CyOTE Precursor Analysis Report: Conti Ransomware Attack on the Health Service Executive (HSE) of Ireland 2021

Technical Report · Thu Oct 16 00:00:00 EDT 2025

DOI:https://doi.org/10.2172/3030058· OSTI ID:3030058

Hall, Andrew John ^[1]; Fetzer, Kathryn Marie ^[1]; Bowman, Scott Timothy ^[1]

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1. Idaho National Laboratory

The Conti Ransomware Attack on the Health Service Executive (HSE) of Ireland 2021 Precursor Analysis Report leverages publicly available information about the attack and catalogs anomalous observables for each technique employed by the adversary. This analysis is based upon the methodology of the Cybersecurity for the Operational Technology Environment (CyOTE) program. The HSE provides public healthcare corporate services and operational services throughout Ireland, with critical functions including the acute national ambulance service, acute hospital service, and community healthcare service. On 14 May 2021, Conti ransomware encrypted 80 percent of the HSE’s Information Technology (IT) infrastructure across corporate, hospital, community, and electronic health record services. Conti is a ransomware-as-a-service operation that encrypts local files, uses double extortion against victims, and is facilitated by many intrusion tools. The attack forced the HSE to shut down its entire IT infrastructure to contain the ransomware, forcing employees to revert to pen and paper recordkeeping and leading to the cancellation of many appointments and procedures. The adversary also exfiltrated 700 GB of data, compromising the confidentiality of patients’ protected health information. Had the adversary targeted the COVID-19 cloud systems or operational technology assets, such as Internet of Medical Things medical devices or smart building management systems, the impact of the attack would almost certainly have been far more severe. Researchers and analysts identified 21 unique techniques (used in a sequence of 23 steps) likely utilized during the attack with a total of 1,185 observables using MITRE ATT&CK® for Industrial Control Systems. The CyOTE program assesses observables accompanying techniques used prior to the triggering event to identify opportunities to detect malicious activity. If observables accompanying the attack techniques are perceived and investigated prior to the triggering event, earlier comprehension of malicious activity can take place. Twenty-one of the identified techniques used during the attack on the HSE were precursors to the triggering event. Analysis identified 1,086 observables associated with these precursor techniques, 850 of which were assessed to have an increased likelihood of being perceived in the 57 days preceding the triggering event. The response and comprehension time could have been reduced if the observables had been identified earlier. The information gathered in this report contributes to a library of observables tied to a repository of artifacts, data sources, and technique detection references for practitioners and developers to support the comprehension of indicators of attack. Asset owners and operators can use these products if they experience similar observables or to prepare for comparable scenarios.

• Research Organization: Idaho National Laboratory (INL), Idaho Falls, ID (United States)
• Sponsoring Organization: USDOE Office of Nuclear Energy (NE)
• DOE Contract Number: AC07-05ID14517
• OSTI ID: 3030058
• Report Number(s): INL/RPT-22-70648
• Country of Publication: United States
• Language: English

Related Subjects

99 - GENERAL AND MISCELLANEOUS
Conti Ransomware
Cybersecurity for the Operational Technology Environment (CyOTE)
HSE Ireland
Precursor analysis