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Incident response teams – Challenges in supporting the organisational security function



Incident response is a critical security function in organisations that aims to manage incidents in a timely and cost-effective manner. This research was motivated by previous case studies that suggested that the practice of incident response frequently did not result in the improvement of strategic security processes such as policy development and risk assessment. An exploratory in-depth case study was performed at a large global financial institution to examine shortcomings in the practice of incident response. The case study revealed the practice of incident response, in accordance with detailed best-practice guidelines, tended to adopt a narrow technical focus aimed at maintaining business continuity whilst neglecting strategic security concerns. The case study also revealed that the (limited) post-incident review process focused on ‘high-impact’ incidents rather than ‘high-learning’ (i.e. potentially useful incidents from a learning perspective) incidents and ‘near misses’. In response to this case study, we propose a new double-loop model for incident learning to address potential systemic corrective action in such areas as the risk assessment and policy development processes.
Incident Response Teams Challenges in Supporting
the Organisational Security Function
Atif Ahmad1, Justin Hadgkiss1, A.B. Ruighaver2
Department of Computing and Information Systems, University of Melbourne, Australia
School of Information Systems, Deakin University, Melbourne, Australia,,,
Abstract. Incident response is a critical security function in organisations that
aims to manage incidents in a timely and cost-effective manner. This research
was motivated by previous case studies that suggested that the practice of
incident response frequently did not result in the improvement of strategic
security processes such as policy development and risk assessment. An
exploratory in-depth case study was performed at a large global financial
institution to examine shortcomings in the practice of incident response. The
case study revealed the practice of incident response, in accordance with
detailed best-practice guidelines, tended to adopt a narrow technical focus
aimed at maintaining business continuity whilst neglecting strategic security
concerns. The case study also revealed that the (limited) post-incident review
process focused on ‘high impact’ incidents rather than ‘high learning’ (i.e.
potentially useful incidents from a learning perspective) incidents and ‘near
misses’. In response to this case study, we propose a new double loop model for
incident learning to address potential systemic corrective action in such areas as
the risk assessment and policy development processes.
Keywords: information security, security management, incident response,
security models, organizational processes, security learning.
1 Introduction
Many organizations retain an incident response capability to address information
security attacks. The response process consists of preparation for, identification,
containment, eradication and recovery from incidents. Responsibility for this function
typically lies with a computer security incident response team (CSIRT) that is part of
a multi-layered approach towards protecting business information assets. Among the
many motivations for the existence of such teams is the increasing numbers of
security incidents as well as the realization that specialist skills are required in
managing incidents. Within organisations, CSIRTs are often seen as ‘fire-fighters’
(Jaikumar, 2002) since their overt function is reactive responding to intrusions and
other such security incidents in order to minimize the effects of attacks and managing
a successful recovery (van Wyk, 2001; Wiik et al., 2005).
Much incident response literature consists of industry white papers that outline
recommended (technical) practices for implementing an incident response capability
in organisations. For example, best practice guidelines provide detailed step-by-step
procedures and actions to handle incidents (SANS, n.d.; NIST, 2008). In particular,
identification of new attack types and corresponding responses attract particular
interest (Mitropolous et al., 2006; Novak, 2007). The fact that incident response
research focuses on a technical view and gives relatively less attention to holistic
socio-organisational perspectives is consistent with trends in information security
research as a whole (Dhillon and Backhouse, 2001; Siponen, 2005; Zafar and Clark,
2009). Recently though, some research has been published by Werlinger et al. (2010)
that considers the (technical) incident response process from a broader perspective by
examining tasks, skills, strategies and tools employed by practitioners in their
diagnostic response.
However, despite some researchers exploring less traditional angles on the incident
response process, there remains little research on the interface between CSIRTs and
the greater organisational environment, in particular during the ‘lessons learned’
phase. In this phase issues arising from the recent experiences of personnel are
discussed with a view to improving the overall incident response process. There is
some literature that highlights the importance of this phase in the overall incident
response process. Tan et al. (2003) emphasises the need for organisations to establish
learning practices, whereas West-Brown et al. (2003) suggest that the lack of
literature on lessons learned may be due to the difficulty in gaining access to
potentially sensitive organisational information. However, even in this area most
advice is based on anecdotal evidence (Wiik et al., 2005) and comes from industry
white papers and other industry guides.
For the preceding reasons this paper explores issues facing incident response teams
that affect the greater organisational security function. The paper begins with
motivations the authors had in conducting this research followed by background on
the incident response process. An in-depth case study is presented featuring two kinds
of incident response teams operating within the same environment. A discussion
follows that explores organisational issues arising from the response process. The
paper concludes by discussing the shortcomings in organisational learning and
presents a model designed to address the identified learning issues.
2 Background and Motivation
The motivation for this research began with multiple case studies on the reporting
of incidents in medium to large organisations in the Australian financial sector. The
organisations in these case studies were chosen on the basis that they were likely to be
represent similar organisations in the financial sector. From this study we noted that
although senior management declared a willingness to investigate incidents, there
were a number of factors that discouraged formal reporting. These included potential
impact on reputation as well as financial penalties and onerous follow-up procedures
applied by regulators as a consequence of incidents. Therefore, organisations that
participated in this study classified incidents as ‘anomalies’ until a decision was made
to prosecute an individual or if prosecution provided tangible benefits to the
organisation. Unfortunately, as a result of not reporting incidents, key security lessons
were not identified in the formal investigation and follow-up phases implying the
organisation was not learning from its security experiences.
A second series of case studies were performed in three medium to large
organisations which consisted of a utility company, a state government department
and a local government organisation (Shedden et al., 2010). The aim of this research
was to examine how organisations conduct information security risk assessments
using standard methodologies and why they choose to conduct these assessments in
their particular ways. During this research it was noted that from an incident response
perspective, risk assessment processes in the organisations were not informed by data
on previous incidents including impact and probability of occurrence. This was an
important outcome because security assessment relies heavily on estimation of
probabilities and impacts of potential hazards which would benefit from a history of
past incidents. This study revealed the lack of communication between related
security functions in the organisation which, once again, implied that organisations
were not using their security experiences to best advantage.
This paper reports on a third series of case studies (one of these will be presented
in this paper) which have been motivated by our observations from previous studies.
That being the proposition that security incident response, like security risk
management, is being conducted in an insular environment where organisations are
not using their incident response function to best advantage.
3 Incident Response Teams: Handling Security Attacks
An information security incident occurs when there is a direct or indirect attack on
the confidentiality, integrity and availability of an information asset. Such incidents
can include attacks such as malicious software, theft of information, the loss of power
and supporting utilities and information leakage (Ahmad et al., 2005; Whitman and
Mattord, 2005). It is inevitable at some stage that organisations will suffer an
information security incident. Such an incident may result in multiple negative
impacts, such as a loss of company reputation and customer confidence, legal issues,
a loss of productivity and direct financial loss (Alberts and Dorofee, 2004).
The main aim of an incident response team is to mitigate the impact of a potential
major incident. Many large international organisations see an incident response team
as a crucial element of their information security portfolio (Killcrece et al., 2003a). At
its most basic level, incident response teams may be purely reactionary, with the team
forming together in an adhoc fashion once an incident has been detected. However,
more advanced computer security incident response teams tend to adopt a proactive
role, seeking out vulnerabilities before they become incidents (Smith, 1994) and
provide advice and educate employees on information security matters (Killcrece et
al., 2003a).
Kossakowski et al. (1999) identify three main areas of recommended practice for
incident response teams: preparing; handling; and follow up, as listed in Table 1.
Table 1: “Summary of Recommended Practices” (Kossakowski et al., 1999)
1. Establish policies and procedures for responding to
2. Prepare to respond to intrusions
3. Analyze all available information to characterize an
4. Communicate with all parties that need to be made aware of
an intrusion and its progress
5. Collect and protect information associated with an intrusion
6. Apply short-term solutions to contain an intrusion
7. Eliminate all means of intruder access
8. Return systems to normal operation
9. Identify and implement security lessons learned
The focus of this study is on the ‘follow-up’ category, where learning and
information dissemination occur. Conducting an incident follow-up means sacrificing
short-term goals (such as correcting technical incidents) for long-term goals (such as
implementing an improved incident tracking system; (Wiik et al., 2005)). This may
include performing a post-mortem, hardening systems and updating incident response
policies and procedures (Killcrece et al., 2004).
Incident response literature places great importance on the post-incident learning
(Killcrece et al., 2003b). However, compared with the level of detail devoted to
technical improvements, there are few clues as to how this process should actually be
implemented. Tan et al. (2003) have found that “many organisations are ill-prepared
for incident handling and/ or choose to react to security incidents by focusing not on
collecting evidence … but on resuming production as their first and perhaps only
priority”. This study emphasised the need for organisations to learn from security
incidents. Incident response teams should be “a key player in providing risk data and
business intelligence to the organisation, based on the actual incident data and threat
reports they receive. This information can then be used in any risk analysis or
evaluation” (Killcrece et al., 2003a).
4 Security Incident Response: An Exploratory Case Study
Our research used an exploratory multiple case study approach, with interviews as
the primary method of data collection, using documentary evidence to support our
findings. Our aim was to provide a deeper understanding and description of
information systems practice within this field (Shanks et al., 1993; Walsham, 1995;
Darke et al, 1998). Case studies were selected due to their excellence in studying
information systems phenomena in-situ and their allowance for in-depth exploration
of new contexts and phenomena (Benbasat et al., 1987; Yin, 2003).
This case study is one of three exploratory studies performed by the authors to
evaluate issues faced by incident response teams that affect the greater organisational
security function.
4.1 The FinanceOrg Case Study
FinanceOrg is a large global financial services organisation with offices on four
continents. The organisation conducts a wide range of financial transactions and
investments to both consumer and corporate clients. FinanceOrg has over 20,000
employees around the world, and well over a million customers. As a major financial
services organisation, its incident response process is subject to compliance regulation
through Basel II and Sarbanes Oxley. Therefore, all incidents have to be assessed and
reported. Being a publicly listed financial institution, the security of financial and
customer information is of paramount concern. High-reliability is essential, as if
systems go down, the organisation does not make money. The organisation is
hierarchical, with a strong base of middle and executive management.
Information security is governed globally by the Information Security Department.
Personnel in this department report to the Chief Information Security Officer (CISO)
who, in turn, reports to the Chief Information Officer (CIO). A separate department,
located in a different building, is dedicated to Business Continuity. Both areas are
funded by a set annual charge from each of the business departments, based on their
size. Each of the business areas has an assigned Information Security and Risk
Manager that (officially) resides in the Information Security Department.
Risk is governed from the Information Security Department, but each business
assesses and manages its own technical and process risk. Risk assessment data is
stored in local databases within the different business areas, and collated monthly by
the information security department. Business areas are responsible for managing
their own risks, and their level of exposure is monitored at an enterprise-wide level.
All incidents must be recorded in the business department’s risk database.
Security policy and procedure documentation exists on two main levels. General
security policy documents are written from the Information Security Department
whereas technical teams write their own policies based on the framework the general
policies provide. The Information Security Department enforces governance for this.
If security policies are broken in a business area, for example, it is the responsibility
of the business to enforce that policy, but advice and recommendations are provided
from the Information Security Department.
4.2 Incident Response Structure and Reporting
Incidents are reported through the organisation’s helpdesk. An incident tracking
system is used to monitor and log the progress of information security incidents. The
system facilitates communication between the technical teams about their activities,
and provides a timeline of activities and chain of evidence for incident handling.
Incidents are classified by the level of impact they have on the organisation. High-
impact incidents are classified as such because of their criticality to the organisation’s
ability to function, high level of risk, customer impact, and financial considerations.
Low-impact incidents are those that have more of an internal focus, do not have a
direct customer impact, and are lower risk.
The Network Incident Response Team (NIRT) team of four resides in the
Information Security Department. The team work full-time in an incident response
capability, and the size of the team is fixed. Their role is to ensure that the core
network at FinanceOrg is protected at all costs. The NIRT deal with both low- and
high-impact incidents using the ITIL and ISO17799 frameworks. The NIRT’s day-to-
day activities include proactive vulnerability and penetration testing of networks
globally and responding to incidents that pose a threat to networks such as virus
The High-impact Incident Response Coordination Team (HIRCT) sits higher in the
hierarchy. They coordinate incident response. The team of four can quickly expand to
dozens of incident responders if necessary, recruiting anyone in the organisation from
their normal role in order to rectify an incident. Their role is full-time in dealing with
high-impact incidents, and includes conducting post-incident reports for incidents
such as the loss of a mainframe or the crashing of a critical website. The two teams
work independently, but are not mutually exclusive. When a high-impact incident
strikes, the HIRCT manage the response and control of the incident until resolution,
liaising with the Network Team (and any others) via teleconferencing, phone, e-mail
and the helpdesk system.
4.3 Interview Participants
To provide an overall picture, and to see how incident response teams are
informing information security in general, half the interviewees were selected from
outside of the incident response team. Two of the participants work full-time in an
incident response capability, while the other two interviewees have been chosen from
areas that (according to literature) should be informed by the incident response team
(see Table 2).
Table 2: Names and Roles of Interview Participants
NIRT MGR is the manager of the organisation’s Network Security Incident
Response Team which operates under the information security department.
NIRT_MGR is highly educated with two postgraduate qualifications in computing.
She has been working at FinanceOrg for two and a half years and has much
experience in networking, and security.
HIRCT_MGR is the manager of FinanceOrg’s High-impact Incident Response
Coordination Team, which operates under the business continuity department. He has
a vast technical and business knowledge of the company’s staff and information
systems. HIRCT_MGR’s main role involves managing the high-severity information
security incidents that may reach FinanceOrg’s systems. He coordinates with business
representatives, technical teams and numerous others until the incident reaches
ISR_MGR is the Information Security and Risk Manager for the organisation’s
Corporate Business Department. ISR_MGR has a strong background in security
spanning many years. The role of ISR_MGR in each of the business departments is to
act as a spokesperson and champion for the cause of information security, manage
information security risk, and handling of minor incidents.
ISPPT_MEMBER is a senior member of FinanceOrg’s Information Security
Policy and Procedure Team based in the Information Security Department. He has a
very strong technical background, including years of experience in security.
ISPPT_MEMBER works in a team of four, and is responsible for producing and
managing the general information security policies for FinanceOrg. This role is not an
enforcement role.
A previously mentioned, ISR_MGRs of various departments reside in the
Information Security department with ISPPT_MEMBERs and the NIRT_MGR. All
three roles report to the Chief Information Security Officer (CISO) who reports to the
Chief Information Officer (CIO).
All interviews were conducted during normal working hours and taped. They
lasted between one hour and two hours. Five template and procedural documents were
gathered for further analysis. Recorded interviews and notes were later transcribed
and analysed via open, axial and selective coding and through the use of specialised
software (Neuman, 2006). The transcribed date was further cross-referenced with the
collected documents for triangulation.
4.4 Case Study Results: Incident Response and Knowledge Gathering
Incident response at FinanceOrg is divided by impact level. High-impact incidents
are coordinated by the HIRCT and ‘fixed’ primarily by the NIRT. Low-impact
network security incidents are dealt with independently by the NIRT. Both teams
have a very different approach to knowledge gathering, which will be demonstrated in
this section.
Network Incident Response Team (Low Impact)
The knowledge gathering process of the Network Incident Response Team is
focused on identifying direct-causes, rather than the underlying causal structure.
NIRT Mgr explained:
NIRT Mgr: “[We] basically go through standard steps of
standard procedure what’s going on, how’s it effecting [systems],
[and] what can we do to remedy it. Part of what we do is quick
and tactical; how do we stop it today right now…”
NIRT Mgr: “…making sure the process executes seamlessly,
smoothly and effectively. And there isn’t that much trivial
administrative burden to deal with during the incident… when the
team are working on an incident, I want them working on that
incident, not filling out paperwork and detail while the rest is
going on… There are certain processes we can follow and they
can log certain things… but the bottom line is - you’ve got to get
it done.”
While the network incident response team, resolves incidents effectively and
efficiently, the information gathered from these low-impact incidents exhibits a strong
focus on technical information, over policy and risk. Although the team does gather a
large amount of this technical information in order to solve problems, gathering
additional information, crucial to future learning is not being considered. The use of
an incident tracking system could also facilitate learning down the track, but that
would require more than a technically-based log which is only filled out on
completion of an incident.
High-Impact Incident Response Coordination Team
The HIRCT does not work independently on incidents. They deal with the
coordination of high-impact incidents called into the Helpdesk and the NIRT. How
incidents receive their impact rating is considered sensitive, thus cannot be discussed
in any detail. Documentation analysis shows that there is a clear, standardised method
of determining an incident’s impact level. The process of gathering operational
knowledge during high-impact incidents is highly mature, and can involve large
numbers of technical and business staff.
HIRCT Mgr: “…after a high severity incident occurs, two
conferences calls are setup (a technical and a business one)…
Two main parties are involved - technical problem managers
(me) and respective business heads will ring in… to get the latest
The role of the business conference call is to communicate progress in a non-
technical way, so that the business is fed information that is relevant and
understandable. This also shows that there is significant business-technology
communication during high-severity incidents.
Post-Incident Knowledge Creation Process
In terms of low-impact incidents, the only formal post-incident practice that occurs
is to write a log entry in the incident tracking system to say that the issue is fixed.
The actual incident review process is only informal. NIRT Mgr explained that
while their processes were adhoc, they still attempted to learn and determine if they
could be improved. However, ISPPT Member (Senior Member of the Policy and
Procedure Team) confirmed the lack of root-cause analysis for incidents:
ISPPT Member: “…however with incidents… you really
should be doing the last stage of it. The… debrief [or] root-cause
analysis… I think FinanceOrg is still immature in that respect.”
In terms of knowledge creation, the difference between low-impact incidents and
high-impact incidents is stark. For high-impact incidents, the process is strictly
formalised; a review occurs for every high-impact incident. The result of these
meetings is a post-incident report (PIR). The HIRCT Mgr explained that his team
aims to conduct investigations within 24 hours of the system services being restored.
The immediacy of the response shows how mature the knowledge creation process is,
and the level of effort devoted to learning from incidents, especially through causal
HIRCT Mgr: “Once the incident is over, we then conduct a
formal investigation into what went wrong. Identify a number of
causal factors, and mitigation actions to prevent it reoccurring.”
The review process involves at least three meetings. Typically, the first sessions
involve brainstorming and do not include members from the risk area and the
business in general (perhaps to prevent outisiders from arriving at premature
conclusions). Whilst the intention seems honourable, the backlash from that is that
only the technical groups are involved in the input, creating bias, and excluding others
from the learning process. Later, a second meeting takes place where they examine
the causal factors and potential mitigation for these factors. The same technical staff
are present at the second meeting. The final post-incident report contains the causal
analysis, a new risk assessment of the system in question and a list of tasks that
multiple parties must complete.
Case Study Results: Information Dissemination
For low-impact incidents, the NIRT produces several formal reports for
management where the focus is on technical aspects. The management report is a
statistical document containing only generalised learning information. However, the
NIRT does use limited informal communication channels in order to disseminate
incident knowledge.
NIRT Mgr: “…identify [risk-related] information and pass
that off to the risk assessment group because then they have more
of an over-arching view of what the infrastructure in the
organisation is.”
These informal channels are largely due to NIRT Mgr’s own initiative.
Furthermore, the ISPPT Member (Senior Member of the Information Security Policy
and Procedure Team) also works in the same office as NIRT Mgr.
The silo structure of the organisation, a trait shared by many large corporations, is
a serious hindrance. Those outside of the Information Security Department such as
ISR Mgr (Information Security and Risk Manager for Corporate Business) are ‘out of
the loop’. ISR Mgr experiences great difficulty in finding relevant incident knowledge
to apply to her own security requirements, demonstrating large information
dissemination problems.
When asked about her biggest challenge in the job, the Corporate Business
Information Security Risk Manager commented:
ISR Mgr: “It’s the sharing, or rather the finding of
information. The information is there. Each day I find a new
resource that’s got great information.”
ISR Mgr provides an interesting perspective on why this is so:
ISR Mgr: “I think it’s just because people get focused on what
they do… so I think we get very insular about it… In our groups
we work, we’re all ‘techies’… I’ll let maybe the server guys in
because I know they’re ‘my people’ and will understand. And I
don’t think we’ve quite made that bridge between technology and
business. We’ve still away to go. I don’t think that it’s they don’t
want to give the information, they probably just think that it’s not
Due to a lack of formal policy on information dissemination and communication
channels, the silos of information remain a problem. ISR Mgr receives the post-
incident reports because she is now on the distribution list. ISPPT Member, however,
has little knowledge that PIRs even exist. After some explanation, ISPPT Member
acknowledged that such information would be very useful for development of policy
and procedure.
Case Study Results: Extent of Incident Learning
Through the analysis and coding of information, a critical element that we searched
for was evidence of learning both in thought as well as practice. Also, the
sophistication of the learning processes taking place in the organisation.
In the previous section on Incident Response and Knowledge Gathering, the quotes
from the NIRT demonstrated that members were focused on resolving the direct
causes of incidents. In this kind of investigation, the learning that typically takes
place arises from incident response personnel taking corrective actions. Here, learning
bridges the gap between what should have happened in the environment and what did
happen i.e. expected and obtained outcomes. The members of the NIRT understand
this kind of learning and practice it in the course of their duties.
However, the manager of the HIRCT demonstrates an understanding of a higher
and more sophisticated type of learning which involves questioning the technological,
organisational and human factors that influenced the circumstances within which the
incident occurred:
HIRCT Mgr: “Everything we do feeds into something else.
Most incidents you will find that the actual cause of the incident
is an underlying gap in the process somewhere. It might be a
process that allows... like people often say someone put a typo in,
that’s your recourse… If we have a process that allows a single
human error, to cause a high-severity incident, that process needs
to incorporate more checks and balances.”
The HIRCT Mgr is questioning the system itself, rather than the user as the cause:
HIRCT Mgr: “…Any time we actually go through… to find
root causes, and even some of the contributing causes, a number
of those I think are actually the big-wins… if it’s contributed to
that one incident, it could contribute to others … and by looking
out for those shared issues, we solve a lot of potential problems.”
These responses from our interviews demonstrate a desire or understanding of the
need to engage in causal analysis and to question the system or methods.
5 Discussion
FinanceOrg is a large, complex, high-reliability, global organisation. Secure
operation depends on having a strong information security backbone with incident
response capabilities - a core component of its portfolio. Our case study has found
that the organisation is closely following the guidelines found in much of the incident
response literature such as described in white-papers published by various CERTs
(Smith, 1994; West-Brown et al., 2003). By following these guidelines, FinanceOrg
exhibits a mature incident response practice, however there are several significant
issues that affect the greater organisational security function.
5.1. Disparity in Incident Response Approaches
There is a positive incident response culture at FinanceOrg, where those who
report incidents are not punished. Once incidents have been reported, systems are in
place (Helpdesk, e-mail and telephone contacts) for incidents to be classified and the
appropriate incident response team is notified. There is a comprehensive incident
response structure with both incident responders and incident coordinators (West-
Brown et al., 2003).
The NIRT is extremely effective at solving incidents that affect the network of
FinanceOrg. They focus on technical aspects, gather large amounts of forensic data
and respond rapidly to resolve the direct causes of incidents. Their focus is on
protecting the core network with containment and escalation implemented if
necessary. The NIRT’s involvement with proactive security measures such as
vulnerability and penetration testing are further evidence of the maturity of their
The communication channels used by NIRT are typically informal and adhoc.
Informal communication channels are opened up to policy and procedure staff,
management and the respective information security and risk managers for each of the
business departments. Post-incident, the incident tracking system which is used to log
the incident is closed, legal ramifications of the incident are followed up and relevant
parties are notified of the repair.
The process undertaken by the HIRCT is vastly different. As an incident occurs
and is classified as a high-impact incident, the HIRCT team consisting of four people
can quickly expand to dozens, with communication facilitated by conference calls for
both technical- and business-related information. Incidents are resolved rapidly and
cost is not a constraint. Within 24 hours of resolution, an investigation begins. Many
technical staff are invited to the PIR meetings, through which a comprehensive post-
incident report is produced. This report details the causal structure of the incident, and
identifies gaps in policy, or maintenance issues. A risk assessment is conducted, and
tasks are allocated via the incident tracking system to the relevant staff. This process
has seen a reduction in incidents of around 200 per month from 2002 down to only 16
at the time of this study.
5.2. Lack of a Formalised Information Dissemination Process
On the topic of information dissemination, previous case studies found that key
security processes were not communicating such as information security risk
assessment and incident response. Our findings from this case study reinforces these
Both participants in our case study from outside the incident response team
complained of a lack of incident knowledge being distributed effectively and agreed
that better information dissemination would assist in improving their security
practices and therefore the security of the organisation. As organisations, such as
FinanceOrg, are often simply following the CERT literature and frameworks such as
ITIL and ISO17799, this finding is hardly surprising. Without formalised processes,
dissemination is made difficult by the siloed nature of FinanceOrg. A formal process
for disseminating incident knowledge particularly the PIR reports is required to
ensure that the valuable information produced by the HIRCT team (at great expense)
should not go to waste.
Other social, operational and technological interventions may also be required to
solve the information dissemination problem. The Information Security and Risk
Manager alleged that part of the problem was cultural. That ‘techies’ talk to ‘techies’
and organisations tend to be insular. It is proposed that by formalising the information
dissemination process, organisational silos would be broken down and the business-
technology gap would be reduced. To facilitate cultural change a formalised process
is required for the conversion of post-incident reports in to a learning document, that
is easily understood by many in the organisation. Both Cooke (2003) and Bishop
(2003a) support the notion that distributing such reports to users, particularly those
that reported the incident, increases their awareness of incidents and the incident
response process in general.
However, the extent to which information is disseminated is also influenced by
learning impact. High-impact incidents result in post-incident reports with valuable
information that must be disseminated. However, low-impact incidents do not result
in such reports despite the fact that they may potentially be more useful from a
learning perspective. In other words, there is a subtle but important difference
between ‘high-impact’ and ‘high-learning’ incidents. The distinction is key to an
efficient learning process in organisations.
5.3. Focus on Technical Learning over Policy and Risk
Technical information is well structured through the incident tracking system, and
technical tasks are automatically logged and allocated. These measures are rapidly
implemented by the relevant technical teams and checks are put in place to make sure
technical deliverables are completed. As our case study shows, technicians are present
at all PIR meetings but business and risk staff are often excluded, especially from the
early stages. Hence, both high-impact and low-impact incidents exhibit a focus on
technical issues rather than gathering information on an inadequate risk assessment or
a gap in policy. Unfortunately, policy and procedure are often seen as ‘soft’ issues in
information security even though the biggest threats to information systems are often
internal (Whitman and Mattord, 2005).
In FinanceOrg low-impact incidents, knowledge gathered is almost purely
technical with the aim to solve the problem quickly and effectively. There is a
reluctance to do anything outside of responding to the incident, including logging and
recording information. As such, costing of incidents and gathering additional
information to facilitate organisational learning does not take place. Since there is
little follow-up procedure as well, current knowledge creation and dissemination is
purely based on statistic reports sent to management and is biased towards
technological knowledge.
For high-impact incidents the technical focus remains, even though non-technical
issues are also considered. Again, it may be a lack of a wider perspective in literature
on incident response that results in poor practices in the workplace. Almost all CERT
guides exhibit a strong emphasis on technical aspects from firewalls and proxies
(Smith, 1994) to forensics (Killcrece et al., 2003a). The aim of the post-incident
process, however, is to get to the root cause of a problem, which is often not a
technical problem (eg. a firewall setting requiring adjustment) but a policy problem
(eg. not having a policy for blocking certain ports on all firewalls). Despite this,
business and risk staff are excluded from the first two post-incident report meetings
which severely limits incident learning in those areas.
5.4. Organisational Learning
The most interesting observations relate to organisational learning. In particular,
learning in thought as well as practice and the sophistication of learning processes
applied in incident response. To assist in analysis, some background in organisational
learning theory is useful.
Organisational learning theories are concerned with organisations learning and
adapting its behaviour (van Niekerk and von Solms, 2004). The origins of
organisational learning theory stem from the work of Argyris and Schon (1978) who
argued that there are two types of learning: single-loop and double-loop.
Single-loop learning is a simplistic, adaptive approach that most organisations use
day-to-day whereby employees simply detect and then correct deviations from
policies, procedures or expected norms. An example could be a security incident
involving a firewall that has taken place because of a configuration problem. A single
loop response would be to simply correct the configuration without an in-depth root
cause investigation that examines the current process and policy for establishing the
firewall configuration.
Double-loop learning involves questioning the very principles such as policy and
procedure that organisations function on, and is more generative in nature. In the
above situation, a double loop response would be to begin with a root cause analysis
followed by an investigation into the process that resulted in the mis-configuration of
the firewall. If the process, hypothetically, handled requests from business units to
open up ports in the firewall to make way for new avenues of network traffic then
double loop learning would include the decision to improve this process such that the
risk of future mis-configuration was minimized.
Most companies focus on single-loop learning. When organisations do look at the
more generative learning or ‘double-loop’ learning, however, more organisational
value will be derived as a result (Argyris, and Schon, 1978; Malhotra, 1996). Double-
loop learning is akin to problem solving, involving continuous experimentation and
feedback (van Niekerk and von Solms, 2004), and is concerned with more long-term
change, rather than short-term goals. Naturally, double-loop learning is more difficult
and future-focused. Carrying out such learning activities as an organisation involves
complex dependencies across individuals and groups (Kim, 1993).
In terms of incident response, bridging the gap between the localised, single-loop
learning of the incident response team, and wider, double-loop learning requires a
system in place to facilitate learning from the incident response team to a wider
audience. Dixon (1999) argues that organisational learning is not simply the sum of
all that its members know, but instead it is the collective use of learning capability. So
it is not just the knowledge itself that is of most importance, but the ability to work
together, synthesise and translate that knowledge.
Literature on organisational health and safety reports that continuous
improvements across the organisation can be achieved by the implementation of a
Incident Learning System as part of their incident response process (Cooke, 2003).
Such a system should also aim to encourage the reporting of incidents. Bishop
(2003a) demonstrates that when an incident learning system is successfully applied,
the reporting rate increases while serious accidents/ incidents are reduced.
Figure 1: Incident Learning System (modified from (Cooke et al., 2006))
Melara et al. (2003) applies the Cooke et al. (2006) Incident Learning System (see
Figure 1) to a study of an insider attack on organisational information security. By
analysing pre-incidents as well as incidents in depth, the researchers found that a
serious insider attack could have been averted. However, without an incident learning
process, the malicious insider caused serious damage to the internal systems of the
case-study organisation (Melara et al., 2003). Failure to learn from pre-cursor
incidents is an ubiquitous trait in all kinds of security incidents.
Both Cooke (2003) and Bishop (2003a) stress the need for causal analysis of
incidents so that the underlying issues leading to the incident can be identified. By
conducting a causal analysis, new knowledge is created which through generalisation
can be used to facilitate organisational learning. Causal analysis is typically part of a
wider post-incident review process that may include a timeline of events, risk
assessments, and root-cause analysis (Bishop, 2003a).
The amount of effort spent per incident will need to be relative to the incident’s
learning potential (Bishop, 2003b) as post-incident reviews are costly, challenging,
and require great skill and expertise to perform (Stephenson, 2003). However, post-
incident reviews are a necessary component of the incident learning process. Unless at
least some small review of an incident occurs, learning will be lost to organisational
memory (Cooke, 2003).
5.5 Learning at FinanceOrg
At FinanceOrg, high-impact incidents have a follow-up procedure in which a
causal analysis is conducted and corrective action is taken. As a result there has been
a rapid and significant reduction in incidents. However, the only learning in
FinanceOrg identified by this case study is confined to the incident response team.
This is unfortunate, as the organisation as a whole has much to learn from incidents,
in particular the security risk management function can use incident data to inform its
risk assessment function (especially estimation of probabilities of risks).
In the case of FinanceOrg, as noted in the section on the Extent of Incident
Learning, the NIRT was largely engaged in single loop learning as it was focused on
resolving the direct causes of incidents. However, HIRCT_Mgr seemed to appreciate
the concept of double loop learning as he questioned the system itself, the governing
variables and the need for a ‘root cause analysis’.
However there is no evidence that FinanceOrg actually practices double loop
learning. In fact, there was evidence to the contrary. FinanceOrg documentation
showed that HIRCT does not respond to incident precursors (a confluence of events
that have the immediate potential to cause a high impact incident). Further, the fact
that information dissemination issues have not been addressed and key areas such as
policy and risk have not benefited from incident based data suggests that double loop
learning is not practiced.
To facilitate double loop learning FinanceOrg should attempt to tighten and
integrate technical incident response, risk assessment and policy and procedure
practices (Meijer and Tucker, 2003). Hence, we argue that the risk management team
and security strategy and policy developers should be formally included in incident
information dissemination and could have a greater participation in the casual analysis
as well. True double-loop learning is only achieved when an organisation is capable
of systemically correcting the issues identified through causal analysis. Identifying
why a risk has not been identified, or why its mitigation has not been addressed
properly, may lead to corrective measures for other risks not directly related to this
incident. Similarly, identifying why a potential incident was not adequately covered
by the current security policy, may lead to further improvements to that policy that
may prevent future incidents not directly related to this incident.
It is reasonable to expect that for FinanceOrg to implement true double-loop
learning, both low-impact incidents and precursor incidents would have to be
examined for high-learning incidents. According to Cooke (2003), critical incidents
are caused by the ignorance of low-impact incidents and precursor incidents. While
high-impact incidents have a follow-up procedure in which a causal analysis is
conducted, low-impact incidents only have a small review process. Cooke’s (2003)
Incident Learning System argues that all incidents should be used for incident
learning and the focus should be on causal structures. This is currently not occurring
in FinanceOrg. Even when moderated by Bishop’s (2003a) assertion that the level
effort devoted to learning should be commensurate with the level of learning that can
be gathered from incidents, the current approach in financeOrg to low-impact
incidents is still inadequate. At the very least, clusters of incidents recognised across
the organisation should be tackled as a whole. A large number of low-impact
incidents are potentially as damaging as a single high-impact incident.
Cooke argues that serious disasters can be averted by learning from precursor
incidents in the same way as actual incidents. As discussed earlier, Melara et al.
(2003) found that by analysing pre-incidents as well as incidents in-depth, a serious
insider attack could have been averted.
Although FinanceOrg does follow the full cycle of the Cooke et al. (2006) incident
learning system, further analysis indicates that there are limitations in the current
system. The process of conducting the causal analysis, combined with an investment
in resources in improving the reports themselves was found to be the most effective
tool in reducing incidents. However, at no stage did we uncover any elements of the
kind of systemic corrective action that Cooke et al. (2006) describe as being the
precursor to double-loop learning (that is, the questioning of the system and core,
fundamental principles). While FinanceOrg did follow the incident learning system
model as it currently stands, the model is not a true reflection of what double-loop
learning actually entails and what significant changes could be made through the
questioning of the organisation’s processes and principles.
In Cooke’s model, learning is the last step of the system. In this step, the supervisor
of the incident writes a ‘lessons learned’ report that is disseminated according to the
value of the lessons learnt to various roles in the organisation. While this report is
supposed to be submitted to a Quality Assurance type committee to consider systemic
changes if need be, our experience from this case study is that there is currently little
understanding in the incident response team on what double loop learning really
involves. We believe that the lack of an explicit double loop learning loop in Cooke’s
model may also have influenced how the actual Causal Analysis is performed and
possibly limit its focus.
Figure 2: Revised Incident Learning System (modified from Cooke et al.,
Hence, we suggest that the Cooke et al. (2006) model should be modified to better
reflect the difference between conducting more direct corrective actions (eg. altering
user behaviour) and more systemic, in-depth, fundamental actions that will change the
system itself. The new model (Figure 2) still emphasizes that causal analysis is the
catalyst for corrective actions and associated learning processes as dictated by the
original model and confirmed by our research. However, we believe that by making
the relationship between Causal Analysis and Systemic Corrective Action more
explicit, it will not only be likely that those stakeholders responsible for Systemic
Corrective Action will be identified by the organisation, but that they could
potentially have a larger involvement in the Causal Analysis stage as well and ensure
a broadening of its focus.
6 Conclusion
Incident response teams are viewed as the ‘fire fighters’ of modern organisations,
responding to and solving security incidents as they arise. However, there is often a
lack of attention to the learning aspects of incident response and post-incident
functions. The importance of double-loop learning as the driver of organisational
learning is paramount, enabling organisations to learn effectively from the past and
not suffer repeat incidents or mistakes. Though single-loop learning is more often
exhibited in organisations, double-loop learning ensures that organisations achieve
strategic and competitive benefit in the longer term. Causal analysis, post-incident
reporting and appropriate information dissemination are important for organisations
to determine the cause of the incident and to apply learning procedures.
To explore organisational learning of incident response we conducted an
exploratory, in-depth case-study. Through semi-structured interviews with the
incident response teams of a global financial institution (FinanceOrg), we established
that while FinanceOrg fields a mature, effective and experienced incident response
team, they are found lacking in their ability to exploit their organisational learning
capability. This is partly due to their focus on high-impact incidents and their
wholesale neglect of low-impact and precursor incidents in their incident learning.
FinanceOrg’s learning practices are further harmed by the lack of incident
information dissemination to all interested or involved parties and their predominantly
technical approach to incident reporting.
Though our case study has uncovered evidence that FinanceOrg does recognise the
need for double-loop learning, we found that there was little understanding of what
double loop learning involves and as a result their approach to learning from security
incidents fell mostly into a direct, single-loop learning capacity. We suggest that by
explicitly identifying potential double loop learning opportunities in such areas as risk
assessment and policy development, organisations may be better able to address
double loop learning. Hence, we proposed a modification of the Incident Learning
System model by Cooke et al. (2006), to encourage a broader focus of the causal
analysis of security incidents and ensure that any systemic corrective actions to risk
management and policy development process are considered.
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Figure 1: Incident Learning System (modified from (Cooke et al., 2006))
Figure 2: Revised Incident Learning System (modified from Cooke et al., 2006)
... Specific procedures for the fourth phase have not been clearly described. However, few studies have focused on the fourth phase [6]. Organisations are simply not learning from mistakes. ...
... Incident learning in improving information security has not yet been successful in the field of information security. In a field survey, Ahmad et al. confirmed that there were unreported incidents even in high-security firms [6]. ...
... confirmed the need for a double loop from field data [6]. Mynard et al. suggested the need to strengthen 'companywide security governance' [18]. ...
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... Due to organizations' different objectives and structures, they add that IRM is not limited to these phases. By taking a more comprehensive view, Ahmad et al. (2012) divide the process into five phases, i.e., preparation, identification, containment and eradication of incidents, and a recovery phase, and extend them by a follow-up ( Ahmad et al., 2020 ). These phases are also proposed by Cichonski et al. (2012) , who describe identification as detection and analysis. ...
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