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Tietoturvasuunnitelma (THL 3/2024)
6.2b: Häiriöiden hallinta ja menettelyt ongelmatilanteissa

Requirement description

Virhe- ja ongelmatilanteiden varalle tulee tietoturvallisuuden omavalvonnan kohteella olla ennalta määritellyt ja selkeät toimintatavat, toimintaohjeet ja vastuut kyseisten tilanteiden ennalta havainnointiin, tiedottamiseen, korjaamiseen ja tilanteista toipumiseen (tietoturvapoikkeaman hallinta - incident management).

Selvittelykäytänteiden ja hallintamallien kuvaaminen sekä vastuiden määrittely tulee tehdä verkko- ja tietoliikenneongelmien, tietojärjestelmien käyttöongelmien sekä havaittujen ja toteutuneiden tietoturvaloukkausten varalta. Lisäksi tulee olla kuvattuna, kuinka palvelunantajan on mahdollista saada käyttöönsä häiriötilanteesta tarkempaa seurantatietoa, kuten esimerkiksi tapahtumalokeja aikaleimoineen tilanteen ja tapahtuneen selvittämiseen.

Potilasturvallisuutta ja tietoturvallisuutta uhanneista tapahtumista tulisi kerätä oleelliset tiedot, jotta toimintaa voidaan kehittää edelleen.

Asiakastietolain 41 §:n mukaisesti tulee tietojärjestelmän olennaisten vaatimusten merkittävistä poikkeamista ilmoittaa tietojärjestelmäpalvelun tuottajalle. Merkittäviä poikkeamia on kuvattu THL:n määräyksen 5/2021 luvussa 10.4. Tietojärjestelmien merkittävistä poikkeamista tulee ilmoittaa Valviralle, erityisesti tilanteissa, joissa poikkeama voi aiheuttaa merkittävän riskin asiakas- tai potilasturvallisuudelle tai tietoturvalle. Merkittävien poikkeamien korjaamiseksi on ryhdyttävä korjaaviin toimenpiteisiin.

Asiakastietolain 41 §:n mukaan, jos palvelunantaja tai muu taho havaitsee tietojärjestelmän olennaisten vaatimusten täyttymisessä tietosuojapoikkeamia, sen on ilmoitettava asiasta tietosuojavaltuutetulle. Henkilötietojen tietoturvaloukkauksesta ilmoittamisesta säädetään EU:n yleisen tietosuoja-asetuksen 33 ja 34 artikloissa. Henkilötietojen tietoturvaloukkausten hallinta tietoturvallisuuden omavalvonnan kohteessa tulee olla dokumentoitu joko suoraan tietoturvasuunnitelmaan tai muihin asiakirjoihin, joihin viitataan tietoturvasuunnitelmassa.

How to fill the requirement

Tietoturvasuunnitelma (THL 3/2024)

6.2b: Häiriöiden hallinta ja menettelyt ongelmatilanteissa

Task name
Priority
Status
Theme
Policy
Other requirements
Treatment process and documentation of occurred security incidents
Critical
High
Normal
Low
Fully done
Mostly done
Partly done
Not done
Incident management
Incident management and response
46
requirements

Examples of other requirements this task affects

12. Transparent information, communication and modalities for the exercise of the rights of the data subject
GDPR
32. Security of processing
GDPR
16.1.5: Response to information security incidents
ISO 27001
T06: Turvallisuuspoikkeamien hallinta
Katakri
6.4: Menettelytavat virhe- ja ongelmatilanteissa
Omavalvontasuunnitelma
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Treatment process and documentation of occurred security incidents
1. Task description

All security incidents are addressed in a consistent manner to improve security based on what has happened.

In the incident treatment process:

  • the reported incident is confirmed (or found unnecessary to record)
  • the type and cause of incident is documented
  • the risks associated with the incident are documented
  • the risks are re-evaluated and treated if that is necessary after the incident
  • risk mitigation measures or a decision their acceptance is documented
  • people who need to be informed of the results of the incident treatment are identified (including external ones)
  • possible need for a post-incident analysis is determined
Designation of an incident management team
Critical
High
Normal
Low
Fully done
Mostly done
Partly done
Not done
Incident management
Incident management and response
29
requirements

Examples of other requirements this task affects

16.1.2: Reporting information security events
ISO 27001
16.1.3: Reporting information security weaknesses
ISO 27001
ID.RA-3: Threat identification
NIST
RS.CO-1: Personnel roles
NIST
5.25: Assessment and decision on information security events
ISO 27001
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Designation of an incident management team
1. Task description

The organization shall ensure that clear persons are assigned to incident management responsibilities, e.g. handling the first response for incidents.

Incident management personnel need to be instructed and trained to understand the organization's priorities in dealing with security incidents.

Personnel guidelines for reporting security incidents
Critical
High
Normal
Low
Fully done
Mostly done
Partly done
Not done
Incident management
Incident management and response
38
requirements

Examples of other requirements this task affects

24. Responsibility of the controller
GDPR
16.1.2: Reporting information security events
ISO 27001
16.1.3: Reporting information security weaknesses
ISO 27001
T06: Turvallisuuspoikkeamien hallinta
Katakri
6.4: Menettelytavat virhe- ja ongelmatilanteissa
Omavalvontasuunnitelma
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Personnel guidelines for reporting security incidents
1. Task description

A process for reporting incidents is maintained to help staff report incidents efficiently and consistently.

Things to report as an incident include e.g.:

  • unauthorized access to data / premises
  • action against security guidelines
  • suspected security issue (e.g. phishing, malware infection)
  • data system outage
  • accidental or intentional destruction / alteration of data
  • lost or stolen device
  • compromised password
  • lost physical identifier (e.g. keychain, smart card, smart sticker)
  • suspected security weakness (e.g. on utilized data system or other procedures)

The personnel guidelines emphasize the obligation to report security incidents as soon as possible in accordance with the agreed process. The instructions also describe other operations in the event of an incident (e.g. recording seen error messages and other details).

Management and documentation of data breaches
Critical
High
Normal
Low
Fully done
Mostly done
Partly done
Not done
Incident management
Data breach management
11
requirements

Examples of other requirements this task affects

18.1.4: Privacy and protection of personally identifiable information
ISO 27001
TSU-14: Tietoturvaloukkaukset
Julkri
5.34: Privacy and protection of PII
ISO 27001
66: Tietoturvaloukkausten hallinta
Digiturvan kokonaiskuvapalvelu
P6.3: Record of unauthorized disclosures of personal information
SOC 2
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Management and documentation of data breaches
1. Task description

The organization must document all personal data breaches and their consequences and the corrective actions taken, regardless of the action ultimately resulting from the breach.

Failure to comply with the documentation obligation or notification is contrary to GDPR and may lead to sanctions defined on the regulation.

Reporting personal data breaches to authorities / data subjects
Critical
High
Normal
Low
Fully done
Mostly done
Partly done
Not done
Incident management
Data breach management
21
requirements

Examples of other requirements this task affects

33. Notification of a personal data breach to the supervisory authority
GDPR
34. Communication of a personal data breach to the data subject
GDPR
6.1.3: Contact with authorities
ISO 27001
16.1.5: Response to information security incidents
ISO 27001
RS.CO-2: Incident reporting
NIST
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Reporting personal data breaches to authorities / data subjects
1. Task description

A personal data breach must be reported to the supervisory authority if the breach may pose a risk to data subjects rights and freedoms. Data subjects, on the other hand, must be informed if the breach is likely to pose a high risk to their rights and freedoms. For example, registrants may take steps to reduce the adverse effect (e.g. by closing their credit card).

The notification must include the following information:

  • a clear description of the personal data breach
  • the name and contact details of the data protection officer or other contact point from which further information can be obtained
  • the likely consequences of the personal data breach
  • the measures proposed or already taken by the controller; where appropriate, measures to mitigate possible adverse effects.
Notifying the system provider of deviations from data system requirements
Critical
High
Normal
Low
Fully done
Mostly done
Partly done
Not done
Risk management and leadership
Continuity management
1
requirements

Examples of other requirements this task affects

6.2b: Häiriöiden hallinta ja menettelyt ongelmatilanteissa
Tietoturvasuunnitelma
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Notifying the system provider of deviations from data system requirements
1. Task description

Organisaation on Asiakastietolain 41 §:n mukaisesti ilmoitettava tietojärjestelmän tuottajalle, mikäli järjestelmässä ilmenee poikkeama järjestelmien olennaisista vaatimuksista. Poikkeamia on kuvattu THL:n määräyksen 5/2021 luvussa 10.4

Tietojärjestelmien merkittävistä poikkeamista on ilmoitettava Valviralle, erityisesti tilanteissa, joissa poikkeama voi aiheuttaa merkittävän riskin asiakas- tai potilasturvallisuudelle tai tietoturvalle. Merkittävien poikkeamien korjaamiseksi on ryhdyttävä korjaaviin toimenpiteisiin.


Managing evidence information for information security incidents
Critical
High
Normal
Low
Fully done
Mostly done
Partly done
Not done
Incident management
Incident management and response
4
requirements

Examples of other requirements this task affects

5.28: Collection of evidence
ISO 27001
6.2b: Häiriöiden hallinta ja menettelyt ongelmatilanteissa
Tietoturvasuunnitelma
4.3.3: Log all activities, results and relevant decisions
NSM ICT-SP
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Managing evidence information for information security incidents
1. Task description

Organization must create processes that identify, collect and store relevant evidence information related to information security incidents. The evidence may need to have been collected in a way that can be accepted in relevant courts or other similar disciplinary bodies.

Regarding the evidence material, it should be possible to demonstrate e.g.:

  • the records are complete and not altered in any way
  • copies of electronic evidence are likely to be identical to the originals
  • the data system from which the evidence was collected was functioning properly at the time of collection

Certification or other assurances of the competency of related personnel and tools may additionally be considered to establish more evidentiary value.

Developing an incident response plan for critical information systems
Critical
High
Normal
Low
Fully done
Mostly done
Partly done
Not done
Risk management and leadership
Continuity management
14
requirements

Examples of other requirements this task affects

RS.RP: Response Planning
NIST
RS.RP-1: Incident response plan
NIST
HAL-17: Tietojärjestelmien toiminnallinen käytettävyys ja vikasietoisuus
Julkri
VAR-09: Tietojärjestelmien toipumissuunnitelmat
Julkri
CC7.4: Responding to identified security incidents
SOC 2
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Developing an incident response plan for critical information systems
1. Task description

The organization shall establish a incident response plan for security incidents to critical information systems. Response plans should also be tested by the necessary organizational elements. The plan should take into account at least:

  • The purpose of the information system and the precautions to be taken in the event of its disruption
  • Recovery plans, targets, and priorities for the order of recovery of assets
  • The role of implementing the response plans and the contact details of the persons assigned to the roles
  •  Continuation of normal operations regardless of the state of the information systems.
  • Distribution, approval and review of response plans

In addition, the plan should at least:

  • Establish a roadmap for developing disruption management capacity
  • Describe the structure and organization of incident management capability
  • Provides metrics to measure incident management capability
The first level response process to security incidents
Critical
High
Normal
Low
Fully done
Mostly done
Partly done
Not done
Incident management
Incident management and response
32
requirements

Examples of other requirements this task affects

16.1.4: Assessment of and decision on information security events
ISO 27001
6.4: Menettelytavat virhe- ja ongelmatilanteissa
Omavalvontasuunnitelma
DE.AE-4: Impact of events
NIST
RS.RP: Response Planning
NIST
RS.RP-1: Incident response plan
NIST
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The first level response process to security incidents
1. Task description

The organization has defined a process and the team involved in responding promptly to security incidents and deciding on the appropriate actions.

The first level response process includes at least:

  • effectively seeking to confirm the identified incident
  • deciding on the need for immediate response
Follow-up analysis for security incidents
Critical
High
Normal
Low
Fully done
Mostly done
Partly done
Not done
Incident management
Incident management and response
22
requirements

Examples of other requirements this task affects

16.1.6: Learning from information security incidents
ISO 27001
6.4: Menettelytavat virhe- ja ongelmatilanteissa
Omavalvontasuunnitelma
ID.RA-4: Impacts on business
NIST
DE.DP-5: Detection processes improvment
NIST
RS.AN-2: The impact of the incident
NIST
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Follow-up analysis for security incidents
1. Task description

If it is difficult to identify the source of a security incident based on the primary treatment, a separate follow-up analysis is performed for the incident, in which the root cause is sought to be identified.

Regular periodic analysis and learning of incidents
Critical
High
Normal
Low
Fully done
Mostly done
Partly done
Not done
Incident management
Incident management and response
29
requirements

Examples of other requirements this task affects

16.1.6: Learning from information security incidents
ISO 27001
PR.IP-7: Protection processes
NIST
PR.IP-8: Protection effectiveness
NIST
DE.DP-5: Detection processes improvment
NIST
RS.AN-2: The impact of the incident
NIST
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Regular periodic analysis and learning of incidents
1. Task description

The knowledge gained from analyzing and resolving security incidents should be used to reduce the likelihood of future incidents and their impact.

The organization regularly analyzes incidents as a whole. This process examines the type, amount and cost of incidents with the aim of identifying recurrent and significant incidents that need more action.

If recurrent incidents requiring response are identified, based on them:

  • new management tasks are created or current ones expanded
  • security guidelines in this area are refined or extended
  • a case example of the incident is created that is used to train staff to respond to or avoid similar incidents

Tasks included in the policy

Task name
Priority
Status
Theme
Policy
Other requirements
No items found.

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1.1 (MIL2): Manage IT and OT Asset Inventory
C2M2
1.1 (MIL3): Manage IT and OT Asset Inventory
C2M2
1.1.1: Availability of information security policies
TISAX
1.1.1: Identify the organisation’s strategy and priorities
NSM ICT-SP
1.1.2: Identify the organisation’s structures and processes for security management
NSM ICT-SP
1.1.3: Identify the organisation’s processes for ICT risk management
NSM ICT-SP
1.1.4: Identify the organisation’s tolerances for ICT risk
NSM ICT-SP
1.1.5: Identify the organisation’s deliverables, information systems and supporting ICT functions
NSM ICT-SP
1.1.6: Identify information processing and data flow
NSM ICT-SP
1.2 (MIL2): Manage Information Asset Inventory
C2M2
1.2 (MIL3): Manage Information Asset Inventory
C2M2
1.2.1: Establish a process to identify devices and software in use at the organisation
NSM ICT-SP
1.2.1: Scope of Information Security management
TISAX
1.2.2: Establish organisational guidelines for approved devices and software
NSM ICT-SP
1.2.2: Information Security Responsibilities
TISAX
1.2.3: Identify devices in use at the organisation
NSM ICT-SP
1.2.3: Information Security requirements in projects
TISAX
1.2.4: Definition of responsibilities with service providers
TISAX
1.2.4: Identify the software in use at the organisation
NSM ICT-SP
1.2: Manage Information Asset Inventory
C2M2
1.3 (MIL2): Manage IT and OT Asset Configuration
C2M2
1.3 (MIL3): Manage IT and OT Asset Configuration
C2M2
1.3.1: Identification of information assets
TISAX
1.3.1: Identify the users of the information systems
NSM ICT-SP
1.3.2: Classification of information assets
TISAX
1.3.2: Identify and define the different user categories
NSM ICT-SP
1.3.3: Identify roles and responsibilities linked especially to ICT security
NSM ICT-SP
1.3.3: Use of approved external IT services
TISAX
1.3.4: Use of approved software
TISAX
1.3: Manage IT and OT Asset Configuration
C2M2
1.4 (MIL2): Manage Changes to IT and OT Assets
C2M2
1.4 (MIL3): Manage Changes to IT and OT Assets
C2M2
1.4.1: Management of Information Security Risks
TISAX
1.4: Manage Changes to IT and OT Assets
C2M2
1.5 (MIL1): Management Activities for the ASSET domain
C2M2
1.5 (MIL2): Management Activities for the ASSET domain
C2M2
1.5 (MIL3): Management Activities for the ASSET domain
C2M2
1.5.1: Assessment of policies and requirements
TISAX
1.5.2: External review of ISMS
TISAX
1.5: Management Activities for the ASSET domain
C2M2
1.6.1: Reporting of security events
TISAX
1.6.2: Management of reported events
TISAX
1.6.3: Crisis preparedness
TISAX
10 §: Johdon vastuu
Kyberturvallisuuslaki
10. Processing of personal data relating to criminal convictions and offences
GDPR
10.1 (MIL2): Establish Cybersecurity Program Strategy
C2M2
10.1 (MIL3): Establish Cybersecurity Program Strategy
C2M2
10.1.1: Policy on the use of cryptographic controls
ISO 27001
10.1.2: Key management
ISO 27001
10.1.2: Key management
ISO 27017
10.1: Continuous improvement
ISO 27001
10.1: Cryptographic controls
ISO 27001
10.1: Cryptographic controls
ISO 27017
10.1: Establish Cybersecurity Program Strategy
C2M2
10.2 (MIL2): Establish and Maintain Cybersecurity Program
C2M2
10.2 (MIL3): Establish and Maintain Cybersecurity Program
C2M2
10.2: Establish and Maintain Cybersecurity Program
C2M2
10.2: Non-conformity and corrective action
ISO 27001
10.3 (MIL1): Management Activities for the PROGRAM domain
C2M2
10.3 (MIL2): Management Activities for the PROGRAM domain
C2M2
10.3 (MIL3): Management Activities for the PROGRAM domain
C2M2
10.3: Management Activities for the PROGRAM domain
C2M2
10: Cryptography
ISO 27001
10: Cryptography
ISO 27017
10: Cybersecurity Program Management (PROGRAM)
C2M2
10: Prosessi väärinkäytöksiin reagoimiseksi
Digiturvan kokonaiskuvapalvelu
11 §: Poikkeamailmoitukset viranomaiselle
Kyberturvallisuuslaki
11. Processing which does not require identification
GDPR
11.1.1: Physical security perimeter
ISO 27001
11.1.2: Physical entry controls
ISO 27001
11.1.3: Securing offices, rooms and facilities
ISO 27001
11.1.4: Protecting against external and environmental threats
ISO 27001
11.1.5: Working in secure areas
ISO 27001
11.1.6: Delivery and loading areas
ISO 27001
11.1: Secure areas
ISO 27001
11.2.1: Equipment siting and protection
ISO 27001
11.2.2: Supporting utilities
ISO 27001
11.2.3: Cabling security
ISO 27001
11.2.4: Equipment maintenance
ISO 27001
11.2.5: Removal of assets
ISO 27001
11.2.6: Security of equipment and assets off-premises
ISO 27001
11.2.7: Secure disposal or re-use of equipment
ISO 27001
11.2.7: Secure disposal or re-use of equipment
ISO 27017
11.2.8: Unattended user equipment
ISO 27001
11.2.9: Clear desk and clear screen policy
ISO 27001
11.2: Equipment
ISO 27001
11.2: Equipment
ISO 27017
11: Digiturvan mittarien määrittäminen
Digiturvan kokonaiskuvapalvelu
11: Physical and environmental security
ISO 27001
11: Physical and environmental security
ISO 27017
12 §: Luotettavuutta edellyttävien tehtävien tunnistaminen ja luotettavuudesta varmistuminen
TiHL
12 §: Poikkeamaa koskeva väliraportti
Kyberturvallisuuslaki
12. Transparent information, communication and modalities for the exercise of the rights of the data subject
GDPR
12.1.1: Documented operating procedures
ISO 27001
12.1.2: Change management
ISO 27001
12.1.3: Capacity management
ISO 27001
12.1.4: Separation of development, testing and operational environments
ISO 27001
12.1: Operational procedures and responsibilities
ISO 27001
12.2.1: Controls against malware
ISO 27001
12.2: Protection from malware
ISO 27001