| Recurring |
one_organization |
(a) The software failure incident related to security vulnerabilities in medical devices, specifically the B. Braun Infusomat Space Large Volume Pump and B. Braun SpaceStation, highlights a concerning issue within the same organization. The incident involving these devices being vulnerable to manipulation by hackers to administer a double dose of medication is a significant security flaw that poses risks to patient safety [117821].
(b) The article does not provide specific information about similar incidents happening at other organizations or with their products and services. |
| Phase (Design/Operation) |
design, operation |
(a) The software failure incident in the article is related to the design phase. The vulnerabilities in the B. Braun Infusomat Space Large Volume Pump and B. Braun SpaceStation were found by researchers from the security firm McAfee Enterprise who were able to manipulate the devices to administer a double dose of medication to victims. They found ways to get around the security barriers that were supposed to prevent direct commands to the devices, ultimately showing that they could double the rate of flow by exploiting vulnerabilities in the system design [117821].
(b) The software failure incident is also related to the operation phase. The attack scenario that the researchers described as realistic and feasible for an attacker to carry out involved exploiting vulnerabilities in the operation of the devices. Once hackers gained control of the SpaceStation, they could seed ransomware or other malware from it to devices across a hospital's network, impacting the operation of the medical facility [117821]. |
| Boundary (Internal/External) |
within_system |
(a) The software failure incident related to the B. Braun Infusomat Space Large Volume Pump and B. Braun SpaceStation was primarily within the system. Researchers from McAfee Enterprise found ways to manipulate the infusion pump and dock by exploiting vulnerabilities within the devices themselves. They were able to breach the security boundary between the SpaceStation and the pump operating system, allowing them to send commands to administer a double dose of medication [117821]. The vulnerabilities discovered included lack of access controls, lack of data integrity verification, lack of command authentication, lack of upload restrictions, and plaintext data transmission without encryption, all of which were internal to the system and not due to external factors. |
| Nature (Human/Non-human) |
non-human_actions, human_actions |
(a) The software failure incident in the B. Braun Infusomat Space Large Volume Pump and B. Braun SpaceStation was primarily due to non-human actions. Researchers from the security firm McAfee Enterprise found ways to exploit vulnerabilities in the devices, allowing a determined hacker to manipulate the infusion pump to administer a double dose of medication to victims. The vulnerabilities included common connectivity vulnerabilities, lack of access controls between the SpaceStation and the pump, lack of data integrity verification, lack of command authentication, lack of upload restrictions, and plaintext data transmission without encryption. These non-human factors introduced by the software design and implementation allowed for the potential compromise of the devices' security and functionality [117821].
(b) However, human actions were also involved in the incident. The McAfee researchers noted that most of the identified vulnerabilities had not been patched in existing products, and B. Braun had to remove the vulnerable networking feature in the new version of its SpaceStations. The company recommended customers to use the latest software versions and implement network security mitigations like segmentation and multifactor authentication to enhance security. Additionally, the researchers highlighted that malicious hackers would need to be skilled and well-resourced reverse engineers to develop such an attack, indicating the potential role of human expertise in exploiting the vulnerabilities [117821]. |
| Dimension (Hardware/Software) |
hardware, software |
(a) The software failure incident in the B. Braun Infusomat Space Large Volume Pump and B. Braun SpaceStation was primarily due to contributing factors originating in hardware. The security vulnerabilities in these medical devices allowed a determined hacker to manipulate the infusion pump to administer a double dose of medication to patients [117821].
(b) The software failure incident also had contributing factors originating in software. Researchers from McAfee Enterprise found ways to exploit vulnerabilities in the software of the B. Braun devices, allowing them to take control of the SpaceStation and manipulate the connected infusion pump's configuration, including changing the rate of infusions. The vulnerabilities were related to lack of access controls, inadequate data verification, lack of upload restrictions, and plaintext data transmission without encryption [117821]. |
| Objective (Malicious/Non-malicious) |
malicious |
(a) The software failure incident in the article is malicious in nature. The incident involved security vulnerabilities in the B. Braun Infusomat Space Large Volume Pump and B. Braun SpaceStation that could be exploited by a determined hacker to administer a double dose of medication to victims. Researchers from McAfee Enterprise found ways to manipulate the devices, allowing an attacker to compromise the security of the devices, escalate privileges, view sensitive information, upload arbitrary files, and perform remote code execution. The vulnerabilities could be exploited by an attacker with access to a healthcare facility's network, and the attack scenario was deemed realistic and feasible for an attacker to carry out [117821].
(b) The software failure incident is non-malicious in the sense that the vulnerabilities were not intentionally introduced by the manufacturer. The vulnerabilities were discovered by security researchers from McAfee Enterprise and German government researchers, indicating that they were not deliberately planted in the software. The company, B. Braun, responded by issuing a security alert to customers, recommending software updates and network security mitigations to keep the devices secure. The vulnerabilities were present in older versions of the software, and the company took steps to remove the vulnerable networking feature in newer versions of its SpaceStations [117821]. |
| Intent (Poor/Accidental Decisions) |
unknown |
(a) The intent of the software failure incident was not due to poor decisions but rather due to a series of vulnerabilities and flaws in the software and network connectivity of the B. Braun Infusomat Space Large Volume Pump and B. Braun SpaceStation. The failure was a result of security vulnerabilities that allowed a determined hacker to manipulate the infusion pump to administer a double dose of medication to victims. Researchers from McAfee Enterprise found ways to exploit these vulnerabilities, demonstrating that an attacker could compromise the security of the devices, escalate privileges, view sensitive information, upload arbitrary files, and perform remote code execution [117821]. The vulnerabilities were not a result of poor decisions but rather a lack of robust security measures and proper access controls in the software and network connectivity of the medical devices. |
| Capability (Incompetence/Accidental) |
development_incompetence, accidental |
(a) The software failure incident related to development incompetence is evident in the case of the B. Braun Infusomat Space Large Volume Pump and B. Braun SpaceStation. Despite being designed to be extremely locked down at the software level to prevent direct commands, researchers from McAfee Enterprise found ways to bypass these security measures and exploit vulnerabilities in the system. The vulnerabilities allowed attackers to manipulate the infusion pump to administer a double dose of medication, potentially putting patients at risk [117821].
(b) The software failure incident can also be attributed to accidental factors, as the vulnerabilities in the B. Braun infusion pump system were not intentionally designed but rather discovered by researchers. The lack of proper access controls, data integrity verification, authentication of commands, and encryption led to accidental loopholes that could be exploited by attackers. Additionally, the unrestricted upload bug was uncovered by German government researchers, indicating accidental oversights in the system's design and implementation [117821]. |
| Duration |
permanent, temporary |
(a) The software failure incident in the article is more likely to be considered permanent. The vulnerabilities found in the B. Braun Infusomat Space Large Volume Pump and B. Braun SpaceStation were significant and allowed for manipulation of medication administration, privilege escalation, viewing sensitive information, uploading arbitrary files, performing remote code execution, changing infusion rates, and compromising the security of the devices [117821]. These vulnerabilities were not easily patched in existing products, and the company had to remove the vulnerable networking feature in the new version of its SpaceStations to address the issues. The attack scenario created by combining multiple vulnerabilities was deemed realistic and feasible for an attacker to carry out, highlighting the seriousness and long-term impact of the software failure incident.
(b) The software failure incident can also be seen as temporary to some extent. While the vulnerabilities were identified and exploited by researchers, the company had not seen evidence that the vulnerabilities had been exploited maliciously in the real world [117821]. The company recommended using the latest versions of its software released in October and implementing network security mitigations to enhance device security. Additionally, the McAfee researchers withheld some details of their findings as a precaution, indicating a temporary measure to prevent potential exploitation of the vulnerabilities until more comprehensive security measures could be implemented. |
| Behaviour |
other |
(a) crash: The software failure incident in the article is not related to a crash where the system loses state and does not perform any of its intended functions. The incident involves security vulnerabilities in medical devices that could be exploited by hackers to manipulate the administration of medication [Article 117821].
(b) omission: The software failure incident does not involve a failure due to the system omitting to perform its intended functions at an instance(s). Instead, the incident revolves around security vulnerabilities that could allow attackers to manipulate the dosage of medication administered by the medical devices [Article 117821].
(c) timing: The software failure incident is not characterized by a failure due to the system performing its intended functions correctly but too late or too early. The focus of the incident is on security vulnerabilities that could be exploited to manipulate the administration of medication by the medical devices [Article 117821].
(d) value: The software failure incident does not involve a failure due to the system performing its intended functions incorrectly. Instead, the incident is related to security vulnerabilities in medical devices that could be exploited by hackers to manipulate the dosage of medication administered to patients [Article 117821].
(e) byzantine: The software failure incident does not exhibit a byzantine behavior where the system behaves erroneously with inconsistent responses and interactions. The incident primarily concerns security vulnerabilities in medical devices that could be exploited by attackers to compromise the security of the devices and manipulate medication administration [Article 117821].
(f) other: The software failure incident involves security vulnerabilities in medical devices, particularly infusion pumps, that could be exploited by hackers to administer a double dose of medication to patients. The vulnerabilities allow attackers to escalate privileges, view sensitive information, upload arbitrary files, perform remote code execution, change infusion pump configurations, and compromise the security of the devices. The incident highlights the importance of addressing cybersecurity risks in medical devices to ensure patient safety [Article 117821]. |