South Wales, Tasmania, Western Australia and the ACT were affected.
Of the nearly 500 calls to triple-0 during the 90 minute outage, Telstra was unable to transfer 148 of them.
It forced Telstra operators to email referrals, some of which were not received by Triple Zero Victoria operators until after 7am.
Telstra has now shared the findings of its investigation publicly and Ms Brady said people should be able to rely on the technology to get help as quickly as possible and "anything less is not good enough".
Three issues caused the outage
Ms Brady said the incident was the combination of three issues.
The first was a technical fault that resulted in connections to the database reaching the maximum limit, in turn triggering an undetected software fault.
The second was a backup process issue. For all 24 state emergency operators, Telstra stores a backup phone number in a secondary database that can be used for manual transfer should it be needed.
For eight of those 24, the stored number was not correct, which prevented operators from being able to make the manual transfer of the call to the respective emergency services operator.
The last issue, according to Telstra, was a communication error that caused delays in some callers receiving call backs from emergency services operators, mainly in Victoria.
It said when the team identified an issue with the phone numbers, they resorted to email and were supplied an updated email address for Triple Zero Victoria during the outage. That address was incorrectly entered into the system.
"Ensuring we have the right contact numbers for emergency services operators is basic and something we should have gotten right," Ms Brady said.
Ms Brady said she was personally overseeing the work to implement a number of improvements identified after the incident.
"Let me reinforce that the series of failures that occurred on March 1 are unacceptable," she wrote.
"The Australian public rely on triple-0 in their times of greatest need, and we let them down by not being prepared enough for the situation."
Earlier this month, the Australian Communications and Media Authority (ACMA) launched its own investigation on the outage and said it would focus on Telstra's obligations as the Emergency Call Person to transfer emergency calls to police, fire, and ambulance services.
A spokesperson for ACMA said that as of now there was nothing to report on their end, adding that "the ACMA does not comment on investigations that are under way. The ACMA will make its investigation findings public once concluded."
Melbourne patient suffered cardiac arrest during the outage
On the day of the outage, March 1, Victorian Ambulance Union secretary Danny Hill told ABC Radio Melbourne Mornings it was complete chaos.
He said a paramedic crew was delayed responding to the Melbourne patient experiencing cardiac arrest.
"I've been told there was a delay getting through but I don't know how long," he said.
"Sadly, it wasn't a successful resuscitation effort and the patient passed away."
Mr Hill said the deceased person's family received a phone call about an hour later, asking if they still required an ambulance.
"[Crews] were dispatched to cases without having a lot of detail, because they couldn't get that detail through, or it was sent via email," he said.
"In many cases it would get to the crew after the crew actually arrived on the scene."
To conclude the findings of the investigation, Ms Brady said she wanted to apologise to everyone who tried to call triple-0 during the outage and "in particular, the family of a man who suffered a cardiac arrest and tragically passed away."