The EPA also could not demonstrate that it has effective governance and oversight of its regulatory operations. The EPA operates in a complex regulatory environment where its regional offices have broad discretions for how they operate. The EPA has not balanced this devolved structure with an effective governance approach that includes appropriate internal controls to monitor the consistency or quality of its regulatory activities. It also does not have an effective performance framework that sets relevant performance expectations and outcome-based key performance indicators (KPIs) for its regional offices. 

These deficiencies mean that the EPA cannot be confident that it conducts compliance and enforcement activities consistently across the State and that licensees are complying with their licence conditions or the Act.

The EPA's reporting on environmental and regulatory outcomes is limited and most of the data it uses is self reported by industry. It has not set outcome-based key result areas to assess performance and trends over time. 

Elements of the EPA’s risk-based regulatory framework for water pollution and illegal solid waste disposal are consistent with the NSW Government Guidance for regulators to implement outcomes and risk-based regulation. There are important gaps in how the EPA implements its risk-based approach that limit the effectiveness of its regulatory response. The EPA could not demonstrate that it effectively regulates licensees because it has not established reliable practices that accurately and consistently detect licence non compliances or breaches of the Act and enforce regulatory actions.

The EPA lacks effective governance arrangements to support its devolved regional structure. The EPA's performance framework has limited and inconclusive reporting on regional performance to the EPA’s Chief Executive Officer or to the EPA Board. The EPA cannot assure that it is conducting its regulatory responsibilities effectively and efficiently. 

The EPA does not consistently evaluate its regulatory approach to ensure it is effective and efficient. For example, there are no set requirements for how EPA officers conduct mandatory site inspections, which means that there is a risk that officers are not detecting all breaches or non-compliances. The inconsistent approach also means that the EPA cannot rely on the data it collects from these site inspections to understand whether its regulatory response is effective and efficient. In addition, where the EPA identifies instances of non compliance or breaches, it does not apply all available regulatory actions to encourage compliance.

The EPA also does not have a systematic approach to validate self-reported information in licensees’ annual returns, despite the data being used to assess administrative fees payable to the EPA and its regulatory response to non-compliances. 

The EPA does not use performance frameworks to monitor the consistency or quality of work conducted across the State. The EPA has also failed to provide effective guidance for its staff. Many of its policies and procedures are out-dated, inconsistent, hard to access, or not mandated.

By 31 December 2018, to improve governance and oversight, the EPA should:
1.	implement a more effective performance framework with regular reports to the Chief Executive Officer and to the EPA Board on outcomes-based key result areas that assess its environmental and regulatory performance and trends over time
By 30 June 2019, to improve consistency in its practices, the EPA should:
2.	progressively update and make accessible its policies and procedures for regulatory operations, and mandate procedures where necessary to ensure consistent application
3.	implement internal controls to monitor the consistency and quality of its regulatory operations.

The requirements for setting licence conditions for water pollution are complex and require technical and scientific expertise. In August 2016, the EPA approved guidance developed by its technical experts in the Water Technical Advisory Unit to assist its regional staff. However, the EPA did not mandate the use of the guidance until mid-April 2018. Up until then, the EPA had left discretion to regional offices to decide what guidance their staff use. This meant that practices have differed across the organisation. The EPA is yet to conduct training for staff to ensure they consistently apply the 2016 guidance.

The EPA has not implemented any appropriate internal controls or quality assurance process to monitor the consistency or quality of licence conditions set by its officers across the State. This is not consistent with good regulatory practice.

The triennial 2016 audit of the Sydney drinking water catchment report highlighted that Lake Burragorang has experienced worsening water quality over the past 20 years from increased salinity levels. The salinity levels were nearly twice as high as in other storages in the Sydney drinking water catchment. The report recommended that the source and implication of the increased salinity levels be investigated. The report did not propose which public authority should carry out such an investigation. 

To date, no NSW Government agency has addressed the report's recommendation. There are three public authorities, the EPA, DPE and WaterNSW that are responsible for regulating activities that impact on water quality in the Sydney drinking water catchment, which includes Lake Burragorang. 

By 30 June 2019, to address worsening water quality in Lake Burragorang, the EPA should:
4.	(a) review the impact of its licensed activities on water quality in Lake Burragorang, and
	(b) develop strategies relating to its licensed activities (in consultation with other relevant NSW Government agencies) to improve and maintain the lake's water quality.

The EPA tailors its compliance monitoring approach based on the performance of licensees. This means that licensees that perform better have a lower administrative fee and fewer mandatory site inspections. 

However, this approach relies on information that is not complete or accurate. Sources of information include licensees’ annual returns, EPA site inspections and compliance audits, and pollution reports from the public. 

Licensees report annually to the EPA on their performance, including compliance against their licence conditions. The Act contains significant financial penalties if licensees provide false and misleading information in their annual returns. However, the EPA does not systematically or consistently validate information self-reported by licensees, or consistently apply regulatory actions if it discovers non-compliance. 

Self-reported compliance data is used in part to assess a licensed premises’ overall environmental risk level, which underpins the calculation of the administrative fee, the EPA’s site inspection frequency, and the licensee’s exposure to regulatory actions. It is also used to assess the load-based licence fee that the licensee pays.

The EPA has set minimum mandatory site inspection frequencies for licensed premises based on its assessed overall risk level. This is a key tool to detect non-compliance or breaches of the Act. However, the EPA has not issued a policy or procedures that define what these mandatory inspections should cover and how they are to be conducted. We found variations in how the EPA officers in the offices we visited conducted these inspections. The inconsistent approach means that the EPA does not have complete and accurate information of licensees’ compliance. The inconsistent approach also means that the EPA is not effectively identifying all non-compliances for it to consider applying appropriate regulatory actions.

The EPA also receives reports of pollution incidents from the public that may indicate non-compliance. However, the EPA has not set expected time frames within which it expects its officers to investigate pollution incidents. The EPA regional offices decide what to investigate and timeframes. The EPA does not measure regional performance regarding timeframes. 

The few compliance audits the EPA conducts annually are effective in identifying licence non-compliances and breaches of the Act. However, the EPA does not have a policy or required procedures for its regulatory officers to consistently apply appropriate regulatory actions in response to compliance audit findings. 

The EPA has not implemented any effective internal controls or quality assurance process to check the consistency or quality of how its regulatory officers monitor compliance across the State. This is not consistent with good regulatory practice.

To improve compliance monitoring, the EPA should implement procedures to:
5.	by 30 June 2019, validate self-reported information, eliminate hardcopy submissions and require licensees to report on their breaches of the Act and associated regulations in their annual returns
6.	by 31 December 2018, conduct mandatory site inspections under the risk-based licensing scheme to assess compliance with all regulatory requirements and licence conditions.

The EPA’s compliance policy and prosecution guidelines have a large number of available regulatory actions and factors which should be taken into account when selecting an appropriate regulatory response. The extensive legislation determining the EPA’s regulatory activities, and the devolved regional structure the EPA has adopted in delivering its compliance and regulatory functions, increases the risk of inconsistent compliance decisions and regulatory responses. A good regulatory framework needs a consistent approach to enforcement to incentivise compliance. 

The EPA has not balanced this devolved regional structure with appropriate governance arrangements to give it assurance that its regulatory officers apply a consistent approach to enforcement.

The EPA has not issued standard procedures to ensure consistent non-court enforcement action for breaches of the Act or non-compliance with licence conditions. Given our finding that the EPA does not effectively detect breaches and non-compliances, there is a risk that it is not applying appropriate regulatory actions for many breaches and non-compliances.

A recent EPA compliance audit identified significant non-compliances with incident management plan requirements. However, the EPA has not applied regulatory actions for making false statements on annual returns for those licensees that certified their plans complied with such requirements. The EPA also has not applied available regulatory actions for the non-compliances which led to the false or misleading statements.

By 31 December 2018 to improve enforcement, the EPA should:
7.	Implement procedures to systematically assess non-compliances with licence conditions and breaches of the Act and to implement appropriate and consistent regulatory actions.

The EPA did not achieve the NSW Illegal Dumping Strategy 2014–16 target of a 30 per cent reduction in instances of large scale illegal dumping in Sydney, the Illawarra, Hunter and Central Coast from 2011 levels. 

In the reporting period, the incidences of large scale illegal dumping more than doubled. The EPA advised that this increase may be the result of greater public awareness and reporting rather than increased illegal dumping activity. 

By June 2018, the EPA is due to implement one outstanding recommendation made by the ICAC but has not set a time for the other outstanding recommendation.  

All four agencies examined in the audit are taking steps to strengthen their risk culture. In these agencies, senior management communicates the importance of managing risk to their staff. They have risk management policies and funded central functions to oversee risk management. We also found many examples of risk management being integrated into daily activities.

That said, three of the four case study agencies could do more to understand their existing risk culture. As good practice, agencies should monitor their employees’ attitude to risk. Without a clear understanding of how employees identify and engage with risk, it is difficult to tell whether the 'tone' set by the executive and management is aligned with employee behaviours.

Our survey of risk culture found that three agencies could strengthen a culture of open communication, so that all employees feel comfortable speaking openly about risks. To support innovation, senior management could also do better at communicating to their staff the levels of risk they are willing to accept.

Some agencies are performing better than others in building their risk capabilities. Three case study agencies have reviewed the risk-related skills and knowledge of their workforce, but only one agency has addressed the gaps the review identified. In three agencies, staff also need more practical guidance on how to manage risks that are relevant to their day-to-day responsibilities.

NSW Treasury provides agencies with direction and guidance on risk management through policy and guidelines. Its principles-based approach to risk management is consistent with better practice. Nevertheless, there is scope for NSW Treasury to develop additional practical guidance and tools to support a better risk culture in the NSW public sector. NSW Treasury should encourage agency heads to form a view on the current risk culture in their agencies, identify desirable changes to that risk culture, and take steps to address those changes. 

In assessing an agency’s risk culture, we focused on four key areas:

Executive sponsorship (tone at the top)

In the four agencies we reviewed, senior management is communicating the importance of managing risk. They have endorsed risk management frameworks and funded central functions tasked with overseeing risk management within their agencies.

That said, we found that three case study agencies do not measure their existing risk culture. Without clear measures of how employees identify and engage with risk, it is difficult for agencies to tell whether employee's behaviours are aligned with the 'tone' set by the executive and management.

For example, in some agencies we examined we found a disconnect between risk tolerances espoused by senior management and how these concepts were understood by staff.

Employee perceptions of risk management

Our survey of staff indicated that while senior leaders have communicated the importance of managing risk, more could be done to strengthen a culture of open communication so that all employees feel comfortable speaking openly about risks. We found that senior management could better communicate to their staff the levels of risk they should be willing to accept.

Integration of risk management into daily activities and links to decision-making

We found examples of risk management being integrated into daily activities. On the other hand, we also identified areas where risk management deviated from good practice. For example, we found that corporate risk registers are not consistently used as a tool to support decision-making.

Support and guidance to help staff manage risks

Most case study agencies are monitoring risk-related skills and knowledge of their workforce, but only one agency has addressed the gaps it identified. While agencies are providing risk management training, surveyed staff in three case study agencies reported that risk management training is not adequate.

NSW Treasury provides agencies with direction and guidance on risk management through policy and guidelines. In line with better practice, NSW Treasury's principles-based policy acknowledges that individual agencies are in a better position to understand their own risks and design risk management frameworks that address those risks. Nevertheless, there is scope for NSW Treasury to refine its guidance material to support a better risk culture in the NSW public sector.

Recommendation

By May 2019, NSW Treasury should:

• Review the scope of its risk management guidance, and identify additional guidance, training or activities to improve risk culture across the NSW public sector. This should focus on encouraging agency heads to form a view on the current risk culture in their agencies, identify desirable changes to that risk culture, and take steps to address those changes.

There is no whole‑of‑government capability to detect and respond effectively to cyber security incidents. There is limited sharing of information on incidents amongst agencies, and some of the agencies we reviewed have poor detection and response practices and procedures. There is a risk that incidents will go undetected longer than they should, and opportunities to contain and restrict the damage may be lost.

Given current weaknesses, the NSW public sector’s ability to detect and respond to incidents needs to improve significantly and quickly. DFSI has started to address this by appointing a Government Chief Information Security Officer (GCISO) to improve cyber security capability across the public sector. Her role includes coordinating efforts to increase the NSW Government’s ability to respond to and recover from whole‑of‑government threats and attacks.

Some of our case study agencies had strong processes for detection and response to cyber security incidents but others had a low capability to detect and respond in a timely way.

Most agencies have access to an automated tool for analysing logs generated by their IT systems. However, coverage of these tools varies. Some agencies do not have an automated tool and only review logs periodically or on an ad hoc basis, meaning they are less likely to detect incidents.

Few agencies have contractual arrangements in place for IT service providers to report incidents to them. If a service provider elects to not report an incident, it will delay the agency’s response and may result in increased damage.

Most case study agencies had procedures for responding to incidents, although some lack guidance on who to notify and when. Some agencies do not have response procedures, limiting their ability to minimise the business damage that may flow from a cyber security incident. Few agencies could demonstrate that they have trained their staff on either incident detection or response procedures and could provide little information on the role requirements and responsibilities of their staff in doing so.

Most agencies’ incident procedures contain limited information on how to report an incident, who to report it to, when this should occur and what information should be provided. None of our case study agencies’ procedures mentioned reporting to DFSI, highlighting that even though reporting is mandatory for most agencies their procedures do not require it.

Case study agencies provided little evidence to indicate they are learning from incidents, meaning that opportunities to better manage future incidents may be lost.

Recommendations

The Department of Finance, Services and Innovation should:

• assist agencies by providing:
  • better practice guidelines for incident detection, response and reporting to help agencies develop their own practices and procedures
  • training and awareness programs, including tailored programs for a range of audiences such as cyber professionals, finance staff, and audit and risk committees
  • role requirements and responsibilities for cyber security across government, relevant to size and complexity of each agency
  • a support model for agencies that have limited detection and response capabilities
     
• revise the Digital Information Security Policy and Information Security Event Reporting Protocol by
  • clarifying what security incidents must be reported to DFSI and when
  • extending mandatory reporting requirements to those NSW Government agencies not currently covered by the policy and protocol, including State owned corporations.

DFSI lacks a clear mandate or capability to provide effective detection and response support to agencies, and there is limited sharing of information on cyber security incidents.

DFSI does not currently have a clear mandate and the necessary resources and systems to detect, receive, share and respond to cyber security incidents across the NSW public sector. It does not have a clear mandate to assess whether agencies have an acceptable detection and response capability. It is aware of deficiencies in agencies and across whole‑of‑government, and has begun to conduct research into this capability.

Intelligence gathering across the public sector is also limited, meaning agencies may not respond to threats in a timely manner. DFSI has not allocated resources for gathering of threat intelligence and communicating it across government, although it has begun to build this capacity.

Incident reporting to DFSI is mandatory for most agencies, however, most of our case study agencies do not report incidents to DFSI, reducing the likelihood of containing an incident if it spreads to other agencies. When incidents have been reported, DFSI has not provided dedicated resources to assess them and coordinate the public sector’s response. There are currently no formal requirements for DFSI to respond to incidents and no guidance on what it is meant to do if an incident is reported. The lack of central coordination in incident response risks delays and increased damage to multiple agencies.

DFSI's reporting protocol is weak and does not clearly specify what agencies should report and when. This makes agencies less likely to report incidents. The lack of a standard format for incident reporting and a consistent method for assessing an incident, including the level of risk associated with it, also make it difficult for DFSI to determine an appropriate response.

There are limited avenues for sharing information amongst agencies after incidents have been resolved, meaning the public sector may be losing valuable opportunities to improve its protection and response.

Recommendations

The Department of Finance, Services and Innovation should:

• develop whole‑of‑government procedure, protocol and supporting systems to effectively share reported threats and respond to cyber security incidents impacting multiple agencies, including follow-up and communicating lessons learnt
• develop a means by which agencies can report incidents in a more effective manner, such as a secure online template, that allows for early warnings and standardised details of incidents and remedial advice
• enhance NSW public sector threat intelligence gathering and sharing including formal links with Australian Government security agencies, other states and the private sector
• direct agencies to include standard clauses in contracts requiring IT service providers report all cyber security incidents within a reasonable timeframe
• provide assurance that agencies have appropriate reporting procedures and report to DFSI as required by the policy and protocol by:
  • extending the attestation requirement within the DISP to cover procedures and reporting
  • reviewing a sample of agencies' incident reporting procedures each year.