The Risks Digest

The RISKS Digest

Forum on Risks to the Public in Computers and Related Systems

ACM Committee on Computers and Public Policy, Peter G. Neumann, moderator

Volume 23 Issue 79

Thursday 17 March 2005

Contents

Professional Risk Assessment
Jack Goldberg
Fallbacks that cry wolf
Steve Summit
Airbus A300/310 rudder problems
David Rose via Harry Crowther
Oyster card fault causes problems on London Underground
Daniel Thomas via Paul Rummell
Computerized Physician Order Entry Systems
Charles J. Wertz
Computerized medical mistakes
Bob Morrell
Ballots "enhanced" by City Clerk
Arthur Kimes
Centralized Privacy Rights Mechanism
Curt Sampson
Man in the middle attack on SSL?
Russell Page
Payment via MSN and related news
Koos van den Hout
Microsoft antivirus - is it beta?
Rob Slade
Re: Viruses being delivered into mailing lists via BCC:
Dave Sill
Re: Richard Clarke: Real ID's, Real Dangers
Marc Auslander
Mike Pritchard
Users of AOL Instant Messenger and other services beware!
Alistair McDonald
Info on RISKS (comp.risks)

Professional Risk Assessment

<Jack Goldberg <jackgoldberg@earthlink.net>>
Sat, 12 Mar 2005 10:30:00 -0800

Risks associated with developing and using computer systems have been
documented widely (e.g., by PGN) and have become part of popular awareness.
Economic costs resulting from these risks are huge, though presently
unquantified.  They include the costs of system failures, abandoned system
developments, and lost opportunities to build valuable systems whose
complexity is deemed beyond present art.

Despite the widespread awareness of this situation, nothing fundamental has
been done to change it. New system technologies attempt to improve matters
by giving system builders better tools.  Large corporate and government
initiatives to improve system trustworthiness have been announced.  Despite
many advances, system development risks have not abated. New systems keep
getting developed whose defects are discovered too late to be repaired
economically.  Repairs become patches and basic defects remain embedded in
the system.  These problems are pervasive, both in safety and
infrastructure-critical applications and in the mundane data-processing
applications that support the national economy.

With all the awareness of the hazards of system building, why does this bad
situation continue?  We suggest that the reason is the weakness of current
risk assessment for new systems.  Warnings about computer system risks that
are given in an early stage do not have the force of warnings in other
disciplines such as medicine and civil engineering and so they are ignored
or discounted.

What can be done to improve the believability of warnings about development
hazards?  We do not envision a super-powerful tool that can generate a
high-confidence hazard assessment for all situations.  Rather we see the
need for a profession of hazard auditors who have earned acceptance based on
their scientific skills and experience.  The need for their skills should be
assumed and demanded in all system development efforts.  Their observations
(and if necessary, testimonies) should be communicated to purchasers,
builders and users.  Tools should be developed to support their analyses.

Building such a profession would be a substantial effort but the effort
would surely be justified by the enormous cost of current development
deficiencies.  Government agencies, corporations, universities and
professional associations all have clear roles to perform.


Fallbacks that cry wolf

<Steve Summit <scs@eskimo.com>>
Wed, 16 Mar 2005 22:55:31 -0500

It's said that every new technology carries with it the possibility of a new
crime, and in a similar way, every new safety feature has some possibility
of actually causing more problems than it's supposed to solve.  This was
brought home to me the other night at Logan airport where I noticed a
shuttle bus whose destination sign persisted in showing the special legend
"Call 911", despite the best efforts of the driver and several dispatchers
whose conversations I was able to listen in on from the driver's radio of
the bus I was on.  I don't know if they eventually got the sign turned off
or had to take the bus out of service, nor do I know how many calls to 911
that night there were about it.


Airbus A300/310 rudder problems

<"Harry Crowther" <crowther@ziplink.net>>
Sun, 13 Mar 2005 07:36:22 -0500

What made an Airbus rudder snap in mid-air?
David Rose - *The Guardian* (UK), The Observer, 13 March 2005
http://observer.guardian.co.uk/international/story/0,6903,1436374,00.html

When Flight 961 literally began to fall apart at 35,000 feet, it increased
fears of a fatal design flaw in the world's most popular passenger jet.

At 35,000 feet above the Caribbean, Air Transat flight 961 was heading home
to Quebec with 270 passengers and crew. At 3.45 pm last Sunday, the pilot
noticed something very unusual. His Airbus A310's rudder - a structure 28
feet high - had fallen off and tumbled into the sea. In the world of
aviation, the shock waves have yet to subside. ...

In November 2001, 265 people died when American Airlines flight 587, an
Airbus A300 model which is almost identical to the A310, crashed shortly
after take-off from JFK airport in New York. According to the official
report into the crash, the immediate cause was the loss of the plane's
rudder and tailfin, though this was blamed on an error by the pilots. ...

There have been other non-fatal incidents. One came in 2002 when a FedEx
A300 freight pilot complained about strange 'uncommanded inputs' - rudder
movements which the plane was making without his moving his control
pedals. In FedEx's own test on the rudder on the ground, engineers claimed
its actuators - the hydraulic system which causes the rudder to move - tore
a large hole around its hinges...

The Observer has learnt that after (an earlier) disaster, more than 20
American Airlines A300 pilots asked to be transferred to Boeings, although
this meant months of retraining and loss of earnings. Some of those who
contributed to pilots' bulletin boards last week expressed anger at the
European manufacturer in vehement terms. One wrote that having attended an
Airbus briefing..., he had refused to let any of his family take an A300 or
A310 and had paid extra to take a circuitous route on holiday purely to
avoid them: 'That is how convinced I am that there are significant problems
associated with these aircraft.'


Oyster card fault causes problems on London Underground

<"Paul Rummell" <rummell@myprivacy.ca>>
Thu, 10 Mar 2005 21:44:49 -0500

"Oyster card fault causes problems on London Underground"
"Automatic updates cause journey renewal problems"
Daniel Thomas, *Computing*, 10 Mar 2005

Londoners were faced with travel problems this morning after an IT error
meant hundreds of commuters could not renew journeys on their Oyster card.

The error, which affected the whole of the London Underground (LU) and
Docklands Light Railway (DLR), was caused when an overnight electronic
updating process went wrong.

Transport for London (TfL) and TranSys - the consortium that operates the
Oyster card scheme - automatically updates the system each night to add new
records and block stolen and canceled cards.

But a glitch in the system early this morning means commuters are unable to
use machines at Underground or DLR station this morning to add new journeys
onto the smart cards.

'Every morning information goes out about stopped cards and it was an error
in the data that caused the problem,' said a spokeswoman for TranSys.

Passengers that have already paid for their journey or using prepay can
still use the system as normal.

TfL and TranSys identified the error at 4am this morning and starting
issuing a fix to the problem by 8.30am.

'We hope everything to be up and running again by the end of the morning,'
said the TranSys spokeswoman. 'We are now looking into what actually caused
the error and ways of ensuring this doesn't happen again.'


Computerized Physician Order Entry Systems

<"Charles J. Wertz" <wertzcj@buffnet.net>>
Fri, 11 Mar 2005 14:47:44 -0500

The 9 Mar 2005 issue of the *Journal of the American Medical Association*
contains two articles and an editorial that should be of interest to Risks
readers.

ROLE OF COMPUTERIZED ORDER ENTRY SYSTEMS IN FACILITATING MEDICATION ERRORS
discusses a variety of issues including poor interface design requiring a
physician to look at as many as 20 screens to see all the information about
a patient, misleading and frequently misinterpreted dosage information,
dosage change requires adding the new and deleting the old, poor integration
of multiple systems, poor handling of discontinuation and resumption of
medications, loss of orders and others. This article appears to be the
result of a well done comprehensive study at one specific hospital.

The Editorial, COMPUTER TECHNOLOGY AND CLINICAL WORK: STILL WAITING FOR
GODOT makes a number of good points such as, "The misleading theory about
technology is that technical problems require technical solutions; ie, a
narrowly technical view that leads to a focus on optimizing the technology.
In contrast, a more useful approach views the clinical workplace as a
complex system in which technologies, people, and organizational routines
dynamically interact." Anyone interested in systems design will find this
interesting.

The other Article, EFFECTS OF COMPUTERIZED CLINICAL DECISION SUPPORT SYSTEMS
ON PRACTITIONER PERFORMANCE AND PATIENT OUTCOMES: A SYSTEMATIC REVIEW
provides a comprehensive review of the topic.

If you have access to this journal and the time to read these articles, you
will find them interesting.


Computerized medical mistakes

<Bob Morrell <bmorrell@triad.rr.com>>
Sat, 12 Mar 2005 09:21:28 -0500

Recent coverage of a JAMA article on the patient errors (cited by R. Akerman
in RISKS-23.78) caused by computers will likely be cited by those who resist
the movement towards an electronic medical record. This despite the fact
that all acknowledge that the current mixed state of computerized and
non-computerized medical systems is abysmal. My perspective on this is that
we often miss the core truth of most medical mistakes: they are caused by
humans, not computers. In the 1990's I developed several programs designed
to find medical mistakes. As such, I spent a lot of time analyzing mistakes,
and dealing with defensive reactions by physicians and nurses to the
mistakes found. The most common mistake, at its core, was raw human
misunderstanding: conceptual misunderstanding leading to misinterpretation
of medical data (surgeons who thought the higher the bacterial MIC number,
the better the antibiotic, when the reverse is true, and therefore put the
patient on an antibiotic guaranteed to be ineffective). A close second was
communication failures, where a key report was pocketed, lost or otherwise
not communicated to others who would understand its importance.

However, in all these cases, the typical hospital political hierarchy sought
to turn each of these medical errors into a computer error, lest a human
(particularly a Doctor human) be found at fault. While I was grumpy about
this at first, I soon realized that there was at least some truth in it, in
that more easily understood medical reports, that highlighted and provided
some interpretation to key information, and were more widely distributed
were in fact improvements worth making to medical systems, and certainly
would prevent far more errors than my mistake finding programs would ever
find. The problem was however, that as the concept of the electronic medical
record began taking shape, resistance to it often cited the end of incident
analysis that blamed the computer, rather than the physician or nurse who
was primarily at fault. The JAMA cases certainly sound like real problems
with the human/computer interface, but they sound suspiciously like the
final reports we used to end up on real mistakes made by real humans.

The medical environment is extremely complex, understaffed and wrought with
automated and semi automated systems that all can fail or conflict whether
they are computerized or not. I routinely saw problems with continuation of
standing order dosing long before those standing orders were computerized.
Blaming the computer misses the point, even if it does point out how the
computer system could be made better.

The risk is one I often see in The Risks Digest: problems with computerized
systems seem to get more attention than the usually much greater problems in
the existing non-computerized systems.

  [Bob, Remember the full name of the Risks Forum!  Actually, I get scolded
  now and then for running noncomputer-related items, but I try to keep
  noting how the noncomputer computer are also illustrative.  PGN]


Ballots "enhanced" by City Clerk

<Arthur Kimes <artki@sbcglobal.net>>
Sat, 12 Mar 2005 07:09:25 -0800

http://www.dailynews.com/Stories/0,1413,200~20954~2758409,00.html

> Los Angeles City Clerk Frank Martinez ordered election workers Tuesday
> night to use blue highlighter pens to re-ink thousands of voters' ballots
> that had "bubbles" partially or faintly filled in, ...

Los Angeles is using the Inkavote system.  The voting machines and ballots
look like the punchcard system (as in Florida 2000) but the ballot is poked
by a special marker that puts a nice round ink blot in the round hole.

The company that makes the counting equipment says that this highlighting
step isn't needed since their machines are supposed to be able to count
ballots that have even a small amount of ink in the right place.

There were only a few thousand votes between the 2nd and 3rd place finishers
in this election - the top two are headed for a runoff in May.


Centralized Privacy Rights Mechanism

<Curt Sampson <cjs@cynic.net>>
Tue, 15 Mar 2005 14:11:27 +0900 (JST)

Bruce Schneier, on his blog recently, mentioned the paper "A Model Regime of
Privacy Protection" by Daniel J. Solove & Chris Jay Hoofnagle.  His link and
discussion is at
     http://www.schneier.com/blog/archives/2005/03/ideas_for_priva.html

The paper's abstract and a link to download it can be found at
     http://papers.ssrn.com/sol3/papers.cfm?abstract_id=681902

There are a lot of good ideas in this paper, but one in particular
struck me as potentially unwise, and certainly underdeveloped:

  In conjunction with the universal notice, the FTC shall develop a
  centralized mechanism for people to exercise their rights with respect to
  their personal information. Such a mechanism would mimic the Do Not Call
  website, which allows individuals to opt-out of telemarketing and verify
  their enrollment by visiting a single website.

Many interesting RISKS are raised by this. How do you identify the people in
the opt-out registry? How do you authenticate requests to deny distribution
of certain information? (A malicious person might try to cause difficulties
for someone by forging a request to deny all credit data to potential
lenders.) How do you determine who may or may not search the registry or
read information in it? How do you keep this from acting as the "central
key" to all the information on a person, effectively moving us closer to
having One Central Database, with all of the problems that brings?

There's a huge can of worms here waiting to be opened.

Personally, my first instinct would be to avoid such a central registry and
instead make it the responsibility of the data collectors to contact each
individual with information about what they're collecting and how they're
using it, and solicit permission to do so, as well as offer the ability to
review the information. This avoids any centralized system, and also avoids
certain types of error. For example, if I'm contact regarding a file that
appears to have nothing to do with me, I can point that out, rather than
have a company mistakenly believe that this file does correspond with my
life. (Or I might just say it does, and use the information for identity
theft. Who knows?)

Curt Sampson  <cjs@cynic.net>   +81 90 7737 2974   http://www.NetBSD.org


Man in the middle attack on SSL?

<"Russell Page" <russellpage@hotmail.com>>
Fri, 11 Mar 2005 12:05:03 +1100

Marketscore (www.marketscore.com) offer a free proxy service web users. They
offer accelerated downloads and e-mail virus scanning. To use their service
users download and install software onto their PCs. Marketscore are quite
explicit that they collect a wide range of information about their
subscribers, and make information available to web site owners on usage
patterns - a sort of "Neilson" for the net.

Unfortunately, they also impersonate SSL sites. If a subscriber attempts to
set up an SSL connection to say, her bank, the Marketscore proxy sends back
it's certificate, and then establishes an SSL connection to the destination.
Clearly for this to work, the servers have to decrypt then re-encrypt all of
the traffic. Equally clearly, large numbers of credit card numbers, account
names, passwords etc are passing through the Marketscore systems in the
clear.

There is a very good explanation of the problem here:
http://www.shellnofcu.com/site/scams.html


Payment via MSN and related news

<Koos van den Hout <koos@kzdoos.xs4all.nl>>
Fri, 11 Mar 2005 10:53:57 +0100

Nu.nl Internet <url:http://www.nu.nl/rubriek.jsp?n=224&c=50>, a current news
website (in Dutch) had the following two headlines following each other this
morning (my translation):

* MSN as form of payment
  http://www.nu.nl/news/495376/57/art.html

* Viruses in chat programs increasing in popularity
  http://www.nu.nl/news/494989/50/art.html

The first article is about the SNS bank in the Netherlands introducing a
service for small payments via Microsoft's MSN Messenger.

The second article is about chat programs like MSN Messenger being used
increasingly for spreading viruses.

With all the phishers and some of the virus-writers targeting online banks
and sites such as Pay-pal, guess where this will be going.


Microsoft antivirus - is it beta?

<Rob Slade <rslade@sprint.ca>>
Wed, 16 Mar 2005 10:03:40 -0800

Some months back, Microsoft announced the purchase of an antivirus company.
For those in malware research, this appeared to be an indicator that
Microsoft would be getting back into the field.  Apparently, very few of us
are old enough to recall the first time Microsoft "produced" an antivirus
product, but those who are remember that the kindest way to describe the
attempt would be "not fully thought through."  Therefore, we did not look
forward to this event with any great enthusiasm.

Subsequently, Microsoft announced it had acquired an anti-spyware company.
Then it announced a beta test version of an anti-spyware product.  Then
there was a flurry of announcements about legalities, copyright
infringements, products that would be free, settlements of copyright
infringement suits, products that would be charged for, and so forth, so I
hope I can be forgiven for not recalling exactly where in that timeline came
the announcement of a beta version of an antivirus product.

I viewed the antivirus beta with some trepidation.  The announcement was not
particularly clear about the capabilities of the product.  It did indicate
that the antivirus would be a) limited to specific malware programs, b)
concentrate on "worms," and c) there seemed to be hints that the program
would run in the background.  With apprehension I downloaded the beta
antivirus and installed it on one machine.

Nothing happened.

Nothing appeared in the Start menu programs list.  Nothing appeared in the
"Program Files" directory.  Nothing appeared in the "Remove Programs" list.
Nothing disappeared from my malware samples directory.

Subsequently, I have been receiving announcements from "Auto Update" that
the "Windows Malicious Software Removal Tool" was ready for installation.
Previously I found this completely bewildering.  In the latest instance, if
you choose "Custom Install," it does inform you that the tool will run once,
and then be deleted from your computer.  This makes a bit more sense.

According to Microsoft, more information for this update can be found at
http://www.microsoft.com/malwareremove.  This page states the same "run and
then disappear" process, along with the assertion that the program will
generate a report on the status of your computer.  (So far, in my
experience, this hasn't happened.)

The page lists seventeen pieces of malware that the program "cleans."  The
mention of "background" operation now seems to be tied to the Auto Update
process, although it isn't completely clear that the antivirus itself
doesn't run in the background.  (The "run and delete" description would seem
to indicate that the antivirus doesn't run in the background.)

I am interested in results from any others who have studied the program in
more detail, including issues related to where the program looks for
infections, what is cleaned, removal of malware from memory, cleanup of the
Registry, scanning of mail files (many of the malware items listed are
spread via e-mail attachments), and so forth.

rslade@vcn.bc.ca      slade@victoria.tc.ca      rslade@sun.soci.niu.edu
http://victoria.tc.ca/techrev    or    http://sun.soci.niu.edu/~rslade


Re: Viruses being delivered into mailing lists via BCC:

<Dave Sill <de5-dated-1111440414.241b1c@sws5.ornl.gov>>
Wed, 16 Mar 2005 16:26:53 -0500
  (Rothwell, RISKS-23.77)

The Delivered-To field is added by qmail (and other MTAs) when the message
is delivered, so it's only visible to the recipient named in the field.

For example, if I send a message to joe@example.com and BCC dave@sill.org,
the copy of the message that Joe receives might get a Delivered-To field
like:

  Delivered-To: joe@example.com

And I'll get one like:

  Delivered-To: dave@sill.org

But since these are completely different copies of the message
residing on different servers, Joe won't be able to see that I
received a copy of the message.

Of course if I were to forward my copy of the message to Joe with
its Delivered-To fields intact, that would expose the blind copy.

Dave Sill, Author, The qmail Handbook


Re: Richard Clarke: Real ID's, Real Dangers (McMullen, RISKS-23.78)

<Marc Auslander <marcausl@optonline.net>>
Wed, 16 Mar 2005 20:58:16 -0500

Actually, it has always seemed obvious to me that the real purpose of the
photo ID check, and the reason the airlines cooperate, is that it interferes
with a secondary market in non-refundable tickets.


Re: Richard Clarke: Real ID's, Real Dangers (McMullen, RISKS-23.78)

<Mike Pritchard <mpp@mppsystems.com>>
Fri, 11 Mar 2005 05:11:38 -0600

Having worked in the bar and liquor store industry for the last 6 years, I
can tell you the scanners are not the end all solution either.  At my work
we have a large collection of fake ID's that scan just fine.  All the info
matches what is printed on the ID, but the ID was still fake.  You can buy a
mag strip writer for a few hundred dollars off the Internet and write
whatever info you want on there.  If you are smart enough, you can generate
the correct 3-D barcode, and print that on the ID, too, and all the high
priced scanners will tell you the ID is fine, even when it is a fake.  The
fake ID people even can get the UV light seals nearly 100% correct.

The other risk here is not checking what the scanner says.  A large number
of the fake IDs I've confiscated scan (reports the person is 21 or older),
but the info doesn't match.  The person producing the fake used a real ID to
generate the barcode info.  Some of our scanners just check age, and don't
display the actual data.  And some states encrypt that data, so the scanner
is useless on those.

At my previous job, we had no scanners, so detecting fakes was all visual
inspection (or by touch, a lot of fakes just don't feel right).  On a number
of fakes I confiscated, I had people insist I scan it!  Told them I had no
scanner, and I knew it was fake, and the only way they were going to gain
entrance was for a police officer to verify the ID.  Had a few call my
bluff, and the cops came and wound up giving them a ticket.  I took some of
those ID's over to another location that had a scanner, and sure enough the
scanner said they were 21!

The place I'm at now has scanners, and some of the staff rely too much on
them.  I've grabbed ID's out of other clerks hands to inspect them when they
ran them through the scanner and it said it was ok, and a lot of times it
does turn out to be fake.


Users of AOL Instant Messenger and other services beware!

<"Alistair McDonald" <alistair@inrevo.com>>
Sat, 12 Mar 2005 23:16:27 -0000 (GMT)

AOL has changed their Terms of Service for users of their services - see
<http://www.aim.com/tos/tos.adp>.

Users of their services, for example AOL Instant Messenger (AIM) in
particular should note the details, including: "by posting Content on an AIM
Product, you grant AOL, its parent, affiliates, subsidiaries, assigns,
agents and licensees the irrevocable, perpetual, worldwide right to
reproduce, display, perform, distribute, adapt and promote this Content in
any medium".

Nice one!

A few points:

1: We've seen this before: a company makes a niche, gains userbase, then
   turns bad in some way ans shafts the user.
2: I've often used IM services to send beta software, specs, and so on to
   clients, using the "send file" option. By transferring them via AIM, I've
   allowed them to be reproduced in any form. There goes client
   confidentiality.
3: Big companies use AOL - one of my clients is one of the largest
   investment banks in the world. Their desktop IM client includes an AIM
   bridge, I guess that some traders use it to communicate with clients (by
   using the bridge, the bank can log everything and keep regulators happy).
   What does this mean to the bank, or another large company?
4: What if some voice over IP (VoIP) provider pulls this one. Or even an
   e-mail provider?

Jabber and ICQ are free (as in beer) IM services. I've used ICQ, but have
no experience of Jabber <http://www.jabber.org/> and
<http://www.icq.com/>.

  Added note, 14 Mar 2005 13:51:55 -0000 (GMT)

  AOL has subsequently clarified its ToS. This has been reported in a
  blog:<http://www.chron.com/cs/CDA/ssistory.mpl/tech/blog/3082956>, which
  itself reports on e-mail and telephone conversations with AOL spokesman
  Andrew Weinstein.

  However, the ToS still read as they did yesterday (I doubt AOL are going
  to modify them without a lawyer casting an eye on them, and this story
  broke over the weekend). The terms are still ambiguous and everyone should
  be careful!

Alistair McDonald, InRevo Ltd (http://www.inrevo.com)  07017 467 396
Author of the SpamAssassin book: http://www.spamassassinbook.com/

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