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Post-Incident Review Template (ISO/IEC 27001 A.5.27, ISO/IEC 27035)

Blameless security incident review: summary, ground rules, timeline, impact, response metrics, 5 whys, fishbone, actions, control changes, risk register update

СУІБ та ISO/IEC 27001ПовнийISO/IEC 27001:2022 + Amd 1:2024 A.5.27, clause 10.2 (cited only); ISO/IEC 27035-1:2023, 27035-2:2023postincidentreview

Як використовувати: Use it after every incident that meets the review rule in the incident response plan, and for near misses with a real lesson. Fill the facts and the timeline from the incident register and logs before the meeting, so the meeting spends its time on analysis. The main pitfall is stopping at human error instead of asking why the system made the mistake easy and the damage large.

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Post-Incident Review: [Incident ID and short title]

A blameless review format for information security incidents: facts, timeline, impact, root cause analysis (5 whys and fishbone), what went well, what to improve, actions, control changes and the update to the risk register. It supports ISO/IEC 27001:2022 + Amd 1:2024 Annex A control A.5.27 (learning from incidents), the lessons-learned phase of the incident management process described in ISO/IEC 27035-1:2023, and improvement under clause 10. Replace every [bracketed] value and every row marked Example.

Document control

FieldValue
Document IDDOC-ISMS-022
Review ID[PIR-YYYY-NNN] (Example: PIR-2027-001)
Incident ID[INC-YYYY-NNN] (Example: INC-2027-001)
Version[1.0]
Status[Draft / In review / Approved / Actions closed]
Owner (review facilitator)[@facilitator]
Approvers/reviewers[@isms-manager], [@incident-commander], [@system-owner]
Last updatedYYYY-MM-DD
Classification[Confidential]
Standard and editionISO/IEC 27001:2022 + Amd 1:2024 (A.5.27, A.5.24 to A.5.28, clause 10.2); ISO/IEC 27035-1:2023; ISO/IEC 27035-2:2023
Severity and category[SEVn, CAT-nn] (Example: SEV3, CAT-02 account or credential compromise)
Review meeting dateYYYY-MM-DD
Next scheduled review[Action follow-up date, YYYY-MM-DD]

Approvals

RoleNameDecisionDate
Review facilitator[@facilitator][Prepared]YYYY-MM-DD
Incident commander[@incident-commander][Facts confirmed]YYYY-MM-DD
ISMS manager[@isms-manager][Approved, actions accepted]YYYY-MM-DD

Revision history

VersionDateAuthorChange
0.1YYYY-MM-DD[@facilitator]Facts and timeline drafted before the meeting
1.0YYYY-MM-DD[@facilitator]Analysis and actions agreed in the review meeting
[x.y]YYYY-MM-DD[@author][Action status update or closure]

Contents

1. Incident summary

FieldValue
Incident ID and title[INC-YYYY-NNN, title] (Example: INC-2027-001, support mailbox takeover through relayed login)
Detected[YYYY-MM-DD HH:MM UTC, source] (Example: 2027-01-09 07:50, identity protection alert)
Declared (awareness time, T0)[YYYY-MM-DD HH:MM UTC] (Example: 2027-01-09 10:05)
Contained[YYYY-MM-DD HH:MM UTC] (Example: 2027-01-09 10:20)
Closed[YYYY-MM-DD] (Example: 2027-01-12)
Affected services and assets[Asset IDs from compliance/asset-inventory] (Example: one support mailbox, customer support process)
Information security properties affected[Confidentiality / Integrity / Availability] (Example: confidentiality)
Personal data involved[Yes / No, categories, role as controller or processor] (Example: yes, names and work contact details of hospital staff, processor role)
Notifications made[Regime, recipient, time] (Example: two hospital customers as controllers, 2027-01-09 17:10)
Review rule that applies[Severity / personal data / novel cause / missed detection] (Example: personal data breach and a delayed detection)

Example summary: on 2027-01-08 a phishing e-mail reached 14 support engineers at Quillmere Health Systems. One engineer signed in on a page that relayed the login, including the multi-factor step, to the real identity provider, and the attacker captured the resulting session. The attacker used the session from a hosting provider address at 17:31, created a forwarding rule and forwarded 37 messages to an external address. An identity protection alert fired the next morning and a colleague reported the same e-mail. The incident was declared at 10:05 and contained 15 minutes later. Nine forwarded messages held names and work contact details of hospital staff; the two affected hospitals were informed the same day as controllers. The main lesson is that the multi-factor method in use for support staff can be relayed, and that medium alerts waited for business hours.

2. Review ground rules

The review follows these rules:

  1. Blameless. The aim is to understand how the system allowed the incident, not who to blame. People describe what they saw, knew and did at the time, and why it made sense then.
  2. Hindsight is named. When someone says "should have", the facilitator asks what information was available at that moment.
  3. Separate from discipline. Statements made in this review are not used in any disciplinary process. Wilful or malicious conduct, if suspected, is handled separately under isms/security-disciplinary-process (DOC-ISMS-052) with its own evidence, consistent with the no-blame rule in isms/security-event-reporting-procedure (DOC-ISMS-023).
  4. Facts before opinions. The timeline is agreed before the analysis starts. Disputed facts are marked and checked against logs.
  5. Every lesson becomes an action or a recorded decision. A lesson with no owner and no due date is not recorded as learned.
Attendee roleWhy presentExample
Facilitator (not involved in the response)Runs the meeting neutrallySecurity team analyst from another rotation
Incident commanderOwns the facts of the responseSecurity operations lead
RespondersGive first-hand accountsOn-call analyst, identity administrator
System or process ownerOwns most actionsHead of customer support
Privacy lead or DPOBreach and notification viewPrivacy lead
ISMS managerLinks actions to the ISMS recordsISMS manager
Person who reported or was targeted (optional, by consent)First-hand accountSupport engineer, by invitation only

3. Timeline

Time (UTC)EventSourcePhase
2027-01-08 16:42 (Example)Phishing e-mail with a fake document-sharing link delivered to 14 support engineersMail gateway logAttack
2027-01-08 17:05 (Example)One engineer enters credentials and completes the multi-factor prompt on the relay page; session token capturedIdentity provider sign-in logAttack
2027-01-08 17:31 (Example)Sign-in with the captured session from a hosting provider address; inbox forwarding rule createdIdentity provider and mailbox audit logsAttack
2027-01-08 17:31 to 2027-01-09 10:20 (Example)37 messages forwarded to an external addressMailbox audit logAttack
2027-01-09 07:50 (Example)Identity protection raises a medium "anomalous token" alert; queued for business-hours reviewSecurity monitoring platformDetect
2027-01-09 09:12 (Example)A second support engineer reports the e-mail with the report buttonEvent report SER-2027-0011Detect
2027-01-09 09:40 (Example)Analyst links the report to the alert and to the forwarding ruleTicketAssess
2027-01-09 10:05 (Example)Incident declared, SEV3, CAT-02; awareness time T0 recordedIncident register INC-2027-001Assess
2027-01-09 10:20 (Example)Sessions revoked, password reset, forwarding rule removed, sender domain blockedTicket, admin audit logRespond
2027-01-09 13:30 (Example)Scoping complete: 37 messages forwarded, 9 with personal data of hospital staff, no patient dataAnalyst notesRespond
2027-01-09 15:00 (Example)Privacy lead assesses a personal data breach in the processor rolecompliance/personal-data-breach-assessment PDB-2027-001Respond
2027-01-09 17:10 (Example)Two hospital customers notified as controllersNotification logRespond
2027-01-10 11:00 (Example)Phishing e-mail purged from the other 13 mailboxes; sign-in review finds no other compromised accountTicketRespond
2027-01-12 16:00 (Example)Incident closed after 72 hours of monitoring with no further activityIncident registerClose
2027-01-15 (Example)Post-incident review meeting (3 working days after closure)This documentLearn

4. Impact assessment

DimensionAssessmentExample
ConfidentialityWhat information left our control, how much, how sensitive37 messages forwarded; 9 contained names, job titles and work phone numbers of 23 hospital staff; no patient data, no credentials
IntegrityWhat was changed without authorisationOne forwarding rule created; no other changes found
AvailabilityWhich services were degraded and for how longNone
Customers and contractsContractual notifications, service credits, customer trustTwo hospitals informed under the data processing agreement; no service credit
Legal and regulatoryRegimes assessed and outcomeGDPR: processor duty to inform controllers without undue delay met; the controllers assessed their own Art. 33 duty. NIS2: assessed as not significant
Financial (Example, use local currency)Direct cost of responseUSD 4,800: USD 3,600 internal staff time (48 hours at USD 75) plus USD 1,200 external review of mailbox logs
Severity checkWas the declared severity right?SEV3 confirmed

5. Response performance

MeasureDefinitionResult (Example)Target (Example)Met?
Time to detectFirst unauthorised access to first detection14 h 19 min (17:31 to 07:50)Under 1 h for identity alertsNo
Time to declareFirst detection to declaration2 h 15 min (07:50 to 10:05)Under 30 minNo
Time to containDeclaration to containment15 min (10:05 to 10:20)Under 4 h at SEV3Yes
Total exposureFirst unauthorised access to containment16 h 49 minAs short as possibleNot a target
Notification timelinessDeclaration to controllers informed7 h 5 min (10:05 to 17:10)Within 24 h by contractYes
Report to declarationStaff report to declaration53 min (09:12 to 10:05)Under 1 hYes

The figures show that containment and notification worked; detection and declaration did not. The review therefore concentrates its root cause analysis on why the attack succeeded and why detection waited.

6. Root cause analysis

6.1 Problem statements

Analyse each distinct failure separately. Example:

  • P1: An attacker could use a phished session to access a support mailbox.
  • P2: The first alert waited 1 hour 50 minutes before an analyst looked at it (2 hours 15 minutes to declaration), after the attacker had already had access for over 14 hours.

6.2 Five whys

StepP1: access succeeded (Example)P2: detection waited (Example)
Why 1The attacker held a valid session token for the engineer's accountThe alert was rated medium and went to the business-hours queue
Why 2The relay page passed the engineer's login, including the push approval, to the real identity providerAlert severity rules rate token anomalies as medium unless the account is privileged
Why 3Push-based multi-factor authentication can be relayed; phishing-resistant methods were deployed for administrators onlySupport accounts were not classed as sensitive, although they hold customer contact data
Why 4The rollout plan treated support staff as low risk and the shared support desktops did not support security keysThe account classification for monitoring was set in 2025 and not reviewed when the support role changed
Why 5 (root cause)The authentication standard set method strength by privilege, not by the data a role can reachNo trigger re-reviews monitoring classifications when roles or data access change

6.3 Fishbone (cause categories)

CategoryCauseType (Example)
PeopleLure imitated the real document-sharing notice; sent late on a FridayContributing
ProcessMonitoring classification not re-reviewed after role changeRoot (P2)
TechnologyPush multi-factor method can be relayed; sessions not bound to a compliant deviceContributing
DetectionMedium identity alerts not reviewed outside business hoursContributing
SuppliersMail filtering did not flag a domain registered two days earlierContributing
GovernanceAuthentication standard ties method strength to privilege onlyRoot (P1)

6.4 Contributing factors that made it worse or better

  • Worse (Example): the forwarding rule ran overnight; external forwarding was not blocked by default.
  • Better (Example): the report button and a fast human report linked the alert to a real attack; the mailbox audit log was enabled and retained, so scoping was exact.

7. What went well and what to improve

IDWhat went well (Example)
WW-01The second engineer reported within minutes of reading the e-mail, as trained
WW-02Containment took 15 minutes from declaration, using the credential compromise playbook in security/soc-playbook
WW-03Mailbox audit logs gave an exact list of forwarded messages, so notification named the real data, not a guess
WW-04The privacy lead joined within 5 hours of declaration and the controllers were informed the same day
IDWhat to improve (Example)Action
TI-01Support staff use a multi-factor method that can be relayedACT-01
TI-02Medium identity alerts wait for business hoursACT-02
TI-03External automatic forwarding is allowed by defaultACT-03
TI-04Monitoring classification of accounts is not re-reviewed on role changeACT-04
TI-05Awareness content does not show relay-style login pagesACT-05
TI-06Newly registered domains are not quarantinedDecision D-01

8. Actions

Action IDActionAddressesOwnerDuePriorityCAPA linkEffectiveness checkStatus
ACT-01 (Example)Extend phishing-resistant authentication (security keys or platform passkeys) to every role with access to customer data; replace shared desktops that cannot support itP1 root cause, TI-01[@identity-lead]2027-04-30HighCAPA-2027-003Sign-in report shows 100% of support sign-ins with phishing-resistant methods for 30 daysOpen
ACT-02 (Example)Route medium identity alerts on accounts with customer data access to the 24x7 on-call analystP2, TI-02[@security-operations-lead]2027-02-28HighCAPA-2027-004Monthly test alert acknowledged within 30 minutes outside business hoursOpen
ACT-03 (Example)Block automatic external forwarding by default; allow by exception through security/security-exception-requestTI-03[@it-lead]2027-01-31Highnone (configuration change CHG-2027-018)Quarterly configuration check finds no unapproved forwardingOpen
ACT-04 (Example)Add "data access changed" as a trigger for monitoring classification review in the joiner, mover and leaver processP2 root cause, TI-04[@isms-manager]2027-03-31MediumCAPA-2027-005Next quarterly access review samples 10 movers and finds classification reviewedOpen
ACT-05 (Example)Add a relay-login example to awareness training and the next phishing simulationTI-05[@awareness-lead]2027-03-31MediumnoneSimulation report rate at or above the last campaignOpen

Decisions not to act are recorded with the reason and the risk owner's acceptance:

Decision IDTopicDecision and reason (Example)Accepted byDate
D-01 (Example)Quarantine of newly registered domainsNot adopted now: trial in 2026 blocked hospital customers' new domains. Residual risk is covered by ACT-01, which removes the value of a stolen sessionHead of IT (risk owner)2027-01-15

9. Control changes and risk register update

9.1 Controls tested by the incident

ControlShort labelWorked? (Example)Change (Example)
A.5.17Authentication information handlingPartly: the credential itself was not reused elsewhere, but the session was capturedACT-01
A.8.5Secure authenticationNo: method was relayable for this roleACT-01; update the authentication rule in isms/access-control-policy (DOC-ISMS-041)
A.8.16Monitoring activitiesPartly: alert fired, response delayedACT-02, ACT-04; update isms/security-monitoring-procedure (DOC-ISMS-064)
A.6.3Awareness, education and trainingPartly: one click, one fast reportACT-05
A.6.8Reporting security eventsYesNone
A.5.26Responding to security incidentsYes: contained in 15 minutesNone
A.5.28Evidence collectionYes: logs preserved and exported with hashesNone
A.5.34Privacy and PII protectionYes: controllers informed the same dayNone

9.2 Risk register update

Use the 5 x 5 scale from compliance/risk-methodology (DOC-ISMS-010): score = likelihood x impact; Low 1-4, Medium 5-9, High 10-16, Critical 17 to 25 (in practice 20 and 25).

Risk IDRiskBefore incidentAfter incident (current)Target after actionsOwner
RISK-014 (Example)Account takeover of staff with customer data access through phishingL2 x I4 = 8, MediumL4 x I4 = 16, High (likelihood raised: the attack worked)L2 x I4 = 8, Medium after ACT-01 and ACT-02[@head-of-it]
RISK-022 (Example)Delayed detection of identity attacks outside business hoursNot in registerL3 x I4 = 12, High (new risk)L2 x I3 = 6, Medium after ACT-02[@security-operations-lead]

Because RISK-014 and RISK-022 are now High, top management reviews the treatment decision as required by the risk acceptance rule, and the treatment is added to compliance/risk-treatment-plan (DOC-ISMS-013). If a control's implementation status changes, update the compliance/statement-of-applicability (DOC-ISMS-011) entry and its evidence reference.

9.3 Document updates

DocumentChange (Example)Owner
compliance/incident-response-plan (DOC-ISMS-020)Add the relay-login pattern to the credential compromise category notesIncident response plan owner
security/soc-playbookAdd check for inbox rules and session revocation as step oneSecurity operations lead
isms/access-control-policy (DOC-ISMS-041)Method strength set by data reach, not only by privilegePolicy owner

10. Sharing the lessons

AudienceWhat they receiveChannelWhen (Example)
All staffTwo-paragraph anonymised story, what to look for, thanks to the reporter (with consent)Staff newsletterWithin 2 weeks
Support teamWalk-through of the lure and the new sign-in methodTeam meetingWithin 1 week
ISMS steering committeeSummary, actions, risk changesCommittee pack (isms/isms-steering-committee-charter)Next meeting
Management reviewTrend input: incident counts, lessons, action statuscompliance/management-review inputNext review
Sector ISAC or CSIRTSender domain, relay page address, other indicatorsAgreed sharing channel, under its sharing rulesWithin 48 hours, if agreed
Affected customersSummary of root cause and actions, if requestedAccount managerOn request

11. Size tiers

AspectSmall: Quillmere Analytics Ltd (46 staff)Medium: Quillmere Health Systems (320 staff)Large: Quillmere Group (2,400 staff, 6 sites)
Who facilitatesHead of Engineering Operations (0.5 FTE ISMS manager), or a peer from engineering if they led the responseA security team member not involved in the responseA trained facilitator pool in the 14-person security office; site leads join for site incidents
Reviews per year (Example)2 to 4, one combined meeting of 60 minutes each8 to 12, 90 minutes each30 or more, with a quarterly cross-site lessons review
Root cause depth5 whys on the main failure5 whys plus fishbone for each problem statementFull method, plus OT-specific causes (safety, plant availability) at the 3 plants
ApprovalISMS manager and CEO for High risk changesISMS manager; top management for High risk changesCISO; group risk committee for High and Critical risk changes
IntegrationActions in the engineering backlog with a CAPA tagCAPA register and risk registerIntegrated management system: same corrective action process as ISO 9001 and ISO 22301

12. Records and evidence

RecordOwnerLocation (Example)Retention (Example)
This review (approved version)Facilitator, then ISMS managerISMS document store, linked from the incident registerCertification cycle plus 1 year (at least 4 years), longer if litigation or regulatory inquiry is open
Timeline sources (log exports with hashes)Security operations leadEvidence store under security/forensic-evidence-recordAs set for the incident's evidence
Actions and corrective actionsAction owners, ISMS managercompliance/capa-nonconformity records3 years after closure
Risk register changeRisk ownercompliance/risk-register historyPer risk register retention
Lessons summary for management reviewISMS managercompliance/management-review inputsWith the review minutes

What an auditor typically samples: the incident register entry, this review, at least one action traced to a changed control and its effectiveness check, and the matching risk register change.

13. References

Standard and licence note

Structure aligned with ISO/IEC 27001:2022 + Amd 1:2024 (Annex A control A.5.27 and clause 10.2) and the lessons-learned phase of ISO/IEC 27035-1:2023. Clause and control numbers are cited with original short labels only; no ISO or IEC text is reproduced, and you need the official standards to implement and audit these requirements. NIST SP 800-61 Rev. 3 is a US government work. The review format, analysis method and worked example are original. Check the current editions before use.

Template licence: MIT.

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