TRANSCRIPT OF PROCEEDINGS · TRANSCRIPT OF PROCEEDINGS O/N H-1193678 MR B. WALKER SC, Commissioner...

.RUBY PRINCESS INQUIRY 1.5.20R2 P-150

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TRANSCRIPT OF PROCEEDINGS

O/N H-1193678

MR B. WALKER SC, Commissioner

IN THE MATTER OF A SPECIAL COMMISSION OF INQUIRY

INTO THE RUBY PRINCESS

SYDNEY

1.30 PM

Continued from 23.4.20

DAY 3

MR R. BEASLEY SC appears with MR N. KIRBY as counsel assisting the

Commission

MS G. FURNESS SC appears with MS K. LINDEMAN for the Health Administration

Corporation

MR M. HUTCHINGS appears for the Port Authority of New South Wales


COMMISSIONER: We’re recording now for transcript. Thank you.

MR R. BEASLEY SC: Commissioner, I think you want to make some orders before

we commence.

5

COMMISSIONER: Yes. The hearing this afternoon for all of the evidence to be

heard this afternoon is in private under subsection 7(2) of the Special Commissions of

Inquiry Act 1983. Do I have a list of the names of all the persons authorised to be

present?

10

MR M. HUTCHINGS: It’s just being prepared at the moment, Commissioner.

COMMISSIONER: We will come to that in a moment then. I will give directions

as to the people who may be present at the hearing. I note there has been convenient

correspondence beforehand for which I’m grateful, and that is under subsection 7(3) 15

of the Act. I also – let me do that now. I direct that the persons who may be present

at the hearing will be the witnesses, Sarah Marshall and Cameron Butchart, and for

the hearing of the evidence of those two witnesses as well, Matthew Hutchings of

counsel, Ashley Tsacalos of Clayton Utz, and Amy Beaumont of the Port Authority.

Thereafter, for the evidence of Kelly-Anne Ressler, apart from that witness with 20

respect to her evidence, Deanne Tadros as well, and, of course, counsel assisting and

the staff of the Commission.

I also give directions under section 8 of the Act preventing, until further direction,

the publication of the evidence given this afternoon, and lest there be any doubt as to 25

what that means, the prevention of publication means the communication of the

content of any of the evidence to any other person at all other than what occurs

during the course of this hearing itself. That order is also until further direction, and

I want to make it clear that by and large there will be as much public disclosure of

evidentiary material as possible at this Commission. That is consistent with the 30

principles and policy in the Act. It follows that evidence that will be heard privately

this afternoon, which is directed at present not to be published, is evidence that may,

nonetheless, in due course come to be published in full. Has anyone got any

inquiries or doubts that they would wish to have cleared about any of that? No.

Thank you. 35

While we’re waiting for the witness to come in, there has been communication, I

think already, formally of my grant of leave to the Port Authority to be represented.

MR HUTCHINGS: Yes. 40

MR BEASLEY: Ms Marshall has a copy of – have a seat please for a moment. Ms

Marshall has a copy of her – a statement she gave to the police which I told my

friend - - -

45

COMMISSIONER: Yes.

.RUBY PRINCESS INQUIRY 1.5.20R2 P-152 S. MARSHALL XN

MR BEASLEY SC

MR BEASLEY: - - - I was happy for her to have. I’ve only had it since this

morning. So I’m not fully familiar with it either. Ms Marshall’s going to need a

copy of the key documents folder.

COMMISSIONER: Yes. 5

MR BEASLEY: And I’m not sure what – whether someone else is being arranged

to take an oath or affirmation from – do you want to take – do you want to swear

your oath on a Bible, Ms Marshall, or give an affirmation?

10

MS MARSHALL: I’ll give an affirmation.

MR BEASLEY: All right. Is someone going to do that? It’s not in my fee

agreement. I’ll have to increase it, if I have to do it.

15

<SARAH MARSHALL, AFFIRMED [1.35 pm]

COMMISSIONER: And that’s what you affirm, is it? 20

MS MARSHALL: That’s what I affirm.

COMMISSIONER: Thank you.

25

MR BEASLEY: Yes, that had an element of Chief Justice Roberts with President

Obama to me, but we’ll get it right the second time.


30

<EXAMINATION-IN-CHIEF BY MR BEASLEY SC

MR BEASLEY: Ms Marshall, my name’s Richard Beasley, by the way. I’m one of 35

the counsel assisting the inquiry. You are the general manager operations Sydney for

the Port Authority of New South Wales?

MS MARSHALL: I am.

40

MR BEASLEY: How long have you held that position?

MS MARSHALL: I’ve held that position since August 2018.

MR BEASLEY: And can you tell the Commissioner, in a general sense, what the 45

duties of the general manager operations of the Ports Authority involve?


MR BEASLEY SC

MS MARSHALL: Yes. So my role involves the oversight of several different

functions within Port Authority of New South Wales in Sydney. Those functions are

our vessel traffic services, our pilot transfer service, our marine operations service,

dangerous – looking after dangerous goods and compliance and planning. So overall

there’s about 100 staff that sit in that group. And I’m happy, if you would like, for 5

me to explain further what each of those services do.

COMMISSIONER: At the moment, at least, I’m most interested in vessel traffic

services.

10

MS MARSHALL: Sure. So vessel traffic services are essentially the

communications hub for the harbour. They look after – you know, support the

process of safe navigation of commercial vessels into the harbour. They play a role

in facilitating all of the groups that – or all of the different players that need to come

together to, you know, book vessels that come in to the harbour, including things like 15

ensuring there’s a pilot to bring a vessel in, securing tugs, lines, where the berth is

that it will come to. So they’re working with vessel agents for that to be booked in.

There’s a system - - -

COMMISSIONER: To whom do the pilots answer to? 20

MS MARSHALL: The – the pilots report to the harbour master.

COMMISSIONER: And where – how does the harbour master relate in a reporting

sense to VTS? 25

MS MARSHALL: So it has slightly changed since the – the point in time that the

Ruby Princess came in. We’ve had a slight change of structure.

COMMISSIONER: Tell me about when the Ruby Princess came in. 30

MS MARSHALL: Okay. At the – at the point in time when the Ruby Princess

came in, the title of harbour master was held by our CEO Philip Holliday and he had

given authority to others to act as duty harbour masters underneath him. So that we

had at that point in time three duty harbour masters. One of those duty harbour 35

masters reports through to me and is the manager of the Vessel TrafficServices team.

His name is Cameron Butchart. His title is Manager Port Services. One of the duty

harbour masters is the pilot manager and manages the pilots on a day to day basis.

And a third duty harbour master also runs special projects, which is a manager of

special projects. 40

COMMISSIONER: So the – the pilot on the night would not answer to Mr

Butchart, but Mr Butchart had responsibilities concerning the coordination of the

pilotage?

45

MS MARSHALL: Coordination of whether the – yes. Whether the pilot is going

ahead and that sort of thing.


MR BEASLEY SC


MS MARSHALL: So they look after – going back to what VTS do, they – they – so

they play that coordination and facilitation role through a system that’s called SHIPS,

and stands for Sydney Harbour Integrated – oh, I’ve just had a – and mental blank. 5

COMMISSIONER: Don’t worry.

MS MARSHALL: Anyway. SHIPS system.

10

MR BEASLEY: You can come back to it.

MS MARSHALL: Yes. And – and also they play a role of being the eyes and the

ears of the harbour and what we can – we consider to be part of the bridge team. So,

for example, when a ship is coming into the harbour the – the VTS are able to assist. 15

So if you – if anybody knows where Bradleys Head is in Sydney Harbour, if you can

imagine that the – the pilot is bringing – is bringing the ship round Bradleys Head,

the VTS play a role in being able to see what’s happening around the corner because

of the – the cameras and the visibility that they have and they can, you know,

guidance on that. And they assist through the whole berthing of the vessel. 20


MR BEASLEY: Just so it’s on the record, because it will go into an annexure of the

report. I’d just like to note that I – I got to ask Ms Marshall her name and occupation 25

before the Commissioner took over. I don’t take it personally. But relevantly to

while we’re here, Ms Marshall, can I – if I say the words Ruby Princess to you, I

assume you know what I’m talking about?

MS MARSHALL: Yes, I do. 30

MR BEASLEY: Can I ask you about an email – I’m going to go back in time after

this, but I want to take you to an email, and I don’t know, Commissioner, if you’ve

got the key documents bundle, but it’s about halfway through tab 13. It’s an email

from Ms Marshall to, amongst others, Emma Fensom, of the 13th of March 2020, 35

sent at 4.13 pm. It’s actually, I think, Annexure J to your police statement.

MS MARSHALL: Yes.

COMMISSIONER: Can I ask, the – this current iteration of something called the 40

key documents, with an index that has, I think, 18 sections, is it convenient if we can

mark that for identification now as - - -

MR BEASLEY: Yes.

45

COMMISSIONER: - - - so as to record it – it’s the form that this witness had?


MR BEASLEY SC

MR BEASLEY: Yes.

COMMISSIONER: Well - - -

MR BEASLEY: So I’d just call it - - - 5

COMMISSIONER: - - - that’ll be marked for identification number 1.

MR BEASLEY: - - - key – key documents, volume 1 can be MFI - - -

10

COMMISSIONER: One.

MFI #1 KEY DOCUMENTS VOLUME 1

15

MR BEASLEY: - - - one. Yes.


20

MR BEASLEY: Someone was whispering to me then whether you had the

annexures to your statement you gave to the police, do you?

MS MARSHALL: I don’t have them handy, no.

25

MR BEASLEY: You don’t? Okay.

MS MARSHALL: No.

MR BEASLEY: It might be easiest if you had the annexures as well, if that’s 30

possible.

COMMISSIONER: While that’s being done, together with such annexures as – as

are supplied, the copy of the statement of Sarah Marshall to the New South Wales

Police Force of the 22.4.2020 will be marked for identification 2. 35

MFI #2 STATEMENT OF SARAH MARSHALL TO NEW SOUTH WALES

POLICE FORCE DATED 22.4.2020

40

MR BEASLEY: Commissioner, these aren’t marked, but apparently they’re all

there.

MS MARSHALL: Thank you. 45



MR BEASLEY SC

MR BEASLEY: All right. I – if – if your bundle’s like mine it’s not going to be

paginated, but if you could find annexure J.

MS MARSHALL: Yes. For clarity, we’re talking about the – the - - -

5

MR BEASLEY: There may be a – an email from you of the 24th of March right at

the very top of the page. 4.36 pm. But underneath the email I’m interested in is 13

March at 4.13 pm.

MS MARSHALL: Yes. 10

COMMISSIONER: So this is - - -

MS MARSHALL: I’ve got it .....

15

COMMISSIONER: This is the – a page that starts with the name Koo Barbi?

MR BEASLEY: It is.

COMMISSIONER: Is that right? 20

MR BEASLEY: Yes. I think that’s who printed it.

COMMISSIONER: Thank you. I understand that. That’s - - -

25

MR BEASLEY: But we can make inquiries as to whether it’s a crucial witness that

we might need to call - - -

COMMISSIONER: No. Please - - -

30

MR BEASLEY: - - - but I doubt it.

COMMISSIONER: Please don’t at the moment. I just wanted to identify it.

Thanks.

35

MR BEASLEY: This email is you raising a concern about some information given

to one of the pilots when he boarded the Ruby Princess on the 8th of March, correct?

MS MARSHALL: It’s raising a concern about the fact that on the 8th of March

health – NSW Health turned up to do some screening. What was considered to be 40

routine screening, and port authority wasn’t advised - - -

MR BEASLEY: Yes.

MS MARSHALL: - - - that there was a risk. 45

MR BEASLEY: Did you even know that they were doing the screening?


MR BEASLEY SC

MS MARSHALL: No, I did not.

MR BEASLEY: No. And that’s something you’ve followed up since that you –

your team needs to – you need to be informed and your team needs to be informed.

5

MS MARSHALL: Correct.

MR BEASLEY: Yes.


MR BEASLEY: Dealing with this, though, the – one of the concerns was what the

email tells us is some potential misinformation given to one of the pilots about

whether there were sick passengers on board the ship on the 8th of March, correct?

15

MS MARSHALL: Correct. But it’s – just to be clear, the information that was

provided was provided to our VTS.

MR BEASLEY: Yes.

20

MS MARSHALL: And then the VTS share that with the pilot.

MR BEASLEY: Sure.

MS MARSHALL: And as it turns out, there was some information handed directly 25

to the pilot as well, but I was principally talking about the declaration that was

provided to VTS.

MR BEASLEY: Yes. Can you tell us; the people that you’ve sent your email to?

30

MS MARSHALL: Yes.

MR BEASLEY: Emma Fensom; what’s her position at the Port Authority?

MS MARSHALL: Emma Fensom is my direct manager. She’s the acting chief 35

operating officer for the Port Authority.

MR BEASLEY: And Jeanine Drummond?

MS MARSHALL: Jeanine Drummond is the harbourmaster in Newcastle. 40

MR BEASLEY: And Sharad Bhasin?

MS MARSHALL: Sharad is the – at this point in time was the harbourmaster for

Port Kembla. 45


MR BEASLEY SC

MR BEASLEY: All right. Before you sent this email to the people on the – that

you’ve listed on 13 March, had you had any discussions with the pilot that went on

the Ruby Princess on 8 March?

MS MARSHALL: I had received an email from that pilot. I had not - - - 5

MR BEASLEY: That’s Mr Dargaville – D-a-r-g-a-v-i-l-l-e?

MS MARSHALL: Yes. Correct.

10

MR BEASLEY: And the email that you’re talking about; he had informed you, had

he, that the ship’s captain had told him that there was no one with any illness on

board?

MS MARSHALL: Correct. 15

MR BEASLEY: And he subsequently found out that there were well over 150

people that had at least given an indication of respiratory disease of some sort?

MS MARSHALL: That’s what he told me, yes. 20

MR BEASLEY: And that concerned him from the point of view of both his safety

and the safety of perhaps other pilots in the future?


MR BEASLEY: All right. And I think you then – the way this had come up, as I

understand it, is you had had some discussions with a doctor called Kelly-Anne

Ressler, had you?

30

MS MARSHALL: That’s correct.

MR BEASLEY: And Kelly-Anne Ressler was – how did you get her name to have

a discussion with her?

35

MS MARSHALL: On the Monday after the Ruby Princess came through on 8

March, we formed a crisis management team.

MR BEASLEY: Yes.

40

MS MARSHALL: In that crisis management team meeting, I took responsibility for

following up on why we weren’t getting this information about health checks that

were happening on cruise ships and to come to Kelly-Anne Ressler’s detail, I

literally just started with the NSW Health – general health line.

45

MR BEASLEY: Right.


MR BEASLEY SC

MS MARSHALL: And then just got pushed around from person to person until

eventually I landed up on – ended up on the phone with Kelly-Anne Ressler.

MR BEASLEY: And I take it she informed you that she was responsible, or had

responsibilities regarding health screening for cruise ships? 5

MS MARSHALL: She did. She explained that that was her role all the time, not

just during COVID, but that she did that all the time and that they had a system for

routine health checks with cruise ships and that they now had an enhanced screening

process in place for COVID-19. 10

MR BEASLEY: And one of the reasons for speaking to her, I assume, was to

ensure that there would be someone, if there was going to be health screening on

cruise ships and in particular if medical people from New South Wales Health were

going to board a ship, that Ports Authority was told? 15

MS MARSHALL: Yes. It was my concern to know that – my primary concern was

for the safety of our staff, our pilots, which I’m happy to expand on, you know, the

role of a pilot if anyone needs me to - - -

20

MR BEASLEY: Just pausing there. In terms of any risk to a pilot boarding a ship

with an illness on it, it’s because they climb a ladder, they get on the ship and they

are at least in close contact with members of the crew in the process of getting to the

bridge - - -

25

MS MARSHALL: Yes.

MR BEASLEY: - - - and then piloting the ship in?

MS MARSHALL: That’s right. 30

MR BEASLEY: Is there anything I’ve missed out in that general description?

MS MARSHALL: You’re correct.

35

MR BEASLEY: Yes.

MS MARSHALL: And the only thing I would add to that is really they’re the first

person, particularly for an international vessel coming in. They’re the first person

that’s going to make contact. So our concern was to make sure that if there was any 40

knowledge about some health risk, that that should be shared with us before we put a

pilot on the vessel.

MR BEASLEY: Now, I know even before 8 March, ports had been supplied with

information concerning COVID-19, correct? 45

MS MARSHALL: We had.


MR BEASLEY SC

MR BEASLEY: Through February?

MS MARSHALL: Yes.

MR BEASLEY: And had pilots begun – by 8 March, would Mr Dargaville have 5

gone on board the ship in – with any protective clothing, a mask, that sort of thing?

MS MARSHALL: He did. We had already communicated and shared with pilots

the information that had come from the Department of Health. That was specifically

- - - 10

MR BEASLEY: Is that the Commonwealth Department or the – yes.

MS MARSHALL: Commonwealth Department of Health. That had specifically

been prepared as information for marine pilots about COVID-19. And within that 15

document it outlines the PPE that they should wear. And we had provided that –

sorry.

MR BEASLEY: Can I – sorry, you finish.

20

MS MARSHALL: Yes. That’s what I wanted to say.

MR BEASLEY: That – the document you’re talking about, that was specific for

marine pilots, was it?

25

MS MARSHALL: Marine pilots, yes.

MR BEASLEY: Okay. Is that in your statement anywhere? I don’t recall.

MS MARSHALL: No, it’s not. 30

MR BEASLEY: All right. Would that be something you would be able to supply to

us?


MR BEASLEY: And could you tell the Commissioner roughly when you think that

sheet giving advice about what pilots should do was provided to ports?

MS MARSHALL: I would have to go and check the dates. 40

MR BEASLEY: I’m not expecting a specific day but was it in February or was it in

early March?

MS MARSHALL: I think it would be early – I think it was in early February. I 45

believe it might have been early February but I couldn’t remember the date.


MR BEASLEY SC

MR BEASLEY: If I said the ship name Diamond Princess, does that mean anything

to you?

MS MARSHALL: Yes.

5

MR BEASLEY: Would it have been around the same time as the outbreak in Japan

on that ship in early February?

MS MARSHALL: I believe it would have – in early February we would have had

that advice in our hands? 10

MR BEASLEY: All right. And so the advice given in this sheet for marine pilots

was something your team actioned?

MS MARSHALL: So – yes, that’s right. 15

MR BEASLEY: All right. Okay. Your discussion with Ms Ressler on – is it the – I

think it’s 8 March. I’ve noticed – one thing I did notice in your statement is she said

to you that she was surprised – I see. She said she was surprised that 360 people had

come forward for an assessment after only 170 had been reported sick through the 20

MARS system. Did she tell you she had actually been on board the ship?

MS MARSHALL: No, she didn’t.

MR BEASLEY: Right. Should the commissioner take it that when you’re saying 25

she was surprised, she was surprised by the number or she was – sorry, she was

surprised that 360 people had come forward or she was surprised to hear from you

that the number was 360?

MS MARSHALL: It wasn’t about her hearing from me. So I can’t – I can’t speak 30

for obviously - - -

MR BEASLEY: Was the figure of 360 something she volunteered rather than you?

MS MARSHALL: Yes, she gave me that figure. 35

MR BEASLEY: Okay. All right. Thank you. All right.

COMMISSIONER: Could I just ask about that? It’s paragraph 22 in your statement

to the police, Ms Marshall. In that conversation, you understood, I take it, from Ms 40

Ressler that her recent experience with the Ruby Princess had involved what she

called an assessment of medium risk?

MS MARSHALL: Yes.

45

COMMISSIONER: Until that conversation, was that an expression or a concept

you were familiar with?


MR BEASLEY SC

MS MARSHALL: No.

COMMISSIONER: And then you recall that she talked about what would happen if

there was a positive case?

5

MS MARSHALL: Yes.

COMMISSIONER: That’s positive COVID-19.

MS MARSHALL: I asked her. Yes. 10

COMMISSIONER: When you asked her, were you talking about a case shown to

be positive by laboratory testing?


COMMISSIONER: And were you at that stage aware that the ships did not have

laboratory equipment?

MS MARSHALL: Yes, I was aware. 20

COMMISSIONER: So you were talking about a laboratory test on shore after the

ship had docked; is that right?

MS MARSHALL: I was asked – what I was asking her was, bearing in mind that 25

we’re having this conversation on 9 March after – on 8 March they had put nine

swabs through for testing and they had come back negative. I was interested to

understand what would have happened if those results had have come back positive.

How were you planning to handle that situation? That was the question I was posing

to her. 30

COMMISSIONER: Well, now, you recall her saying something that I take it has

stuck with you, because the way you express it is that she emphasised - - -


COMMISSIONER: - - - that they – that means the health people – wouldn’t know if

it was COVID until the ship had come in.


COMMISSIONER: Actually means until the ship had come in and the swabs had

been taken off and they had been sent to the lab and the tests had come back.



MR BEASLEY SC

COMMISSIONER: Did you, at that time, have an idea as to what might be the

expected duration required for – of time for those activities to take place?

MS MARSHALL: Only what I had experienced from the day before, which was

that they took the swabs in the morning and they didn’t come back until around 5 5

pm, I believe. So at that point in time everybody understood it was quite a lengthy

wait to get results back.

MR BEASLEY: Had she informed – sorry. Did Ms Ressler at any stage inform you

about how New South Wales Health were making risk assessments on ships, 10

including low, medium or high - - -

MS MARSHALL: She didn’t go into that detail, no.

MR BEASLEY: Right. Okay. And that was something, I take from that answer, 15

that Ports Authority hadn’t been informed about either.

MS MARSHALL: No.

MR BEASLEY: All right. 20

COMMISSIONER: But you had a concern about the occupational health and safety

of your pilots.

MS MARSHALL: I did. 25

COMMISSIONER: And if I may say so, not just because they’re fellow human

beings but because they’re highly skilled and not easily replaced - - -

MS MARSHALL: Correct. 30

COMMISSIONER: - - - operators of the harbour. Isn’t that right? Yes.

MS MARSHALL: Well, you know - - -

35

COMMISSIONER: I don’t mean to - - -

MS MARSHALL: No, no.

COMMISSIONER: I don’t mean that disrespectfully. 40

MS MARSHALL: But it’s our concern to make sure that – one of the things with

our planning towards COVID-19 was how do we ensure that we keep the port open

and running.

45

COMMISSIONER: Yes.


MR BEASLEY SC

MS MARSHALL: And so of course I was concerned for the health and safety of

them as individuals, but also as a group.

COMMISSIONER: Of course.

5

MS MARSHALL: Yes.

COMMISSIONER: Please don’t misunderstand me.


COMMISSIONER: And I don’t mean any disrespect to the pilots. Far from it. And

if I may say so, it strikes me that, from what you’ve told the police and so far told us

that you were concerned that in advance of getting back lab tests of any swabs, there

was an un-excluded, real possibility that COVID-19 in what might we call a 15

contagious state on the ship. Is that right?

MS MARSHALL: Yes. Correct. And not just on the ship, but with disembarked

passengers.

20

COMMISSIONER: Yes.

MS MARSHALL: Yes.

COMMISSIONER: Sorry. Before they disembarked - - - 25

MS MARSHALL: Yes.

COMMISSIONER: - - - the passengers and the crew and all the surfaces in question

where there was an un-excluded real possibility of COVID-19 about which you 30

needed some information and/or warning to take precautions for the safety of your

pilot.

MS MARSHALL: That’s right.

35

COMMISSIONER: Now, you’ve told the police that you were told by Ms Ressler

that if it was medium risk, some but not all of the passengers would be kept on-board

while their swabs were tested. Is that right?

MS MARSHALL: No. That’s not what she told me. 40

COMMISSIONER: What did she tell you?

MS MARSHALL: She told me – in the discussion she explained that they go

through a process of assessment. As I said, she didn’t outline how they do that, and I 45

didn’t ask her. but she said they then classify ships as low, medium or high risk, and

she said they only turn up to assess and do these routine checks on ships that they


MR BEASLEY SC

have assessed as medium to high risk, so she said she would contact me in the future,

or Port Authority, I should say, in the future if a ship had been assessed as medium to

high risk. She didn’t go into detail around how that would work once they were

there doing the - - -

5

MR BEASLEY: Just to help you on that, if you go to annexure G of your police

statement, I think you will find an email of 9 March sent by Ms Ressler to you at

7.11 pm in the evening.


MR BEASLEY: That follows an email you had sent to Ms Ressler at 5.04 pm in the

afternoon - - -


MR BEASLEY: - - - where you’ve said:

It’s really important for us to get information about when New South Wales

Health are completing their routine screens – 20

etcetera, etcetera.

MS MARSHALL: Yes.

25

MR BEASLEY: And Ms Ressler has then apologised and told you that when

you’ve got medium or high risk, we’re going to let you know.

MS MARSHALL: Exactly.

30

MR BEASLEY: And she mentions a ship called the Sea Princess and the Pacific

Explorer in that email.

MS MARSHALL: Yes.

35

MR BEASLEY: The Pacific Explorer I think came in a couple of days before the

Ruby Princess. Is that right?

MS MARSHALL: I do recall that it came in - - -

40

MR BEASLEY: If you go to paragraph 30 of your statement to the police - - -

MS MARSHALL: I think it came in on 16 March.

MR BEASLEY: Yes. And if we go to – it’s going to be annexure K, it looks like. 45

So I will just try and turn up myself – yes. You’ve got K.


MR BEASLEY SC

MS MARSHALL: Yes, I’ve got it. Yes.

MR BEASLEY: So because it’s an email chain, we go back to the beginning.

MS MARSHALL: Yes. 5

MR BEASLEY: 16 March 2020 at 3.52 pm, you’ve sent an email to Ms Ressler that

you’re hearing New South Wales Health is involved with a matter on-board the

Pacific Explorer and we didn’t get any formal notification. Can I ask you what you

heard and who it was from? 10

MS MARSHALL: I actually can’t recall what I heard. I don’t think I have any

written record of it. I believe it would have been a phone call. And I - - -

MR BEASLEY: From someone with imports. 15

MS MARSHALL: I believe it would have – it was most likely from Cameron

Butchart.

MR BEASLEY: Right. 20

MS MARSHALL: But I don’t recall specifically speaking to him about the details.

MR BEASLEY: All right.

25

MS MARSHALL: He knew that I had a contact now within NSW Health, and we

were making sure we utilised that contact to get information.

MR BEASLEY: Okay. And so Ms Ressler then informs you by return email they

have submitted four people’s swabs – so that’s the ship has submitted four people’s 30

swabs for testing. You – I take it you took it that testing meant testing for COVID-

19.

MS MARSHALL: Mmm.

35

MR BEASLEY: Did you have any phone conversation with Ms Ressler about - - -

MS MARSHALL: Not about this.

MR BEASLEY: Was it – this was all by email. 40

MS MARSHALL: This was all we had. Yes.

MR BEASLEY: All right. You then responded at the 16th at 4.31 pm:

45

Thank you. Can you please let us know why we didn’t get alerted. I know our

staff are going to be up in arms about this.


MR BEASLEY SC

This raises the same issue about pilot safety and safety of ports people when

passengers go off that you discussed with the Commissioner.

MS MARSHALL: Exactly. Yes.

5

MR BEASLEY: Yes. Kelly-Anne Ressler then informs you the ship – this is now

at 4.45 pm:

The ship was assessed as low risk not requiring an on-board health team

response. I would have let you know if it was medium or high. 10

You say:

Thanks, Kelly. I appreciate the challenges.

15

She then emails you with this on the 16th at 5.54:

All four specimens are negative. I have just informed the doctor and agent that

all are free to disembark.

20

I’m just wondering whether you know was that – and if you don’t know, please tell

us – but “free to disembark” – did you take that as a reference to the four people who

were given specimens, or is that everyone on the ship?

MS MARSHALL: I’m sorry, I’m not following where you’re up to. 25

MR BEASLEY: Sorry. We’re still on annexure K.

MS MARSHALL: I can’t find the reply.

30

MR BEASLEY: All right. If you go right at the top you will see an email 17 March

at 7.20 am.

MS MARSHALL: That’s not on this copy that I have here. I actually think that

might refer to a different email chain about some different vessels. 35

MR BEASLEY: It has certainly got - - -

MR HUTCHINGS: Commissioner, might I approach? I’ve turned up the

document. 40

MR BEASLEY: Certainly annexure K on mine. And says Pacific Explorer.

COMMISSIONER: This is – that’s the document that is annexure K or should be?

45

MR HUTCHINGS: It is.


MR BEASLEY SC

MS MARSHALL: It’s not in my pack here. I think it’s missing.

MR BEASLEY: I’m happy for my friend to assist.

COMMISSIONER: Yes is the answer. 5

MS MARSHALL: Thank you. Great.

COMMISSIONER: I’m obliged.

10

MR BEASLEY: All right. So right at the top it has got Sarah Marshall, indicating

you printed it. Very top of the page.

MS MARSHALL: So he’s talking about an email on 17 March, not 16 March.

15

MR HUTCHINGS: 4.15 pm.

MR BEASLEY: No. I’m just trying to – is the email at the very top of that page 17

March at 7.20 am?

20

MS MARSHALL: No.

MR BEASLEY: No?

MS MARSHALL: I - - - 25

MR BEASLEY: Then I’m going to approach and I’m going to show the witness

what I’m talking about. Do you have – so what I’ve got here is it has got annexure

K?

30

MS MARSHALL: Mmm.

MR BEASLEY: So this is your police statement. And what I’m taking you to is –

just follow in a line?

35

MS MARSHALL: Okay.

MR BEASLEY: From Kelly-Anne to you on five – 4.45?


MR BEASLEY: The ship was assessed as low-risk:

I would have let you know if it was medium or high.

45

MS MARSHALL: Mmm.


MR BEASLEY SC

MR BEASLEY:

I totally appreciate –

then Kelly-Anne Ressler has sent an email to you at 5.45? 5

MS MARSHALL: Right.

MR BEASLEY: All four specimens are negative?

10

MS MARSHALL: Mmm.

MR BEASLEY:

I have - - - 15

COMMISSIONER: So we’re now on the same page?---Yes, we are.

MR BEASLEY: I hope we are.

20

MS MARSHALL: Yes.

MR BEASLEY: Entirely:

I’ve just informed the doctor and agent that all are free to disembark. 25

MS MARSHALL: Mmm.

MR BEASLEY: You may not know the answer to this, which is fine to tell us, but

did you have any information beyond this email as to whether “disembark” referred 30

to the four people who had specimens or was it the whole ship?

MS MARSHALL: No, I didn’t. I didn’t. No.

MR BEASLEY: All right? 35

MS MARSHALL: Sorry.

COMMISSIONER: Do I understand that the Pacific Explorer is a considerably

smaller vessel - - - 40

MS MARSHALL: I’m sorry.

COMMISSIONER: - - - than the Ruby Princess?

45

MS MARSHALL: I couldn’t tell you the size of that vessel. No.


MR BEASLEY SC

COMMISSIONER: That’s all right. That’s all right. In that same annexure, on 16

March, Ms Ressler, at 4.15 pm, emailed you to the effect that the New South Wales

Health Expert Panel had requested what she calls “those people” to stay onboard.

And I read that as a reference to the four people whose swabs had been submitted

and all others had - - - 5

MR BEASLEY: Yes.

COMMISSIONER: - - - been allowed to disembark?

10

MS MARSHALL: Mmm.

COMMISSIONER: So you were aware of this idea that those from whom swabs

were taken would be kept on board until tests were back, but all others would be

allowed to disembark in the meantime. Is that how you understood it? 15

MS MARSHALL: It – I agree that it reads that way. I guess what I should clarify is

I wasn’t analysing, at this point in time, when I got her email, how – how they were

handling that. All I was analysing was why wasn’t I being told - - -

20

COMMISSIONER: Yes?

MS MARSHALL: - - - about there being risk, because I was frustrated that we had

had that conversation before.

25

COMMISSIONER: All right. I understand. Yes?

MS MARSHALL: Yes. So, yes, I agree it reads that way, but it wasn’t something

that I was particularly concerning myself with.

30

COMMISSIONER: Don’t concern yourself. I won’t be pursuing why you didn’t

appoint yourself a public health official, but I am interested to know whether

anything apart from what you’ve told us in your police statement or your exchange

with her in the emails whether there was any other explanation that you recall her

giving – her giving - - - 35

MS MARSHALL: Mmm.

COMMISSIONER: - - - for why – in what was either hers or the departmental view

a justification for letting other people off the vessel while awaiting information about 40

swabs?

MS MARSHALL: The only recollection that I have of getting her view about

disembarking people was on that phone conversation that I had with her on 9 March.

45

COMMISSIONER: Now, that referred to the Ruby Princess - - -


MR BEASLEY SC

MS MARSHALL: And that was referring to the Ruby Princess. That - - -

COMMISSIONER: - - - in such a way as to suggest it was an example to be

avoided; is that right?

5

MS MARSHALL: In such a way as to suggest that it was always their intention to

allow passengers to – all passengers to disembark or the majority of passengers to

disembark before they knew if other passengers had been tested positive.

COMMISSIONER: So the way you recalled it to the police was that, among other 10

things, she said they’d be getting people off the ship and not isolating them on board

like the Diamond Princess?

MS MARSHALL: When I – okay. How I would explain that is - - -

15

COMMISSIONER: Is that how you recall it?

MS MARSHALL: I specifically asked her if they were going to treat it the way the

Diamond Princess had been treated where everybody had been held on board, and

she specifically said, “No. We wouldn’t treat it like the Diamond Princess. We 20

would get people off the ship and we’d prioritise the elderly.”

COMMISSIONER: Prioritising the elderly, meaning getting them off first?

MS MARSHALL: Getting them off first is what I understood. 25

COMMISSIONER: Do you recall her telling you anything else, by way of an

explanation or reason for that being her understanding of what would be done?

MS MARSHALL: No. 30

MR BEASLEY: Getting people off the ship, was there any elaboration as to what

that meant? Allowing them off is one thing. Did she say what would happen

afterwards?

35

MS MARSHALL: She said that in the process of communication with the ship in

that period of between 48 and 24 hours before the vessel would arrive, they would

gather up all of the contacts – the contact details for every passenger on the ship.

And so what they would do would be they’d let them disembark and then, if they

needed to contact them, they’d just use that contact list to – to reach out to them. 40

MR BEASLEY: Wherever they’d gone?

MS MARSHALL: Wherever they’d gone.

45

MR BEASLEY: Yes?


MR BEASLEY SC

MS MARSHALL: That’s what she explained to me. And she explained that – I

think I’ve got it in here that they would form an IMT – an incident management team

– and contact those passengers and then they would find a way to deal with getting

the crew off the ship as well.

5

MR BEASLEY: All right. I’m sorry to jump around a bit, but I just want to go

back to Mr Dargaville, the pilot?

MS MARSHALL: Mmm.

10

MR BEASLEY: I think he sent someone called Wendy Doran an email on the 8th of

March. Who’s Ms Doran?

MS MARSHALL: Wendy Doran is one of the duty harbourmasters.

15

MR BEASLEY: Right?

MS MARSHALL: And on 8 March, she was the harbourmaster - - -

MR BEASLEY: Okay? 20

MS MARSHALL: The duty harbourmaster on call.

MR BEASLEY: And if you need to look at it it’s annexure C to your police

statement? 25

MS MARSHALL: Mmm.

MR BEASLEY: And he copied you in on the email, but this is where, in one of his

bullet points he says: 30

The captain told me, when I arrived on the bridge, that everyone was well.

And he:

35

…spoke to the port agent about positioning the ship and –

the port agent didn’t – he says –

he – 40

so we know, possibly, who it is –

did not inform me of any issues with health even though the team was standing

with him. 45

MS MARSHALL: Mmm.


MR BEASLEY SC

MR BEASLEY: Did you have a conversation with Mr Dargaville about this email?

MS MARSHALL: I didn’t. No.

MR BEASLEY: All right. I think – and there’s no need for you to turn it up – but, 5

eventually, did you see a form of apology from Carnival?

MS MARSHALL: I saw an explanation.

MR BEASLEY: And that explanation was that the Commodore said he thought the 10

question specifically related to Coronavirus, not - - -


MR BEASLEY: - - - other illnesses; correct? 15

MS MARSHALL: Yes.

MR BEASLEY: All right. I think that’s annexure N of your police statement?

20

MS MARSHALL: Mmm.

MR BEASLEY: Now, I want to ask you do you have in front of you that bundle of

key documents?

25

MS MARSHALL: I do.

MR BEASLEY: All right. If you can open that up and you will see, if you’ve got –

have you got white dividers? If you’ve got white dividers, you’ll find there’s a white

divider 8 - - - 30

MS MARSHALL: Mmm.

MR BEASLEY: But within white divider 8, hopefully you have a tag that says

“8A”? 35

MS MARSHALL: I do. Yes.

MR BEASLEY: All right. If you turn the page for that - - -

40

MS MARSHALL: Mmm.

MR BEASLEY: - - - you’ll find an email from you to Ms Ressler - - -


MR BEASLEY: - - - of 18 March at 3.41 pm?


MR BEASLEY SC

MS MARSHALL: Yes.

MR BEASLEY: And it says:

Can you please tell me if New South Wales – 5

this is now about the Ruby Princess obviously?

MS MARSHALL: Yes.

10

MR BEASLEY:

… has any plans to process any routine health screening aboard the Ruby

Princess tomorrow.

15

MS MARSHALL: Yes.

MR BEASLEY: Continuing:

We are hearing whispers that may be the case. 20

MS MARSHALL: Yes.

MR BEASLEY: Can you tell the Commissioner what you mean by what was

behind the comment: 25

We are hearing whispers that may be the case.

MS MARSHALL: Yes. I had had an email from Cameron Butchart, which I

received – I’m not sure whether I’ve got it in this pack or not – but I’d had an email 30

from him to say that he’d been – I forget his language – but, you know - - -

MR BEASLEY: Okay. Just to help you, I’ve just found this myself. I think it

might be annexure N of your police statement, which is - - -

35

MS MARSHALL: I’m not sure I’ve got it in here, because these were printed off by

– the pack I have is printed by somebody else.

MR BEASLEY: All right. I’ll come up with my annexure N.

40

MS MARSHALL: Yes.

MR BEASLEY: This looks like the email you’re talking about. So what I’ve got

here is that, just before this 3.41 pm - - -

45

MS MARSHALL: Yes.


MR BEASLEY SC

MR BEASLEY: - - - you’ve got 3.26 from Cameron - - -


MR BEASLEY: - - - to you, saying: 5

Sarah, I’ve been fielding information for a couple of days regarding this ship.

MS MARSHALL: Yes.

10

MR BEASLEY:

According to the correspondence below, Health will be boarding.


MR BEASLEY:

Can you please find out - - -

20

COMMISSIONER: Sorry. This is annexure?

MR BEASLEY: Sorry. N, Commissioner.

COMMISSIONER: N. 25

MR BEASLEY: Capital N, N for Nelly.


30

MR BEASLEY: I will just wait till you - - -

COMMISSIONER: I’ve got it. Yes.

MR BEASLEY: Have you got it? 35

MS MARSHALL: Yes.

MR BEASLEY: So I was just discussing with the witness the 3.26 pm email - - -

40

MS MARSHALL: Yes.

MR BEASLEY: - - - which seems to suggest Mr Butchart had some information

that Health would be boarding.

45

MS MARSHALL: Yes, which has come from - - -


MR BEASLEY SC

MR BEASLEY: Julie Taylor.

MS MARSHALL: Well, Julie Taylor replied to Rob Rybanic, but it came from

Rob Rybanic, where he says:

5

Carnival have requested Ruby Princess to arrive earlier tomorrow - - -

MR BEASLEY: I see.

MS MARSHALL: 10

- - - at 2.30 am. They’re unsure if NSW Health will be boarding. They have

some routine swabs to send off. Any concerns with the request –

and then he advises Julie, who is his duty manager cruise operations, at what time the 15

operations will – will be planned for.

MR BEASLEY: Yes. Do you know where – how do I – is it Mr – is it Rybanic? Is

that how I say it?

20

MS MARSHALL: Yes.

MR BEASLEY: Do you know where he got his information from?

MS MARSHALL: I don’t know. 25

MR BEASLEY: All right. Can I ask you this just to – do Ports Authority get the

MARS report from the ship?

MS MARSHALL: My understanding is that the vessel agents get the MARS report. 30

MR BEASLEY: Right.

MS MARSHALL: After the 8 March issue with the Ruby Princess, I did endeavour

to get a copy of the MARS report because I felt it would be a good way for us to kind 35

of get information directly rather than relying on the declaration of the master, which

is what we were doing.

MR BEASLEY: Right. When you say “the declaration of the master”, that just

means him orally advising you. 40

MS MARSHALL: No.

MR BEASLEY: No?

45

MS MARSHALL: So we have put in practice – we, Port Authority, have put in

practice from the beginning – end of January, beginning of February, something new


MR BEASLEY SC

and different, which was that we would four hours before arrival send some

questions to the master of the vessel.

MR BEASLEY: Yes. I know what you’re talking about now.

5

MS MARSHALL: Yes.

MR BEASLEY: Yes.

MS MARSHALL: And so – and we were relying on those questions to be answered 10

truthfully and making decisions about whether we should put a pilot onboard based

on those answers.

MR BEASLEY: And that was done in this case.

15

MS MARSHALL: And on 8 March the master of the vessel answered the question

– sorry. I don’t have it at hand, but - - -

MR BEASLEY: Yes. I think I will be able to find it for you, but you keep - - -

20

MS MARSHALL: I think he answered the question as to - - -

MR BEASLEY: If you just pause there. So I will help you. It’s – if you’ve got tab

13 of the key documents.

25

MS MARSHALL: Yes.

MR BEASLEY: Can you turn that up and go right to the very back, so just before

tab 14. First of all, you will have the human health report, which I think is the

MARS report. 30

MS MARSHALL: Right.

MR BEASLEY: And after that I think you’re going to find an email from Ports

Authority, I’m not sure who - - - 35

MS MARSHALL: Yes.

MR BEASLEY: - - - to Ruby Bridge, Ruby Captain - - -

40

MS MARSHALL: Yes.

MR BEASLEY: - - - with those questions you’re referring to.

MS MARSHALL: Yes. So I’m referring to the question where he answered - - - 45

MR BEASLEY: And his answer is the next page.


MR BEASLEY SC

MS MARSHALL: He says, “No,” there’s – no one is - - -

MR BEASLEY: That’s no to symptoms.

MS MARSHALL: Sorry. That’s the 18th. Sorry. That’s the 18 March one. 5

MR BEASLEY: Yes.

MS MARSHALL: But on 8 March we asked the question if there was anybody –

any – sorry. I don’t have the actual wording of the question with me, but we had 10

asked if anybody was sick onboard and – and he said, “No.”

MR BEASLEY: Yes. Right. Can I ask you. These questions that – were they

formulated by Ports Authority or were they guided by information from government

about what questions should be asked? 15

MS MARSHALL: They were formulated by Port Authority.

MR BEASLEY: Right. Okay.

20

MS MARSHALL: And so until that point in time, 8 March, we had been relying on

the answers to those questions to provide us with assurance that it was safe to put a

pilot onboard the vessel. After 8 March, where we saw that the vessel declaration

had been incorrect from the master, I looked into having better access to the MARS

report so that we didn’t have to solely rely on the declaration from the master of the 25

vessel.

COMMISSIONER: Can you explain to me. Is there some reason, as you

understand it, why formerly – or then you did not routinely have access to the MARS

information? 30

MS MARSHALL: I’m – I’m not aware of the reason.

COMMISSIONER: MARS stands for?

35

MS MARSHALL: Maritime Arrivals Reporting System.

COMMISSIONER: That sounds like something that might be useful for you.

MS MARSHALL: It does, doesn’t it? Yes. 40

COMMISSIONER: But, in particular, it would give you information similar to that

contained in the ARD, acute respiratory diseases, log for the ship, would it not?

MS MARSHALL: I believe – the whole reason I asked for access was I believe that 45

it would give us the information that we needed to ensure the health and safety of our

pilots.


MR BEASLEY SC

COMMISSIONER: Now, please don’t take this amiss. Would you have set about

interpreting an ARD log yourself?

MS MARSHALL: No, I wouldn’t.

5

COMMISSIONER: So how would you have used – let me assume the ARD log

disclosed a number of persons with influenza-like illness or acute respiratory

symptoms.

MS MARSHALL: Given I - - - 10

COMMISSIONER: What would you have done with that information?

MS MARSHALL: I didn’t know what the information that came from MARS

looked like. I didn’t know if the information was clear and easy to – to read or 15

understand, if it would give us indications of whether there was likely to be COVID

onboard or not. So I asked for access to the information so that we knew what was –

what was coming in. After the incident with the Ruby Princess on 8 March, I was

concerned that we were in the dark.

20

COMMISSIONER: Tell me. Nowadays do you get MARS information?

MS MARSHALL: I don’t – I have had - - -

COMMISSIONER: Has anybody explained to you why you shouldn’t? 25

MS MARSHALL: No. I have had a reply from – and it is in my annexure. I did

get a reply from the MARS group to – because I did ask for access to their system.

COMMISSIONER: Which annexure is that? Sorry. 30

MS MARSHALL: I’m not sure of the number – the letter because these aren’t

labelled.

COMMISSIONER: What date is it? 35

MS MARSHALL: Do you know which – does anybody – do you know which

annexure it is?

COMMISSIONER: Which - - - 40

MR BEASLEY: While that’s - - -

MS MARSHALL: Hang on. It might be here in this - - -

45

MR BEASLEY: While we’re looking for that - - -


MR BEASLEY SC

MS MARSHALL: It’s annexure I.

MR BEASLEY: Right.

COMMISSIONER: I. Thank you. 5

MS MARSHALL: Yes.

MR HUTCHINGS: Paragraph 28 of the statement.

10

MS MARSHALL: So on Tuesday, 10 March, I simply went online and tried to

obtain access and was given an automated response from the system.

MR BEASLEY: I’ve done the same thing.

15

MS MARSHALL: And then at - - -

MR BEASLEY: You see how you’re ringing the Department of Agriculture?


MR BEASLEY: Just pausing there. I just want to go back in time. You had also

tried to contact or get some information from ABF. Correct?

MS MARSHALL: I had tried to contact ABF. 25

MR BEASLEY: Why – why – first of all, why did you want to contact ABF? What

was the purpose?

MS MARSHALL: Again, we felt a little bit like we were in the dark and that we 30

weren’t getting the information that we needed, and we considered that the agencies

that we – that at this point in time – that point of time might have had that

information were NSW Health and ABF and so I was looking for people who could

provide that information.

35

MR BEASLEY: All right. Eventually you were given the name of someone called

- - -

MS MARSHALL: Alice Stanley.

40

MR BEASLEY: Yes.

MS MARSHALL: Yes.

MR BEASLEY: Now, had you asked for someone with a particular – that would be 45

in a position where they would know something about health information on cruise

ships? Is that – how were you seeking your - - -


MR BEASLEY SC

MS MARSHALL: The only reason I was given Alice Stanley’s name was Emma

Fensom - - -

MR BEASLEY: Yes.

5

MS MARSHALL: - - - who’s – who’s my manager, had given me her contact email

address. I didn’t have a phone number, just an email address.

MR BEASLEY: Had she been looking – had Emma Fensom been looking for

someone within ABF that could assist with making sure Ports Authority was given 10

relevant information about health situations on the cruise ships?

MS MARSHALL: I – I would assume, yes, but I don’t know.

MR BEASLEY: All right. And do you know what position Alice Stanley is within 15

the ABF?

MS MARSHALL: Not off the top of my head.

MR BEASLEY: Just - - - 20

MS MARSHALL: I believe I’ve seen an email signature at some stage.

MR BEASLEY: Yes. No. I don’t think it tells you the – what – it’s – unless there’s

another one. The email I’ve got is annexure E of your police statement and it doesn’t 25

disclose what position she’s in. In any event, you had some – you’ve had a lot of

difficulty having any contact with her?

MS MARSHALL: I couldn’t – I mean, I – she said she would return my calls, so I

- - - 30

MR BEASLEY: Yes.

MS MARSHALL: - - - left it at that. And when she didn’t, I followed her up again

and – twice – and then she – she still never called me back. 35

MR BEASLEY: She still hasn’t?

MS MARSHALL: Yes.

40

MR BEASLEY: Okay. All right.

COMMISSIONER: Could I just ask you about your email exchange that finished

on 17 March with the MARS administrator.

45

MS MARSHALL: Yes.


MR BEASLEY SC

COMMISSIONER: Mr Craig Yorston?

MS MARSHALL: Yes.

COMMISSIONER: Have there been any further dealings between you and him 5

concerning access to information of a kind that you may be able to see through the

MARS system?

MS MARSHALL: No. After I got his final email on the 17th, I didn’t push any

further requests for MARS access, but - - - 10

COMMISSIONER: And have you got – have you had access that’s satisfactory to

you since then to health information for the purposes of protecting your pilots?

MS MARSHALL: No. 15

COMMISSIONER: So you are still in what you might call “the dark” to use your

expression?

MS MARSHALL: I – I don’t receive anything from MARS and I have – and I 20

never got anything through these lines of inquiry.

COMMISSIONER: Have – were you given any contact at Commonwealth Health

Department?

25

MS MARSHALL: The only health contacts that we’ve had have been from NSW

Health.

COMMISSIONER: You see that Mr Yorston offered a contact in what he called

“Federal health”? 30

MS MARSHALL: He’s offering some online resources.

COMMISSIONER: No, no, no. Just before he sent his regards, he says - - -

35

MS MARSHALL: Right. He does too.

MR BEASLEY:

If you need a contact in Federal health – 40

etcetera. Do you see that?

MS MARSHALL: I never actually asked him for one.

45

MR BEASLEY: All right. Thank you?


MR BEASLEY SC

MS MARSHALL: Yes. Sorry. I forgot what I was going to say.

MR BEASLEY: But as you say he gave you an online reference?

MS MARSHALL: Yes. 5

MR BEASLEY: So have you had any conversations – not email – but voice

conversations with him?

MS MARSHALL: I – not with Craig. I had made a phone call to someone called 10

Guy Bursle from the Department of Agriculture, Water and Environment.

MR BEASLEY: How do you spell his surname?

MS MARSHALL: B-u-r-s-l-e. He is - - - 15

MR HUTCHINGS: Paragraph 28.

COMMISSIONER: Yes.

20

MS MARSHALL: Paragraph 28, the director for – director, conveyances and ports

compliance controls. I came to speak to him in much the same way that I came to

speak to Kelly-Anne Ressler, just by calling someone and then getting passed around

until I found Guy. And I asked him for access to MARS in the same way that I had

been trying to pursue it through the system. And he explained to me that, you know, 25

from an IT perspective, it would be quite tricky for us to get access, because - - -

COMMISSIONER: What does that mean?

MS MARSHALL: This is how I understood it: was that they couldn’t – they 30

couldn’t automate sending us that – the information that I wanted to know.

COMMISSIONER: Why not?

MS MARSHALL: I’m not sure. That’s just what he had explained to me. 35

MR BEASLEY: Print it, scan it, email it.

COMMISSIONER: That doesn’t – that doesn’t self-evidently obvious to me - - -

40

MS MARSHALL: Mmm.

COMMISSIONER: - - - that IT would present a barrier rather than a means - - -

MS MARSHALL: Mmm. 45


MR BEASLEY SC

COMMISSIONER: - - - for communication between Federal and State authorities

about a matter of joint or common concern?

MS MARSHALL: This was my understanding of what he was telling me.

5

COMMISSIONER: Now, this is not a criticism - - -

MS MARSHALL: Yes.

COMMISSIONER: - - - what I’m about to ask you. Have you pressed him for an 10

explanation of IT problems?

MS MARSHALL: So what – so how that conversation continued was that he said

that what he could potentially do – well, sorry – he said what he was concerned about

was because he couldn’t – the system couldn’t automate it, he was concerned that, if 15

they gave it to us manually, that that created a risk of error and he didn’t want to

create a manual process.

COMMISSIONER: What? So humans may err, but machines can’t. That’s how

you were left; is that right? 20

MS MARSHALL: That’s what he had said to me. And then he did say, look,

maybe a human health inspection could be a cue for the regional inspection team to

let Port Authority know.

25

COMMISSIONER: Well, I’m glad you’ve raised that. I didn’t understand what

that reference means:

Where a notification would cued as required by human health inspection.

30

What does that mean?

MS MARSHALL: So – what – sorry. I think there’s been a little bit of an error

there.

35

COMMISSIONER: Yes?

MS MARSHALL: But I think what he was trying to say is that – and I don’t – I

don’t know the inner workings of how the MARS report comes out or what it spits

out – but my understanding was that if a human health inspection had been cued by 40

the system, he was suggesting that what they potentially could do was then that could

be a trigger to let Port Authority know, because a human health inspection had been

cued in the system.

COMMISSIONER: Now, has that, in fact, eventuated? 45


MR BEASLEY SC

MS MARSHALL: No. So he said, “Leave it with me. I’ll have some discussions

and get back to you early next week.”

COMMISSIONER: Well, the last sentence of your paragraph 28, is that still true,

you’ve not heard back? 5

MS MARSHALL: I’ve never heard back.

COMMISSIONER: So it presently is the case that, so far as you understand, Mr

Bursle thinks there will be, from time to time, a state of affairs where a human health 10

inspection is projected for a ship coming in and that it might provide a cue for you

and your staff to be notified for the sake of protecting pilots; correct?

MS MARSHALL: He – yes. He was going to speak to the regional teams - - -

15

COMMISSIONER: Yes?

MS MARSHALL: - - - to see if that could be arranged.

COMMISSIONER: And you’ve not heard back? 20

MS MARSHALL: I’ve not heard back.

COMMISSIONER: It’s the 1st of May. You still haven’t heard back?

25

MS MARSHALL: Not heard back.

COMMISSIONER: And do you put that down to the fact that we don’t have ships

arriving anymore?

30

MS MARSHALL: I – I put it down - - -

COMMISSIONER: Now, I had understood - - -

MS MARSHALL: I put it down to maybe the – the incident of the Ruby Princess, 35

you know, highlighted that there were these issues and me asking these questions

was maybe inconvenient. I don’t know.

COMMISSIONER: Well, that strikes me as a reason why you might hear back

about things being fixed? 40

MS MARSHALL: Yes.

COMMISSIONER: I – it’s not as if they’re now run off their feet with cruise ships

coming in? 45

MS MARSHALL: Yes. I don’t know why I haven’t heard back.


MR BEASLEY SC

COMMISSIONER: No. Have you heard any, to use a colloquialism, scuttlebutt

about why you haven’t heard back?

MS MARSHALL: No, I haven’t. No.

5

COMMISSIONER: Have you speculated about that with your staff or

management?

MS MARSHALL: When I referred to the actual response I got from the MARS

administrator, who said if the vessel crew or representative is contacting your office 10

to book a pilot, then that would be an opportune time to request a current health

status and travel history of the vessel crew. I - - -

COMMISSIONER: What about the vessel passengers?

15

MS MARSHALL: Well, this is what – that – this – I’m just saying what he said.

COMMISSIONER: Yes.

MS MARSHALL: I took it that he said – sorry. And above that, he said, “If staff 20

are concerned about being exposed then they should be wearing the appropriate

PPE.” I took it that their position was it’s kind of Port Authority – it is Port

Authority’s role to ask the vessel agent or the vessel themselves about the safety of

the crew and, in any case, “Protect your staff by using PPE,” and that there’s not a

role for MARS administration team to play in providing that information directly to 25

the Port Authority.

COMMISSIONER: What do you think about that as a meritorious approach or not?

MS MARSHALL: I thought, which is why I contacted them in the first place, that it 30

would have been sensible for us to share that – for them to share that information

with us directly.

COMMISSIONER: Has anybody ever suggested to you, apart from these circled IT

problems, why it would not be a good idea to share it with you? 35

MS MARSHALL: No.

COMMISSIONER: So the only explanation you’ve received is that IT may require

what’s called manual ad hoc transmission to you and that the introduction of human 40

hands may produce error?

MS MARSHALL: Error.

COMMISSIONER: And, then, what? Then you and your pilots may be misled. Is 45

that - - -


MR BEASLEY SC

MS MARSHALL: Yes.

COMMISSIONER: Is that what you understood the problem to be?

MS MARSHALL: Yes. And, actually, the other IT reference is – is from Craig 5

Yorston when he replied to me on the 12th of March. He says:

Thanks for getting in touch. Despite it being a registration option, I don’t

believe the access type for port authorities was fully implemented.

10

COMMISSIONER: So that – I don’t profess to understand all of that English, but I

take it that means that although somebody like yourself might be forgiven for

thinking that you would be able to be, as it were, copied in, for some technical reason

that appeared not to be available.

15

MS MARSHALL: I take his response, because he – he then follows it up by saying:

I’d need to confirm this with the development team.

COMMISSIONER: What’s that? Software development? 20

MS MARSHALL: I take it that he’s talking about an IT problem here. As in, they

go limited ability to provide us that access.

COMMISSIONER: So it’s a compatibility problem between federal and State 25

databases, is it?

MS MARSHALL: That’s how it appears to me. Of course, there – the only other –

I mean, beyond the IT explanation – explanation which I see – I’ve been given, may

be the only thing I can speculate on is that because we’re not a health authority they 30

don’t want to provide us with health information that we’re not, you know, skilled in

dealing with in interpreting. Yes.

COMMISSIONER: Thanks.

35

MR BEASLEY: Just going back to the email we were discussing in tab 8A of the

key documents bundle.

MS MARSHALL: Yes. Yes.

40

MR BEASLEY: And I’d ask you about we’re hearing whispers to that – that case

and that was from Mr Butchart email we discussed. You then got a response from

Kelly-Anne Ressler on the 18th of March at 4.38 telling you that at least by that time

the ship – an assessment had been made that the ship was low risk so health wouldn’t

be there. And telling you that 15 samples of – for COVID would be tested just to be 45

cautious, whatever that means.


MR BEASLEY SC

Then over the page you’ve sent Ms Ressler an email the next morning at 10.19 am

saying that you understood from your manager Emma Fensom that there was a lot of

uncertainty about what was happening with the Ruby Princess in the early hours of

the morning. Should we take that to be – and I apologise if this is in your statement

and I just haven’t picked it up. Do we take that to be a reference to some uncertainty 5

about whether passengers that were being taken off the ship by ambulance were

being taken off the ship because they had symptoms consistent with COVID-19 or

had different medical conditions that required them to come off?

MS MARSHALL: I – I recall having the phone conversation with Emma the 10

following morning.

MR BEASLEY: Yes.

MS MARSHALL: And – and what she was frustrated with was when there was this 15

confusion, and I couldn’t tell you whether it’s the confusion over the ambulance or

whatever, but that’s - - -

MR BEASLEY: Yes.

20

MS MARSHALL: - - - what I took away from it. What they didn’t have at hand

was the capacity to pick up the phone and actually speak to someone directly from

NSW Health, and if they had of had that it would have helped them.

MR BEASLEY: Yes. While you’re saying that, I’ve – I’ve noticed this is – this is – 25

what you’ve just said is in paragraph 34 of your statement. And I take it that lack of

ability to contact someone at New South Wales Health for some guidance or

information is what prompted some contact between you and Professor Ferson?


MR BEASLEY: And in his email to you of 19 March 2020 at 12.05, he starts by:

Thanks for taking my call.

35

MS MARSHALL: Yes.

MR BEASLEY: Clearly there was a phone conversation between you and Professor

Ferson?

40

MS MARSHALL: Yes.

MR BEASLEY: And can you tell us as best as you can recall now what was

discussed during that telephone call?

45

MS MARSHALL: The email that Professor Ferson sends through was a really good

summary of the - - -


MR BEASLEY SC

MR BEASLEY: Oh, I see.

MS MARSHALL: - - - phone conversation that we had. I – I explained to him the

frustrations that my colleagues had experienced the – during the night before.

5

MR BEASLEY: Yes.

MS MARSHALL: And that whilst it had been helpful to have Kelly-Anne Ressler

as a contact, you know, in the – during the last week we really needed somebody that

we would call in the middle of the night because we run a 24/7 operation. 10

MR BEASLEY: Of course.

MS MARSHALL: And – and that’s when – everything that’s he put here in writing

he spoke to me about on the phone. 15


MR BEASLEY: All right. In the documents – and I won’t take you all the way

through it because I believe it’s someone else’s document. But there was a – a 20

chronology prepared. A document that commences:

Chronology, Ruby Princess, 18 month 2020,

With a description of various communications at various times in the afternoon of the 25

18th of March through to the early hours of the morning of the 19th of March. It may

have been prepared by Mr Butchart. Is that your understanding?

MS MARSHALL: I’m not sure. Where – where is that document?

30

MR BEASLEY: All right. My – I have a copy that’s in the middle of Tab 13 of the

key documents bundle. What I’m not sure is whether it’s in your police statement.

MS MARSHALL: I don’t believe I - - -

35


MS MARSHALL: - - - put that chronology in my station.

MR BEASLEY: All right. We might – I – what I might do is find it for you. If I 40

can just approach the witness, Commissioner. It’s going to be easier because it’s not

paginated.

COMMISSIONER: Which one is this?

45

MR BEASLEY: So if you go to – might have to approach you to. If you go - - -


MR BEASLEY SC

COMMISSIONER: No, no, no, just - - -

MR BEASLEY: - - - to the middle of – there we go. No, that’s not it. Here we are.

So if you go to the middle of tab 13. I can’t be more - - -

5

COMMISSIONER: That’s all right.

MR BEASLEY: - - - precise than that. But you’ll find a document that is headed –

that I’ve just drawn to the witness’s attention. It’s – it’s headed, “Re, Ruby Princess

chronology.” 10

COMMISSIONER: Yes.

MR BEASLEY: Printed 11.34 - - -

15

COMMISSIONER: No, I got it. Yes.

MR BEASLEY: - - - am. You got that?

COMMISSIONER: Yes. Thank you. 20

MR BEASLEY: What I wanted to ask you, Ms Marshall, is that – first of all, did

you prepare this document?

MS MARSHALL: No, I did not. 25

MR BEASLEY: All right. Do you know who prepared the document?

MS MARSHALL: No, I don’t.

30

MR BEASLEY: Have you seen it before?

MS MARSHALL: No.

MR BEASLEY: All right. 35

COMMISSIONER: Probably not useful to explore - - -

MR BEASLEY: That ends that. Yes.

40

COMMISSIONER: - - - that.

MR BEASLEY: There was only one other matter I wanted to discuss with you

today. Something I hadn’t seen before but I did see in your police statement. I don’t

know. Do you have annexure Q of your police statement? 45

MS MARSHALL: Let me just – no. Which is annexure Q? I should have.


MR BEASLEY SC

MR BEASLEY: It’s - - -

MS MARSHALL: Yes.

MR BEASLEY: I think it’s the – yes. Could well be the very last annexure. It’s an 5

email from you to Wendy Doran of 23 March at - - -

MS MARSHALL: Yes. I – actually I don’t - - -

MR BEASLEY: - - - 8.43? 10

MS MARSHALL: - - - have it, but I do recall the email. Yes.

MR BEASLEY: I’m going to take that up to you as well then. So in that email - - -

15

MS MARSHALL: Mmm.

MR BEASLEY: - - - which you’ve copied Ms Fensom and Mr Butchart in.


MR BEASLEY: Am I saying his name correctly?

MS MARSHALL: Butchart. Yes.

25

MR BEASLEY: Butchart. Yes. Thank you. You spoke to Franz from Biosecurity.

Where is that gentleman from? Is that biosecurity - - -

MS MARSHALL: Franz - - -

30

MR BEASLEY: - - - federally?

MS MARSHALL: Franz Odermatt. So - - -

MR BEASLEY: Yes. 35

MS MARSHALL: - - - actually if you go back to the email that - - -

MR BEASLEY: Yes.

40

MS MARSHALL: - - - from - - -

MR BEASLEY: I think I saw his name before there.

MS MARSHALL: If – where Professor Ferson refers to - - - 45

MR BEASLEY: To him.


MR BEASLEY SC

MS MARSHALL: - - - to him. He tells me that he – in that phone conversation that

I had with Professor Ferson - - -

MR BEASLEY: Yes.

5

MS MARSHALL: - - - he did say to me that I – I should speak to Doctor Sean

Tobin or we can speak to Doctor Sean Tobin - - -

MR BEASLEY: Yes.

10

MS MARSHALL: But he says:

I feel it is desirable to include Franz Odermatt or his colleague in that

conversation as normally access to the CHBO –

15

Which is Doctor Sean Tobin –

is through the relevant Port Biosecurity Officer.


MS MARSHALL: And so I had a question. It was after hours - - -

MR BEASLEY: Yes.

25

MS MARSHALL: - - - before I contacted or – or had our duty harbour master

contact the doctor, I wanted to follow what Professor Ferson had requested that I do.

MR BEASLEY: Yes.

30

MS MARSHALL: And I contacted Franz Odermatt.

MR BEASLEY: But can you – is – when it says Mr Oder – Odermatt from

biosecurity, is he within the department – federal Department of Agriculture and

Water? 35

MS MARSHALL: I – yes. He – he – he fits - - -


40

MS MARSHALL: It’s commonly referred to as biosecurity, but I understand it fits

under the Department of Agriculture, Water and Environment.

MR BEASLEY: Right. And he – he said there’s been no additional human health

reports since Saturday because apparently nothing has changed since then. He also 45

admitted he won’t put his guys on the ship unless the COVID-19 samples come back

as negative. Do you recall him – is that literally what he said to you or do you have


MR BEASLEY SC

any better recollection than – that may be your best recollection, what’s in this email,

but - - -

MS MARSHALL: I think I’ve – I’ve paraphrased him. I’m confident I’ve

paraphrased him. 5

MR BEASLEY: Yes. All right. He couldn’t help you any more. What specific

help were you seeking from Mr Odermatt?

MS MARSHALL: Well, the reason I called him was that after the Ruby Princess 10

came in on the early hours of 19 March, I understand, although I wasn’t involved in

it, that Emma Fensom had arranged for us to get a statement of health every time a

cruise ship came in after that. And the statement of health - - -

MR BEASLEY: From? From? 15

MS MARSHALL: From NSW Health.

MR BEASLEY: Right. Yes.

20

MS MARSHALL: And the statement of health that came in for the Carnival Spirit,

I believe I – Emma Fensom had asked for Cameron Butchart and myself to be copied

on those statement of health. And when I had a look at it, it – you know, I think from

memory we were on the – it was 23 March but I noticed that the reference to the

latest human health update was 21 March. And you know, considering – it seemed 25

to me that that was a pretty big gap in time and we were supposed to be relying on

this report. So it was after hours, from recollection, it was sort of 8 o’clock at night

or something like that, or 9 o’clock at night, something along – around that. So I

thought, “Okay, I will” - - -

30

MR BEASLEY: You’re concerned about more people becoming ill between the

date of the document being prepared and the ship - - -


35

MR BEASLEY: - - - actually arriving.


MR BEASLEY: Yes. 40

MS MARSHALL: So that’s why I called Franz. I felt that his response saying, “Oh

well, nothing has changed since then. You know, apparently nothing – apparently,”

– I recall him saying, “apparently, nothing has changed since then,” to me seemed

inadequate and he sort of said, “Call,” you know, “You can call Health.” The reason 45

I gave this over to Wendy Doran in an email - - -


MR BEASLEY SC

MR BEASLEY: Yes.

MS MARSHALL: - - - was because that’s actually the role of the duty

harbourmaster.

5

MR BEASLEY: Right.

MS MARSHALL: It was after hours. I wanted her to be armed with the

information. I provided her Dr Sean Tobin’s contact details with that background.

10

MR BEASLEY: Thank you.

MS MARSHALL: Yes.

MR BEASLEY: I don’t have any more questions today, Ms Marshall. 15

COMMISSIONER: When you had your conversation with Kelly-Anne Ressler, you

were told by her that your pilot would, in her terms, be a casual rather than a close

contact for tracing purposes.

20

MS MARSHALL: Yes.

COMMISSIONER: She thought.


COMMISSIONER: And in that context, you were told by her that the master, the

captain of the ship, presumably meaning the senior deck officer on the bridge when

the pilot was working there, would be the only person likely to – for the pilot to have

close contact with; is that right? 30


COMMISSIONER: So did you understand that she was describing that as being

casual contact or that as being the only close contact? 35

MS MARSHALL: That as being the only close contact. So in order for her to

provide that advice to me, I had explained the role of the pilot to her, who that – you

know, how they generally interact on the bridge. And after me explaining that to her,

she had suggested that they would categorise that as being casual contact, except for 40

the captain, because when our pilot boards a vessel, they do something called the

master/pilot exchange, and to do that, they will often sort of – well, they will, not in

COVID times, they’ve been making a bit more distance but usually they would stand

next to each other and discuss how, you know, how the pilotage was going to occur

and go through the details. So they would be in close proximity to each other. 45


MR BEASLEY SC

And also when they’re berthing the ship, they might be out on a bridge wing, looking

over the edge together, quite close to each other. So that level of contact with the

captain or the master of the ship, she said, yes, that could be considered close

contact. But everybody else that’s on that bridge, they would consider that they

haven’t distanced themself, they haven’t been close enough to be considered a close 5

contact.

COMMISSIONER: And did you take from that that close contact with the master in

the circumstances you’ve described was not something that a pilot should worry

about? 10

MS MARSHALL: I just took away that it is still important for our pilots to be very

mindful and alert as to, when they go on a vessel, the risk of COVID because there’s

at least one person on the ship that they’re going to have close contact with.

15

COMMISSIONER: No one is suggesting that captains are immune.

MS MARSHALL: That’s right. So that’s really what I was taking away – was that

there is still a genuine concern for the health and safety of our pilots. Even if the

majority of the contact that they have is not considered to be close contact, there is 20

some potential level of close contact, which is how it gets transmitted.

COMMISSIONER: As you sit here this afternoon, are you content with the level of

information available to you and your staff for the purposes of protecting the pilots?

25

MS MARSHALL: No.

COMMISSIONER: And is that for reasons you’ve already explained - - -


COMMISSIONER: - - - or is there something else you would like to add to that?

MS MARSHALL: No. It’s for reasons I’ve already explained.

35

COMMISSIONER: If routine access either to MARS information or to health status

information provided by somebody who does have access to MARS information – if

that were added to your store of information routinely, would that be a significant

improvement, from your point of view?

40

MS MARSHALL: Yes.

COMMISSIONER: Is there anything that you would like to see routinely added?

MS MARSHALL: I think, in terms of lesson learned – I – I think that agencies 45

should know better who to contact and who to talk to, and I felt that in this

circumstance some of the chasing down of contacts could have been avoided if we

.RUBY PRINCESS INQUIRY 1.5.20R2 P-196 C.T. BUTCHART

had had better understanding of, you know, who – who is who and who knows what,

and I would like to see that improve for us in the future.

COMMISSIONER: Thank you. Does anybody want to ask any questions? No.

5

MR HUTCHINGS: Commissioner, the acronym that the witness referred to earlier,

SHIPS, is Sydney Harbour Integrated Port Systems, if that - - -

COMMISSIONER: And it just coincidentally spells “ships”.

10

MR HUTCHINGS: Indeed.

COMMISSIONER: I’m glad people spend their time thinking about these things.

MR BEASLEY: It’s like the cops have one called COPS. 15

COMMISSIONER: Thank you. You are excused from the present summons. I’m

afraid I can’t assure you that you won’t be back.

MS MARSHALL: Okay. 20

COMMISSIONER: Thank you very much for your help.

MS MARSHALL: Thank you.

25

<THE WITNESS WITHDREW [2.53 pm]

MR BEASLEY: And I think we have Mr Butchart here. Can I suggest after 30

Mr Butchart’s evidence – or it has been suggested to me that there then be a short

break to enable a change of personnel in the room.

COMMISSIONER: Certainly. Mr Butchart is here, I gather.

35

MR BEASLEY: I think he is.

MR HUTCHINGS: He is. Yes.

MR BEASLEY: Yes. 40

COMMISSIONER: Yes.

<CAMERON TREVOR BUTCHART, AFFIRMED [2.54 pm] 45

.RUBY PRINCESS INQUIRY 1.5.20R2 P-197 C.T. BUTCHART XN

MR KIRBY

<EXAMINATION-IN-CHIEF BY MR KIRBY


5

MR KIRBY: Could you please tell the Commissioner your name, sir.

MR BUTCHART: Cameron Trevor Butchart.

MR KIRBY: And, Mr Butchart, you’re the port services manager. 10

MR BUTCHART: Correct.

MR KIRBY: And you’ve been in that role for about 18 months?

15

MR BUTCHART: Yes. Correct.

MR KIRBY: And in that role, you also acted as duty harbourmaster. Am I right?

MR BUTCHART: Yes. That’s correct. 20

MR KIRBY: And you shared that duty role with two others.

MR BUTCHART: Yes. That’s correct.

25

MR KIRBY: It’s a 24-hour, seven day a week role.

MR BUTCHART: Yes. That’s right. Yes.

MR KIRBY: And is that why it’s shared? 30

MR BUTCHART: Yes. That’s – that’s correct.

MR KIRBY: So do you have – is it every day divided into three shifts?

35

MR BUTCHART: No. It’s Friday to Friday, the duty harbourmaster roster, and

then we do a handover every Friday to one of my colleagues.

MR KIRBY: I see. Now, you’ve got in front of you, I think, your – the statement

that you made to the police a few days ago? 40

MR BUTCHART: Yes. That’s correct. Yes.

MR KIRBY: And do you have the – the – I think you call them “appendices” to

that, the emails and things that you attach and refer to in it? 45

MR BUTCHART: I believe my – not with me, but – I do now.


MR KIRBY

MR KIRBY: You do now. So in paragraph 4 – just so you understand, Mr

Butchart, this hearing is a private hearing. You will likely be required to come to a

public hearing next week.

MR BUTCHART: Yes. 5

MR KIRBY: So the questions that I will ask are really just gap-filling questions and

just so I understand a little bit better the way the – and the Commissioner

understands better the way the operation works, your role in the VTS - - -

10

MR BUTCHART: Yes.

MR KIRBY: - - - and a little bit more about the events of the arrival of the Ruby

Princess on maybe 8 March and certainly 19 March. So you describe that you, as

harbourmaster, or duty harbourmaster, have the power to approve or deny vessels 15

coming into the harbour.


MR KIRBY: And you say that that power can be invoked, that is, the power to deny 20

vessels if they pose a threat due to navigation or pollution risk.


MR KIRBY: Do you know what the source of that power is? 25

MR BUTCHART: I – that power is under the Marine Safety Act.

MR KIRBY: Marine Safety Act. And is it limited to navigation and pollution or

can you – do you have a general power to deny a ship entry into the harbour? 30

MR BUTCHART: I can deny a – a pilotage to a vessel if I believe it’s – it’s going

to pose a threat to the marine environment, looking into the prevailing circumstances,

weather, tide, depths at certain berths, certain scenarios like that.

35

MR KIRBY: Right. Could you deny a ship a pilot if you had concerns about the

OH&S risk to that pilot?

MR BUTCHART: Yes, I could, if I had concerns generically about the pilot ladder

or something that would put the pilot at direct risk, or I would certainly escalate that 40

concern to a – to the other body, AMSA, that we - - -

MR KIRBY: And denying a ship a pilot would have the effect of denying them

entry.

45

MR BUTCHART: Would deny – would deny the pilotage operation, which would,

in lieu, deny the entry, yes.


MR KIRBY

MR KIRBY: Okay. So in paragraph 5 you reference an email to Franz Odermatt.

MR BUTCHART: Yes.

MR KIRBY: Now, he’s, you mention there, from the Department of Agriculture, a 5

biosecurity officer.

MR BUTCHART: Yes. Yes.

MR KIRBY: Is that – did you have – in the days before COVID, did you have 10

much dealings with him or his department?

MR BUTCHART: Very little dealings with his department. However, it was noted

to us that he was the representative that we deal with for any issues relating to

biosecurity with ships in our port. That – that’s about as far as that relationship went. 15

MR KIRBY: Who told you that and when?

MR BUTCHART: Within our ships booking portal - - -

20

MR KIRBY: Right.

MR BUTCHART: - - - which is a booking system that we use, his number is the

defined number for the clearing of vessels for pratique.

25

COMMISSIONER: Biosecurity would extend to bilge water as well to diseased

humans.

MR BUTCHART: It would - - -

30

COMMISSIONER: Is that right?

MR BUTCHART: That’s correct. And ballast water.

COMMISSIONER: And much in between. 35

MR BUTCHART: Yes. Ballast water, bugs on ships, yes.

COMMISSIONER: Ballast water. Yes. Thanks.

40

MR KIRBY: And had you, in your 18 months in the role – had you had cause to

have any contact with - - -

MR BUTCHART: No. Not me directly. My staff may have contacted him with

day-to-day items, but no, certainly not myself. 45


MR KIRBY

MR KIRBY: You say later in your statement that it’s not uncommon for cruise

ships to come in with lots of sick people and with ambulances arranged. Do you

remember saying that?

MR BUTCHART: Yes. It’s common to have ambulances on arrival. 5

MR KIRBY: I may have actually put the wrong words in your mouth. You do say

about ambulances that it’s not uncommon. Is it, in your experience, uncommon for

cruise ships to come in with lots of sick people? Do you even get told whether or

not? 10

MR BUTCHART: It’s not something that I do get told. During COVID, with the

internal implications we put into place, I did start to get told this information, but

prior to that it was not something that I was privy to, no.

15

MR KIRBY: And the internal communications – this was the four hour pre-arrival

email that you would send to the bridge?

MR BUTCHART: This is the four hour email that we would send out.

Occasionally we would get back a MARS form with that, with that information. But 20

prior to - - -

MR KIRBY: That would be – pardon. Sorry. Didn’t mean to interrupt.

MR BUTCHART: Prior to that, I never witnessed a MARS document in that form. 25

MR KIRBY: Right. And – but when you did in response to those emails questions

to the bridge - - -

MR BUTCHART: Yes. 30

MR KIRBY: When you did receive a MARS response back - - -

MR BUTCHART: Yes.

35

MR KIRBY: - - - that was just luck, that is, it was volunteered by the ship, it was

not required by the email that was sent.

MR BUTCHART: No. We did not ask. Occasionally they would just attach it with

our declaration. 40

MR KIRBY: You mention that after the Prime Minister’s announcement on 15

March - - -


MR KIRBY: Or actually you say the Australian government rule change.


MR KIRBY

MR BUTCHART: Yes.

MR KIRBY: There was a lot of ships coming back to Sydney quickly.

MR BUTCHART: Yes, there was. 5

MR KIRBY: And you could see that on the marine traffic ..... website.

MR BUTCHART: Yes, that’s correct, yes.

10

MR KIRBY: Do you recall whether or not the Ruby Princess was one of those

rapidly approaching vessels?

MR BUTCHART: I don’t recall. There was a lot of ships heading our way to

various locations and different ports throughout Australia. 15

MR KIRBY: You mentioned a call that you had on the evening of Sunday 15

March with a whole group of agencies or stakeholders.

MR BUTCHART: Yes. That’s correct, yes. 20

MR KIRBY: You remember – you were on that call.

MR BUTCHART: Yes, I was.

25

MR KIRBY: And it was run by - - -

COMMISSIONER: Which time was this? Which time – which o’clock?

MR KIRBY: At 8 pm, paragraph 10 of the statement. 30


MR KIRBY: You say that amongst all these agencies – and there was New South

Wales Health and there was Australian Border Force and there were a whole bunch 35

of port agents. Just pausing there, by port agents you mean the corporate port agents

for the cruise ship companies.

MR BUTCHART: Yes, that’s correct. The invite was sent out to stakeholders

wide. 40

MR KIRBY: Do you know how many people roughly were on this call?

MR BUTCHART: It was just under 100, I believe. It was Australia-wide.

45

MR KIRBY: Australia-wide.


MR KIRBY

MR BUTCHART: Australia-wide. Ports all over Australia.

MR KIRBY: Was – and New South Wales Health was convening it, was it?

MR BUTCHART: Yes, they were. I was invited by Vicki Sheppeard of New South 5

Wales Health.

MR KIRBY: And you mentioned that the port agents were the most vocal and no

answers were provided. When you say port agents, did you mean people like

Carnival agents and - - - 10

MR BUTCHART: I don’t recall if a Carnival agent spoke specifically, but certainly

various agents throughout the country rose their concerns, including other ports

across the country.

15

MR KIRBY: You mean the cruise ship – the cruise lines agents, not agents of Port

Authorities like you.

MR BUTCHART: The cruise lines. No, no, yeah. Cruise line – agents – vessel

agents. Yes, that’s correct. Cruise agents and vessel agents. 20

MR KIRBY: And do you remember what sort of questions – well, what

vocalisations they were making, why they - - -

MR BUTCHART: A lot of the questions were around which vessels can enter and 25

which ones can’t enter. It was a lot of misunderstanding around if they departed

Australian waters and coming back, were they allowed in, or were you only letting

vessels back in that had not – some of these cruise ships just go in and out sort of

thing. Are they the only ones that were allowed back in? There was a lot of angst

around what exactly does it mean. 30

MR KIRBY: Right.

MR BUTCHART: What’s banned and what’s not banned.

35

MR KIRBY: I see. And a few days later you had a telephone call with one of those

agents, Valerie Burrows.

MR BUTCHART: Yes. I speak with Valerie quite often. Yes.

40

MR KIRBY: Yes. Approximately daily during the cruise ship season.

MR BUTCHART: Would have been daily. Especially during this period. Yes.

MR KIRBY: And she – you recall her raising sick people on the Ruby Princess. 45

MR BUTCHART: Yes, she did.


MR KIRBY

MR KIRBY: And that stuck out in your mind.

MR BUTCHART: I think with the circumstances that were happening, it triggered

in my mind, yes.

5

MR KIRBY: Why? What were the circumstances that made that stick out?

MR BUTCHART: We were in a – you know, COVID was a common topic at the

time. We had already had our own internal policies in place for COVID. It was

certainly something that we were alert to. There’s sick people on a lot of ships, 10

cruise ships. As I said, there’s ambulances ..... that common. Just stood out to me.

That’s all.

MR KIRBY: But you followed up specifically asking if it was COVID-19, and she

said no. Is that right? 15

MR BUTCHART: That’s correct, yes.

MR KIRBY: But you said that you felt the fact that she mentioned this was

interesting to you: 20

…and I felt this needed to be further investigated.

What means did you have - - -

25

MR BUTCHART: I thought it was out of character.

MR KIRBY: Yes. I understand you found it suspicious, in a sense, or - - -

MR BUTCHART: I guess that’s a word I could – yes, suspicious would be a word – 30

I had suspicions.

MR KIRBY: I’m just wondering how did you intend - - -

COMMISSIONER: What were the suspicions and why did you have them? 35

MR BUTCHART: I didn’t – we had a ship the – the day before, the 16th, where we

still weren’t aware if New South Wales Health were telling us the full situation on

board these vessels, which would then give angst to me, because the pilot groups

would hear different things, and then I would have to try and work with the pilot 40

group and try and give them the affirmation that it’s safe, the ship that they’re going

onto. So - - -

COMMISSIONER: So what was the suspicion you had?

45

MR BUTCHART: The previous day, the 16th, we had heard reports that New South

Wales Health were doing swabs on board the – I can’t quote the ship. I think it could


MR KIRBY

have been the Pacific Explorer. It’s in my emails. Which they were, but we still

hadn’t been notified that they were on board.

COMMISSIONER: That who was on board?

5

MR BUTCHART: New South Wales Health were on board that particular ship.

COMMISSIONER: That other ship that - - -

MR BUTCHART: Yes, that’s correct, yes. So I guess I had – I was cautious if – I 10

didn’t want to put a pilot in a position where they get on board the ship and they hear

something that they didn’t know previously.

COMMISSIONER: Well, now, if you knew that swabs had been taken for the

purpose of testing for COVID-19 but that they had not yet been delivered to the 15

laboratory, and therefore there were no results back yet, where did - - -

MR BUTCHART: This is - - -

COMMISSIONER: Just in general at this time - - - 20

MR BUTCHART: Yes.

COMMISSIONER: Where did that leave you with your pilots? What could you do

with that? 25

MR BUTCHART: That ship turned out not to be the case with that one, but I have

got other ships that I can reference where we did have incidences where there were

potential COVID on board and we did need to put measures in place.

30

COMMISSIONER: So potential COVID meaning, for example, swabs had been

taken for the purpose of testing for it, but the results were not back yet. Is that right?

MR BUTCHART: That’s correct.

35

COMMISSIONER: That’s what you mean by potential.

MR BUTCHART: That’s what I mean by potential, yes.

COMMISSIONER: The un-excluded, real possibility that there was COVID. 40


COMMISSIONER: During that time, that is, before you get back the test results,

positive or negative, what – how did you deal with concerns your pilots would have? 45


MR KIRBY

MR BUTCHART: If – if the vessel was deemed to be positive, our biggest concern

was defining whether that was a passenger or a crew member. We were of the

opinion and believed that we could still safely pilot a vessel if we could ensure that

the bridge team, the chief officers, second officers were not COVID cases.

5

COMMISSIONER: How would you ensure that in your mind?

MR BUTCHART: They – they were questions that we would – we would have to

ask.

10

COMMISSIONER: What, for self-diagnosis? “Do you have COVID-19?”

MR BUTCHART: Yes.

COMMISSIONER: You could ask me that. I could ask you that. But I hope 15

nobody would rely upon - - -

MR BUTCHART: But that – that was the - - -

COMMISSIONER: - - - their answers. 20

MR BUTCHART: - - - the question as well on our eternal – our internal declaration

that we were sending out to SHIPS. It was primarily looking at the bridge team.

COMMISSIONER: I understand that - - - 25

MR BUTCHART: Yes.

COMMISSIONER: - - - concern entirely. And, please, I’m not going to be critical

about this - - - 30

MR BUTCHART: Yes.

COMMISSIONER: - - - with you. You understood, not as a medico, but as

somebody with your - - - 35

MR BUTCHART: Yes.

COMMISSIONER: - - - your occupation and responsibilities, you understood that it

was apparently believed, probably still is believed - - - 40

MR BUTCHART: Mmm.

COMMISSIONER: - - - that a person can be infected with COVID-19 - - -

45

MR BUTCHART: Yes.


MR KIRBY

COMMISSIONER: - - - and not display or feel symptoms, correct?

MR BUTCHART: Yes. Correct.

COMMISSIONER: And whether or not such people can be a source of contagion of 5

others was unknown but was considered a real possibility?

MR BUTCHART: Yes. Yes. Correct.

COMMISSIONER: Which is put – putting your mind back to those days in March, 10

16, 17, 18, 19 - - -

MR BUTCHART: Yes.

COMMISSIONER: - - - that was one of the reasons why COVID-19 was the cause 15

of such apprehension about the introduction of crew and passengers from a ship

arriving from the high seas.

MR BUTCHART: Yes.

20

COMMISSIONER: Is that correct?


COMMISSIONER: Yes. But you’d never be able to tell your pilots yes or no there 25

is COVID-19 on this ship without a lab test, would you?

MR BUTCHART: To my understanding, no. No we would not.

COMMISSIONER: Yes. So – so you would never know whether the captain was, 30

unknown to himself or herself already carrying COVID with sufficient load to infect

others, would you?

MR BUTCHART: No, we wouldn’t. We were basically going off the assumption

of our – our internal assessment. 35

COMMISSIONER: Yes. And, again, I’m – please, I will not be criticising anyone

about this - - -


COMMISSIONER: - - - there is a risk assessment involved, I’m not suggesting by

you as a medical practitioner - - -

MR BUTCHART: Mmm. 45


MR KIRBY

COMMISSIONER: - - - but there’s a risk assessment involved. Ships have to be

piloted. It’s not realistic to let them drift like the Flying Dutchman. So they have to

be piloted when they come into harbour.

MR BUTCHART: Yes. 5

COMMISSIONER: And at least a pilot made aware of these risks can ensure that

he or she does not mix closely with anybody apart from the bridge crew with whom

contact is appropriate, is that right?

10


COMMISSIONER: And at least even if it be true that even the captain can’t know

if his or her infective state, nonetheless, that’s only one person rather than hundreds.

15

MR BUTCHART: Yes.

COMMISSIONER: It’s all part of the risk assessment. And then there’s – and then

there’s PPE that you and your pilots give consideration to using, is that right?

20

MR BUTCHART: PPE was one of our barriers along - - -

COMMISSIONER: Yes.

MR BUTCHART: - - - with – we tried – changed some of our pilotage mechanisms 25

such as the use of touching bridge equipment and things like that. But PPE was our

number one barrier.

COMMISSIONER: Now, casting your mind back to those same days in March, 16,

17 and 18, had you been told by a doctor on a ship, “Look, I can’t say there is 30

COVID on board because although I’ve taken swabs, we don’t have a lab and we

won’t know in laboratory terms until those swabs have been tested. But I think we

do.” Right? And then the doctor go – if the doctor had gone on and said, “And I

think you and your pilot should proceed on the basis that there is COVID on board,”

and then in the same breath adds, “But you’ll be pleased to know no one on the 35

bridge team seems to be involved in close contact with the people – the – the

passengers or crew members that I think may have COVID.” What would you have

done then?

MR BUTCHART: With that information myself I would have certainly had to have 40

escalated it through to our - - -

COMMISSIONER: I’m sure.

MR BUTCHART: - - - CMT. It wouldn’t have been a decision straight from 45

myself. I – from looking - - -


MR KIRBY

COMMISSIONER: Are there industrial reasons why that might make piloting very

difficult?

MR BUTCHART: The – the pilots weren’t – I wouldn’t say industrial. They just

wanted to be sure they were safe. You know, we – we - - - 5

COMMISSIONER: Well, I’m old fashioned enough and think safety is an aspect of

industrial concerns.

MR BUTCHART: Yes. So I – yes. There was industrial issues with ensuring the 10

pilots safety and to ensure we could continue moving port – ships throughout the

port.

COMMISSIONER: Did you ever feel yourself under any pressure, either from the

pilots or from the ships, or from the companies at this time to either overstate a risk 15

of COVID or to understate it?

MR BUTCHART: Not – not – not pressured, but certainly I was willing to – to try

and work with both parties to get a – an ample solution.

20

COMMISSIONER: Which would involve docking, testing, screening, quarantining,

disembarking, as the health authorities thought fit, is that right?

MR BUTCHART: That’s correct. I was of the opinion that the health authorities

and Border Force were doing those – were doing those mechanisms as well. 25

COMMISSIONER: What was your understanding about what Border Force was

doing?

MR BUTCHART: Probably shouldn’t disregard Border Force, but certainly 30

agriculture - - -

COMMISSIONER: No, I’m not going to disregard Border Force. What was your

understanding - - -

35

MR BUTCHART: It was sure sight.

COMMISSIONER: - - - about what Border Force was doing?

MR BUTCHART: I was of the – the opinion that they were involved in – in the 40

pratique. The clearing - - -

COMMISSIONER: In what - - -

MR BUTCHART: - - - and the pratique of vessels. It’s ..... previous to being at the 45

port Authority I spent many years on the bridge of very large ships trading around

the world and it’s always been the first two people on board a vessel is Border Force


MR KIRBY

and AQIS quarantine, or Agriculture for that matter, to clear the vessel. I was always

of the opinion that these bodies would be clearing vessels safely.

COMMISSIONER: Relevantly the pratique being sought would depend upon,

among other things, would depend upon human health questions, wouldn’t it? 5

MR BUTCHART: I’m – I’m – I’m not aware what the pratique questions were

given to ships before that pratique is cleared.

COMMISSIONER: But you are familiar with the fact that pratique typically 10

involves consideration of human health?

MR BUTCHART: Human health, yes.

COMMISSIONER: So have I got it correct you thought that pratique would involve 15

Border Force somehow or other?

MR BUTCHART: No, I’m not. Shore-side personnel being agriculture primarily.

COMMISSIONER: And if I use the expression, “Home Affairs,” does that change 20

the matter so far as you’re concerned?

MR BUTCHART: To my understanding Home Affairs and Border Force are the

same identity.

25

COMMISSIONER: Right. Thanks. Mr Kirby.

MR KIRBY: Commissioner, thanks. You – you mention – I withdraw that. Franz

Odermatt send you – sent you an email on the 30th of January which mentioned a

body called the Maritime National Coordination Centre. Do you recall that? 30

MR BUTCHART: Sorry?

MR KIRBY: That’s annexure A.

35

MR BUTCHART: Which paragraph?

MR KIRBY: Well, it’s – it’s appendix A of your statement.

MR BUTCHART: Just – sorry. Can you rephrase the question? 40

MR KIRBY: Sure. Have you heard of the Maritime National Coordination Centre?

MR BUTCHART: I recall – I recall seeing it during this - - -

45

MR KIRBY: But you’re not familiar with its workings? You don’t have anything

to do with them on any regular basis?


MR KIRBY

MR BUTCHART: No, I don’t. No.

MR KIRBY: And you don’t know what they do?

MR BUTCHART: No, I don’t, sorry. 5

MR KIRBY: Okay. You – you asked in an email on the 29th of January - - -

MR BUTCHART: Yes.

10

MR KIRBY: - - - or you expressed interest in attending any stakeholder meetings.

This was an email to Mr Odermatt - - -

MR BUTCHART: Yes.

15

MR KIRBY: - - - where you expressed interest in attending any stakeholder

meetings within the airport if and when they occur. What was happening there?

MR BUTCHART: I – I felt with all the restrictions that were occurring back at this

time seemed to be very much focused around airports. The majority of my staff, 20

being pilots – the issues they were raising were there’s certain restrictions on these

aeroplanes, but this – if my ship was an aeroplane, it would reflect totally differently.

So a lot of their safety concerns were raising from different policies they put on

aircraft. So I reached out to Agriculture. I – I guess when I go back to what I said

previously, I believe that shore-side were responsible for health and human health. I 25

– I also felt that they were responsible from all – all this. Once the vessel was

alongside the wharf, the pilot had been disregarded from any procedure or policy.

We still had a pilot getting up a rope ladder at sea onto Chinese vessels, but hence

Sydney Airport were at this stage not – not landing aircraft from China.

30

MR KIRBY: I see.

MR BUTCHART: So I guess our – my mindset was, yes, there’s terrific policies,

but they’re only happening once the ship is alongside the wharf and our pilot had

been disregarded. 35

MR KIRBY: And did anyone from shore-side or the Department of Agriculture or

any other agency invite you to attend any such meetings - - -

MR BUTCHART: No. No. 40

MR KIRBY: - - - or provide any information on what they were doing?

MR BUTCHART: No. I got absolutely nothing. I also followed up with a phone

call and I still got – I think I got a very generic email back to tell the pilots to wear 45

PPE.


MR KIRBY

COMMISSIONER: What, in every case?

MR BUTCHART: Basically that’s the reply to that email. Yes. Then later on that

was still the information we were receiving: that the pilots need to wear correct PPE.

5

COMMISSIONER: Mr Kirby, does Mr Butchart have the core - - -

MR KIRBY: The key documents?

COMMISSIONER: The key documents folder. 10

MR KIRBY: I think it’s still there.

MR KIRBY: It’s next to him.

15

COMMISSIONER: Yes. I wonder if I could just ask you, Mr Butchart, please.

That folder: could you turn to tab 13, please.

MR KIRBY: It’s not the – not the yellow tabs, the grey tab 13. I might be wrong to

say that. 20

MR BUTCHART: Transport for New South Wales?

COMMISSIONER: No. No. Have I got it in a different form? White tabs with

black numerals? 25

MR KIRBY: Is the first page Transport for New South Wales?

COMMISSIONER: No.

30

MR BUTCHART: Yes. That’s what I have.

COMMISSIONER: Yes.

MR KIRBY: Yes. Okay. That’s the right 13. 35

COMMISSIONER: Yes.

Could you go to the first of the pages with text on that, please. It has Koo Barbi up

the top. Do you see that? 40

MR BUTCHART: Yes, I do.

COMMISSIONER: Now, I’m not going to take you in great detail at the moment.

It suffices to say that this – these contain two emails from you in exchange with 45

Emma Fensom. Isn’t that right?


MR KIRBY


COMMISSIONER: And these were exchanges whereby you and she were seeking

to record by way of summary the events of the latter part of the 18th, the early part of

19 March with the arrival in port of the Ruby Princess. Is that correct? 5


COMMISSIONER: And then if you go over, I think, five red tabs. You will find a

document headed Re Ruby Princess Chronology printed 11.34 am, 4 April. Have 10

you found that?

MR BUTCHART: Sorry. Five pages from here?

COMMISSIONER: No. Red tabs. Have you not got red tabs? 15

MR KIRBY: I don’t think he has – he hasn’t got red tabs, Commissioner.

MR BUTCHART: No. I haven’t got red tabs.

20

MR KIRBY: I will – I will find it. It’s easier. I know where it is. I will just help

the witness. Is your – are you doing the 11.24 am version?

COMMISSIONER: 11.34 am.

25

MR KIRBY: There’s a lot of versions. Right. Okay.

COMMISSIONER: Thanks.

MR KIRBY: Has it got handwriting saying Incident Report? 30

COMMISSIONER: Yes. That’s the one.

MR BUTCHART: Yes.

35

COMMISSIONER: That’s a document that has a number of different fonts and the

like. Should I take it that that is a document to which you contributed?

MR BUTCHART: I – I believe this – yes. This – this is correct. This is – yes.

40

COMMISSIONER: Did you largely prepare that yourself?

MR BUTCHART: I put the – I put the first – the first – the first, I guess, email out.

Yes. I put this document together and then Emma added into the document.

45

COMMISSIONER: I just wanted to ask you about - - -


MR KIRBY

MR BUTCHART: There was confusion creating this document, though, if I can –

may.

COMMISSIONER: Yes. Explain, by all means.

5

MR BUTCHART: The – and I don’t know if it’s – if it’s just the one – this

document was built based on some emails coming from the Ruby Princess, and when

we built the document, the timestamps on the emails for the Ruby Princess were in

New Zealand time.

10

MR KIRBY: Right.

MR BUTCHART: Okay. So when we were putting this together, we were

confusing ourselves, thinking, “No. I called you before that email,” or “after that

email,” until we later found out that the Ruby Princess was still giving us New 15

Zealand timestamps.

COMMISSIONER: So by the time we look at the exchange between you and

Emma Fensom - - -

20

MR BUTCHART: Yes.

COMMISSIONER: - - - on 19 March - - -


COMMISSIONER: Are the times still mucked up there or they have been fixed?

MR BUTCHART: I – I – I – I think this second one you brought me to is the

correct – is a corrected version. 30

COMMISSIONER: Yes. I see. Thank you. Well, in relation to that, at – there’s an

entry at the top of the second – third page, approximately 0050 hours. Do you see

that?

35

MR BUTCHART: Yes, phone hook-up with Emma.

COMMISSIONER: No.

MR BUTCHART: Yes: 40

EF talks to Paul Mifsud.

COMMISSIONER: That’s it.

45

MR BUTCHART: Yes.


MR KIRBY

COMMISSIONER: That’s the one.

MR BUTCHART: Yes.

COMMISSIONER: There was, I take it, in quick succession, a phone conference 5

between you, Mr Rybanic and Ms Fensom. Is that right?

MR BUTCHART: That’s correct. Yes.

COMMISSIONER: And then, as you understood it, Ms Fensom talking to Paul 10

Mifsud from Carnival – or Carnival executive?

MR BUTCHART: That’s how I understood it on the evening. Yes.

COMMISSIONER: And she informing you - - - 15

MR BUTCHART: Yes.

COMMISSIONER: - - - of the result of that call. Is that correct?

20

MR BUTCHART: I believe the – the phone hook-up – it was Rob Rybanic

informing myself in the phone hook-up that he had spoken with Paul Mifsud.

COMMISSIONER: But when it says “EF calls CB back”, that’s Ms Fensom calling

you back. Is that right? 25


COMMISSIONER: Did that happen?

30

MR BUTCHART: Yes, it did. There were numerous phone call, but – yes. Yes.

COMMISSIONER: So there would appear at 10 to 1 in the morning to have been

three phone calls. Is that right?

35


COMMISSIONER: Approximately. I don’t - - -

MR BUTCHART: Approximately. The - - - 40

COMMISSIONER: I’m not suggesting that happened as in a legal instant. No.

MR BUTCHART: Yes. There was a lot of phone calls getting around.

45

COMMISSIONER: In the email exchange between you and Ms Fensom that I took

you to, there’s a notation:


MR KIRBY

Phone hook-up with Emma, Rob and I –

as you write it:

A decision is made that New South Wales Ambulance have received incorrect 5

information and the ship should enter.

And then same time:

Ship granted approval. 10

Those, I take it, are entries that correspond to what you say is the version you would

prefer in the later document I’ve taken you to; is that right?

MR BUTCHART: Just rephrase that again. Sorry. 15

COMMISSIONER: No, I’m not going to rephrase it. I’d like you to answer it if

you could, please.

MR BUTCHART: No. Could you just say the question again. 20

COMMISSIONER: All right. There is an entry for 0050 hours?

MR BUTCHART: Yes.

25

COMMISSIONER: And then two entries each approximately 0058 hours?

MR BUTCHART: Yes.

COMMISSIONER: You see that? 30

MR BUTCHART: Yes. I do, yes.

COMMISSIONER: You ask me to prefer that as your summary recollection to the

version that you put in the email exchange with Ms Fensom on the 19th; is that 35

correct?

MR BUTCHART: Can I just read this just quickly?

COMMISSIONER: Yes, of course. 40

MR BUTCHART: Yes, that’s correct.

COMMISSIONER: Well, is it you personally who had advised the ship at half-past

11 the night of the 18th that their booking was denied? 45

MR BUTCHART: No, it was the – one of the VTS operators under my guidance.


MR KIRBY

COMMISSIONER: And so it was at your direction that - - -


COMMISSIONER: - - - message was sent? 5

MR BUTCHART: Yes.

COMMISSIONER: Yes.

10

MR HUTCHINGS: That guy was Steve Howieson

COMMISSIONER: Yes.

MR BUTCHART: That’s – that’s right. Yes. 15

COMMISSIONER: And if you look at the version I’ve asked you about which is

the version printed at 11.34 on the 4th of April, on that same page I’ve been asking

you about, you see there’s a later entry for 0150 hours; do you see that?

20

MR BUTCHART: Yes.

COMMISSIONER: Is it still your recollection that you took from your dealings or

understanding of dealings with the ship’s doctor and with Mr Mifsud, the notion that

there was no COVID-19 concern that had caused the request for ambulances? 25


COMMISSIONER: There was no other source of your coming to that belief than

what you understood the ship’s doctor had relayed and what Mr Mifsud had said; is 30

that correct? No other source?

MR BUTCHART: Yes. The internal documentation, our own declaration as well.

COMMISSIONER: When you say your own declaration? 35

MR BUTCHART: The declaration we were sending with four hour – our four hour

notice.

COMMISSIONER: So the answer to the five or six questions - - - 40

MR BUTCHART: To the five or six questions. There was also nothing on there to

indicate COVID-19.

COMMISSIONER: You’d better explain to me what is it about those questions that 45

excludes COVID-19.


MR KIRBY

MR BUTCHART: I haven’t got them in front of me, but I believe it’s question

number 2 asked the question is there a - - -

MR KIRBY: The questions, if it assists, and the answers are, if you go to the – right

to the end of tab 13 - - - 5

COMMISSIONER: Yes.

MR KIRBY: - - - in the key documents bundle.

10

COMMISSIONER: Yes.

MR KIRBY: And you will work forward from the back, you will first get the

human health report and then you get the email with the questions and then the email

from - - - 15

COMMISSIONER: Yes.

MR KIRBY: - - - the first officer with the answers.

20

COMMISSIONER: Yes. Pages 3 and 2, I think, respectively, of the print. Yes.

MR BUTCHART: Yes.

COMMISSIONER: Have you found them? 25

MR BUTCHART: Yes. I’ve got that here. Yes.

COMMISSIONER: So on the page numbered 3, Mr Howieson, the VTS operator

asks six questions in red; do you see that? 30

MR BUTCHART: Yes.

COMMISSIONER: On the page preceding, that comes from Ruby Bridge.

35

MR BUTCHART: Yes.

COMMISSIONER: The biosecurity declaration, in answer to them?


COMMISSIONER: Which is the question you were drawing to my attention?

MR BUTCHART:

45

Are any crew members showing symptoms of COVID-19 on board?


MR KIRBY

COMMISSIONER: Why do you say that excludes COVID-19?

MR BUTCHART: Sorry. Wasn’t the original question what pieces of information

- - -

5

COMMISSIONER: Yes.

MR BUTCHART: - - - did I have that would - - -

COMMISSIONER: Tell you that there was no COVID-19 reason that had led to the 10

request for ambulances.

MR BUTCHART: Request for ambulances.

COMMISSIONER: At all times, you knew the request for ambulances were for 15

passengers, not crew; is that correct?

MR BUTCHART: No, that’s not correct.

COMMISSIONER: When – did you ever discover that? 20

MR BUTCHART: The - - -

COMMISSIONER: Did you ever discover that?

25

MR BUTCHART: Yes. I was told it was passengers.

COMMISSIONER: You were told on the night, I take it.

MR BUTCHART: Yes, I was. 30

COMMISSIONER: So how would a question about symptomatic crew members

assist you to know whether there was a COVID-19 reason for calling for

ambulances?

35

MR BUTCHART: No, it wouldn’t.

COMMISSIONER: Do you think, on the night, you actually did read “no” to the

question:

40

Are any crew members showing symptoms of COVID-19 - - -

MR BUTCHART: Yes, I did.

COMMISSIONER: 45

- - - on board.


MR KIRBY

MR BUTCHART: Yes.

COMMISSIONER: Do you think, on the night, you regarded that as an indication

that there was not any COVID-19 reason for ambulances to be sought for two

passengers? 5

MR BUTCHART: The – the – the information I received from the ambulance

didn’t align with – well, I guess, because the key word here is “crew”, it excluded

passengers. So – no.

10

COMMISSIONER: I think you’re asking yourself the questions at the moment. But

that’s all right, saving time. The answers to these questions are actually completely

consistent with the ambulances, in fact, being sought for COVID-19 patients; isn’t

that right? They don’t say it. They are completely consistent with it, aren’t they?

Such passengers would be fairly called “ill”, I take it? 15

MR BUTCHART: Yes.

COMMISSIONER: And you were told there were ill passengers on board.

20

MR BUTCHART: Yes.

COMMISSIONER: And the only question about COVID-19 symptoms showing

were with respect to crew members.

25

MR BUTCHART: Yes.

COMMISSIONER: And you knew the ambulances were being sought for

passengers.

30

MR BUTCHART: Yes.

COMMISSIONER: So the answers are completely consistent with COVID-19

being a reason for the ambulances being sought, isn’t it?

35

MR BUTCHART: Yes.

COMMISSIONER: Now, let me make it crystal clear. I’m not suggesting that’s

why the ambulances were sought. I’m trying to understand your thought process on

the night. Can you tell me anything else about, first of all, do you recall consciously 40

thinking, when you got these answers, “Well, that’s a relief. There’s no need to be

concerned about COVID-19 on that ship.” Did you really think that?

MR BUTCHART: I – these questions were specific for our pilot. I – I strongly

believed that the passenger arrangements would have been dealt with appropriately 45

on the shore side.


MR KIRBY

COMMISSIONER: By “on the shore side”, you mean - - -

MR BUTCHART: Between the other agencies.

COMMISSIONER: Any one or more of agriculture, ABF - - - 5


COMMISSIONER: - - - and New South Wales Health; is that correct?

10

MR BUTCHART: That’s – that’s correct.

COMMISSIONER: And for anything acute, the ambulance?

MR BUTCHART: That’s correct. These questions were developed specifically 15

with our pilots to give - - -

COMMISSIONER: No. I understand that. I - - -

MR BUTCHART: - - - give them some reassurance. 20

COMMISSIONER: No. I understand that. And would it have made any difference

to what you contributed to the decision-making that night if you had been told from

the ship that there are no crew members showing symptoms of COVID-19, but there

are some passengers who may well have COVID-19. Swabs have been taken, but 25

can’t be tested until we get on shore. Would that have made any difference to you?

MR BUTCHART: I would have certainly raised it with the CM – with our crisis

management team, but I believe we would have still moved that ship putting

appropriate barriers in place for our pilot. 30

COMMISSIONER: Now, when these questions are sent and answered, may I take

that you expect that they will be answered with the most up-to-date information

Ruby Bridge can supply, is that right?

35

MR BUTCHART: We – yes. The – that’s the reason we – this was – the four hours

notice is a – a notice that we issue to all ships. It’s the ship’s last chance to tell the

port if they’ve got engine problems, propulsion problems. This – that’s really the

last email comm we have. So it was the last chance to get the most up to date health

of a bridge team. 40

COMMISSIONER: Well, the kind of problems you’ve just referred to, they must

come from other questions. They wouldn’t be called up by these six questions,

would they?

45

MR BUTCHART: The propulsion and manoeuvrability?


MR KIRBY

COMMISSIONER: Yes.

MR BUTCHART: Yes, it would be another email. But generically, this – the

guidance that went out with these was it was to be sent with your four hour notice.

So within the four hour notice period. I think the reason you haven’t got those other 5

question is it’s - - -

COMMISSIONER: No. That’s all right. Don’t worry about it.

MR BUTCHART: - - - we’ve yet to receive it. Yes. 10

MR KIRBY: What was your first – when did arrive on the scene ..... did you

actually receive this email with the answers that night? I can’t see on the .....

MR BUTCHART: No. I’m not, but I’m – I have access to the VTS inbox from my 15

home, from my laptop. Generally, I would be copied into these emails. This one, I

wasn’t, and - - -

MR KIRBY: Did you look at it that night?

20

MR BUTCHART: Yes. I would have. Yes. I spoke with the – it was probably the

first question I asked the operator, “Have we received a bio-declaration?”

COMMISSIONER: So when you updated Home Affairs, to whom were you

speaking? 25

MR BUTCHART: I – I have – I have – don’t – I can’t recall the name of the

individual who called me.

COMMISSIONER: Was it a man or a woman so far as you could judge? 30

MR BUTCHART: It was a woman. It was – that – I spoke to them twice. The first

call was a woman and the second call – and the 2 am calls were also a female.

COMMISSIONER: Could you just show me where in your summary document 35

where these two calls are noted?

MR BUTCHART: Sure.

COMMISSIONER: I can see one at 2.15. Home Affairs. 40

MR BUTCHART: There should be another one at 2.

MR KIRBY: 2.20?

45


MR KIRBY

MR BUTCHART: Two – 2 am and 2, I thought it was. There was – there’s two at

2.15, one called Home Affairs and one, Australian Border Force. And then five

minutes later - - -

COMMISSIONER: I’m asking about Home Affairs. You’ve got 2.15. It’s 5

consistently, between the two versions I’m looking at,

Home Affairs contacts me.

Meaning you. Do you see that? 10

MR BUTCHART: Yes. I’m just trying to find the – yes ..... the - - -

COMMISSIONER: It says Home Affairs contacts me. That – your recollection is

that was a woman? 15

MR BUTCHART: It was, but I - - -

COMMISSIONER: And you talked about a second - - -

20

MR BUTCHART: Yes. But - - -

COMMISSIONER: - - - call.

MR BUTCHART: - - - this - - - 25

COMMISSIONER: Did you make the call or did she?

MR BUTCHART: Yes. But this timestamp’s incorrect.

30

COMMISSIONER: No. Did you make the call or did she?

MR BUTCHART: She made the call.

COMMISSIONER: All right. So both calls were made - - - 35

MR BUTCHART: Yes. That’s right.

COMMISSIONER: - - - the woman you understood to be from Home Affairs?

40

MR BUTCHART: Yes. So the – there’s two 2.15s. So the first 2.15 - - -

COMMISSIONER: Yes.

MR BUTCHART: - - - that timestamp is incorrect. It needs to be – it’s – that has 45

been corrected in another version. The next 2.15 was made by a woman from Border


MR KIRBY

Force, who advised me that she was in charge of the disembarkation process at

Circular Quay.

MR KIRBY: A different woman to the first call?

5

MR BUTCHART: I can’t recall. I – it wasn’t – yes. I – a different woman because

they – the first one that happened, I haven’t got the correct time here. We do have it

elsewhere. She advised me she was Home Affairs. The second woman advised me

that she was Border Force and she was in charge of the disembarkation process at the

OP ..... 10

COMMISSIONER: So - - -

MR KIRBY: And behaved in that phone call like she hadn’t just spoken to you 15

minutes earlier to say - - - 15

MR BUTCHART: No. She was specifically concerned about the matter of people

in isolation.

COMMISSIONER: So just let me get it clear, two different people, both apparently 20

female - - -

MR BUTCHART: Yes.

COMMISSIONER: - - - one announcing herself from Home Affairs, one 25

announcing herself from Border Force?


COMMISSIONER: And did either of them speak to you in two separate 30

conversations or not?

MR BUTCHART: Yes. Two separate conversations.

COMMISSIONER: For each of them – that is, four altogether – or two for one and 35

one for the other? How many conversations?

MR BUTCHART: Three. Three with two different ladies.

COMMISSIONER: And in the version of the chronology I’m looking at, 2.15: 40

Home Affairs; 2.15: Border Force; 2.20: Border Force. Is that right?

MR BUTCHART: Yes. But the zero – the 2.15, that’s either a typo or it’s - - -

MR KIRBY: Can I help, because there’s other versions. I can 45

COMMISSIONER: I know.


MR KIRBY

MR KIRBY: - - - turn them up.

MR BUTCHART: That - - -

MR HUTCHINGS: We can provide the right version. 5

MR KIRBY: Well, I will just see whether this is - - -

MR BUTCHART: That’s not correct.

10

MR KIRBY: All right. So you’ve got that. And if we flick over to – still behind

tab 13, Commissioner, but - - -

MR BUTCHART: I believe it would have been midnight, 15. This was where we

got confused with timestamps. 15

MR KIRBY: Okay. There’s an email – if we go further on, there’s an email from

Mr Butchart from Ms Fensom of 19 March 2020 at 11.40 am - - -

COMMISSIONER: Yes. I’ve been using that one. 20

MR KIRBY: ..... 11.34 am, and that has actually got - - -

COMMISSIONER: I have been using that one. Yes.

25

MR KIRBY: - - - 21.50. That Home Affairs contact to me. Is that wrong to - - -

COMMISSIONER: Well, that must be wrong.

MR BUTCHART: That’s wrong. 30

COMMISSIONER: They’re wrong.

MR KIRBY: Yes. It should be 0019 and it’s at paragraph 44 or 44 - - -

35

COMMISSIONER: Well, I don’t know what it should be, but - - -

MR KIRBY: Yes.

COMMISSIONER: - - - that’s another version. That’s a third version. 40

MR KIRBY: There’s another version, if we keep going, I think.

MR BUTCHART: As I said, the ship’s timestamp caused havoc with trying to

create these. 45


MR KIRBY

COMMISSIONER: Are you – sitting here now, are you able to tell us what, so far

as you were concerned, if any, is a written summary of these contacts for which you

are responsible which you think is accurate as to times?

MR BUTCHART: Which version out of the ones you’ve shown me? 5

COMMISSIONER: Yes.

MR KIRBY: Hang on, can we go to the last one? If we turn the page from the one

that has got 21.50, there’s – over the next page, there’s one that mentions 1 am: 10

Home Affairs; 2 am: Border Force and 2.30: ABF .....

COMMISSIONER: Now, I’ve assumed that they were wrong and they’ve been

superseded because that was the earlier version, is that right?

15

MR BUTCHART: No. This last - - -

COMMISSIONER: On 19 March at 10.32, you sent Emma Fensom an incident

report.

20

MR BUTCHART: That’s right. Yes.

COMMISSIONER: You invited her to amend it and change as needed, do you see

that?

25

MR BUTCHART: Yes.

COMMISSIONER: And it has, as Mr Beasley has pointed out, at the end of its list,

1 o’clock in the morning:

30

Home Affairs contacts me.

Do you see that?

MR BUTCHART: Yes. That’s 35

COMMISSIONER: Two o’clock in the morning - - -

MR BUTCHART: Border Force.

40

COMMISSIONER: - - - ABF call me. 2.30 in the morning, ABF call me, do you

see that?

MR BUTCHART: That’s – yes.

45

COMMISSIONER: That has changed in the later version, about which I have

already asked you questions. It has this anomalous notation of a time, 02150 hours.


MR KIRBY

But charitably, that should be read as 0215 hours. Is that correct? Do you see the

entry that reads 02150 hours?

MR BUTCHART: Yes.

5

COMMISSIONER: That must be wrong. Presumably, it should be read as 0215. Is

that correct?

MR BUTCHART: No. It happened a lot earlier in the piece.

10

COMMISSIONER: How should I read those numerals?

MR BUTCHART: I haven’t got - - -

MR KIRBY: I’m wondering if the witness could be given some help by being able 15

to refer to his statement to the police, which has a different version or – you may

want to explore without that, but in case - - -

COMMISSIONER: In fact, I do. Yes.

20

MR KIRBY: Right.

MR BUTCHART: The – we got – the creating of the document with the timestamps

and our own internal phone recording device, which has actually resulted in us

purchasing another device because of the timestamping caused a lot of confusion in 25

the creation of this document, which had me - - -

COMMISSIONER: Well, no doubt - - -


COMMISSIONER: - - - we will be investigating further, but as you sit here now,

how many calls do you recall getting from somebody calling themselves Home

Affairs?

35

MR BUTCHART: One from Home Affairs and I believe it was around midnight,

not 02 am. The next two are correct, 2.15 and 2.30, those times are precise within

five or 10 minutes.

MR KIRBY: Well, as you say, precise within five or 10 minutes, I’m sorry, that’s 40

not my understanding of precision at all. In one version you’ve got 2.15 to 2.30 and

another version you’ve got 2.15 to 2.20, which is of some significance because in

one version you’ve got 2.29:

The Ruby Princess is secure at berth. 45

Is that right? What time did the pilot go on?


MR KIRBY

MR BUTCHART: 0100. 0100, to my recollection.

COMMISSIONER: I take it that the ABF called you and advised you that the ship

was clear to go alongside before the ship was secure at berth?

5

MR BUTCHART: The ABF called me when the vessel was rounding Bradleys

Head.

COMMISSIONER: The answer to my question is, “Yes,” I take it?

10

MR BUTCHART: Yes. I then advised that lady – I looked, I opened my iPad to

check where the vessel was and I advised her, “If you want to turn this vessel around,

you’ve got about 20 minutes. We could still turn her around between Bradleys

Head.”

15

COMMISSIONER: No, no, no, you’re not listening to my question. The second

call from ABF advising that the ship was clear to go alongside. That call came

before the ship was secure at berth?

MR BUTCHART: It was before the ship was alongside the berth. I would have 20

stopped the vessel, waiting for that phone call, but there was no need. It was an easy

location to stop the vessel.

COMMISSIONER: Quite. Your version of the chronology that says:

25

2.29 is when the Ruby Princess was secure at berth.

I take it that’s not complicated by New Zealand time differences?

MR BUTCHART: No, no. 02:29. 30

COMMISSIONER: So 2.30 for ABF calling you to advise the ship was clear to go

alongside couldn’t be right, could it?

MR BUTCHART: No, it’s not. It’s not correct. 35

COMMISSIONER: I see in that version I’ve asked you about; that call is now

assigned 2.20. Do you see that?


COMMISSIONER: Do you ask me to prefer 2.20 to 2.30 for that second ABF call?

MR BUTCHART: Yes, please.

45

COMMISSIONER: Does it accord with your recollection that it’s about five

minutes between the first ABF call and the second ABF call?


MR KIRBY

MR BUTCHART: Yes, that’s about – yes.

COMMISSIONER: During that first ABF call, do you think you were told to whom

you were speaking?

5

MR BUTCHART: The best – I think her name was Lisa and she advised me that

she was in charge, that’s all, of the disembarkation process at the OPT.

COMMISSIONER: Now, you can take this as critically as you like. Do you and

ABF really deal with each other on the telephone with first names only when you 10

don’t know each other?

MR BUTCHART: I never deal with ABF. That’s my first - - -

COMMISSIONER: Does that not prompt you to believe that you were told by the 15

person who telephoned you, claiming to be from ABF, you were told her name, that

is, first and last name?

MR BUTCHART: I can’t remember her name.

20

COMMISSIONER: Would you really have dealt with somebody saying “Hi, I’m

Lisa from ABF. Tell me about the ship.” Why would you respond to that?

MR BUTCHART: She introduced herself as the individual in charge of the

disembarkation process and her main concern was what she was going to tell her 25

staff about the amount of people in isolation. That was her biggest concern.

COMMISSIONER: Her staff? ABF staff?

MR BUTCHART: Her staff. Her main concern was what she was to tell her staff 30

about the amount of people in isolation.

COMMISSIONER: Do you think she told you her name? Not just “Lisa,” I mean.

MR BUTCHART: I – I – no. 35

COMMISSIONER: You don’t think she did?

MR BUTCHART: I don’t recall.

40

COMMISSIONER: Did you make any note of this dealing?

MR BUTCHART: No, I didn’t.

COMMISSIONER: Was it only by memory that you set it down in a summary 45

chronology?


MR KIRBY

MR BUTCHART: No. I recall it happening. It was - - -

COMMISSIONER: No, no, no. Was it only from memory that you put it down in a

summary chronology? Did you have any record of any kind that you drew on in

preparing this chronology? 5

MR BUTCHART: No.

COMMISSIONER: Just your memory?

10

MR BUTCHART: Yes. Well, I was able to ascertain Bradleys Head as a key part

to that phone call - - -

COMMISSIONER: I’m just asking about your – all you had was your memory?

15

MR BUTCHART: Yes.

COMMISSIONER: And you were doing it that same morning, preparing this

chronology, the morning of 19 March?

20

MR BUTCHART: Yes.

COMMISSIONER: And did you make any attempt to find out to whom you had

spoken, by using your telephone, for example?

25

MR BUTCHART: No. We have tried to obtain call records and we haven’t been

able to.

COMMISSIONER: What do you mean? You don’t have records for your

telephone? 30

MR BUTCHART: It was a received phone call so it’s not on the telephone bill.

COMMISSIONER: Did it call a landline or a mobile?

35

MR BUTCHART: It called my mobile phone.

COMMISSIONER: I see. Have you made any attempt since 19 March to find out

to whom it was you spoke?

40

MR BUTCHART: No, I haven’t.

COMMISSIONER: I take it since 19 March, the significance of the ABF calling to

advise that the ship is clear to go alongside has appeared quite large to you?

45

MR BUTCHART: Yes, it has.


MR KIRBY

COMMISSIONER: Have you made any efforts to find out who it was who told you

that?

MR BUTCHART: Not personally, no.

5

COMMISSIONER: What do you mean by “not personally?”

MR BUTCHART: Well, we had a crisis management team dealing with this crisis

on itself, doing – you know, other – I’m not a part of. They were fully aware - - -

10

COMMISSIONER: Who was in charge of the CMT?

MR BUTCHART: Emma Fensom.

COMMISSIONER: Have you discussed with her at any stage finding out who it 15

was, claiming to be from ABF, to whom you spoke?

MR BUTCHART: I’ve raised the question many times throughout the Port

Authority with various people.

20

COMMISSIONER: Why have you raised it many times?

MR BUTCHART: Because I’ve wanted to clarify these phone calls.

COMMISSIONER: And have you received any information? 25

MR BUTCHART: No, I have not.

COMMISSIONER: Does that strike you as unsatisfactory?

30

MR BUTCHART: Yes, it does.

COMMISSIONER: Have you complained about it to Emma Fensom?

MR BUTCHART: Not directly, not directly. 35

COMMISSIONER: Why not?

MR BUTCHART: I don’t – I don’t talk with Emma on a daily basis. I don’t report

through to Emma. 40

COMMISSIONER: That’s not – that doesn’t seem to me to be a reason not to

complain to somebody. Why haven’t you complained to her if you thought it

unsatisfactory that you have not been able to be informed who it was to whom you

spoke, claiming to be from ABF, clearing the ship to go alongside. 45


MR KIRBY

MR BUTCHART: It has certainly been – it has certainly been a concern but I’ve –

this week it’s hard to – it was just so busy and - - -

COMMISSIONER: Which week are you talking about?

5

MR BUTCHART: The last – this week primarily. This – just this day.

COMMISSIONER: You mean the week which includes 19 March, you mean?

MR BUTCHART: Yes, that’s correct. 10

COMMISSIONER: Has Emma Fensom told you not to worry about who it was to

whom you spoke at ABF or words to that effect?

MR BUTCHART: No, she has not, but I’ve got no direct contact through CMT or 15

any kind of relationship for that matter.

COMMISSIONER: Crisis management, relevantly, you understood to be finding

out what happened that produced the Ruby Princess event; is that correct?

20

MR BUTCHART: Crisis management team was set up previous to Ruby Princess

to deal specifically with COVID-19.

COMMISSIONER: Perhaps you could answer my question. Crisis management

was going to find out what exactly happened with the Ruby Princess; is that right? 25


COMMISSIONER: That’s why it had been set up, to deal with such things as they

occurred; is that correct? 30


COMMISSIONER: Have they ever been – has anyone, on behalf of CMT, been in

touch with you concerning with whom you spoke claiming to be from ABF? 35

MR BUTCHART: No, they haven’t.

COMMISSIONER: Do you know any name or names of the CMT who would be

carrying out those investigations? 40

MR BUTCHART: I know people on – everybody on the CMT.

COMMISSIONER: They are?

45

MR BUTCHART: We’ve got Sharad Bhasin, Jeanine Drummond from Newcastle,

Bruce Cooper from Newcastle, Emma from Newcastle, John Paul Babbington from


MR KIRBY

Sydney and Sarah Marshall. There’s somebody from Crews and Finance, I believe

as well.

COMMISSIONER: And none of them or anyone on their behalf has ever been in

touch with you to find out about who it was you spoke to claiming to be from ABF. 5

MR BUTCHART: No.

COMMISSIONER: Do you have any information about whether they have

ascertained who that person was by other sources? 10

MR BUTCHART: I’ve raised concern about the phone call, because I – I’ve read

about the phone call in media outlets as well. I’ve certainly - - -

COMMISSIONER: Well, you were involved in the phone call. 15

MR BUTCHART: Yes. I understand. And I’ve certainly showed concern around

the phone call.

COMMISSIONER: Is there anything in the media reports of the phone call that you 20

thought was wrong?

MR BUTCHART: No. I was – I was I guess relieved that – if you believe the

media, one of the articles said that Border Force had agreed the phone call took

place. 25

COMMISSIONER: You mean you were relieved that - - -

MR BUTCHART: I took that as evidence that the phone call took place, yes.

30

COMMISSIONER: So far as you’re concerned, it’s your memory that constitutes

the evidence, isn’t it?

MR BUTCHART: Yes, that’s right.

35

COMMISSIONER: And you’re relieved that it did not appear that ABF was

denying it.

MR BUTCHART: When I read the report, yes, that’s right.

40

COMMISSIONER: Doing the best you can, tell me what was said in this first

conversation in which the subject matter included a concern about the number of

people in isolation.

MR BUTCHART: The – her concern was how she would relay this to her staff was 45

her primary concern.


MR KIRBY

COMMISSIONER: You better help me understand that. You can relay information

to people by telling them something. What - - -

MR BUTCHART: I - - -

5

COMMISSIONER: Do you mean it was sensitive or - - -

MR BUTCHART: I believe she felt it was sensitive for her staff and she hadn’t

seen this many people in isolation on board a ship before.

10

COMMISSIONER: So a formidable if not overwhelming task for the staff. Is that

the impression - - -

MR BUTCHART: That’s the impression - - -

15


MR BUTCHART: The impression I got was her staff weren’t going to be well

received to this information when she alerted them on it.

20

COMMISSIONER: What, an industrial problem?

MR BUTCHART: That’s – that’s – yes, that’s how I sensed it.

COMMISSIONER: Well, it was in that context that she, as you recall it, alerted you 25

that the ship may need to go back to sea.

MR BUTCHART: No. I advised her if it was an issue we could send – we could

still send the ship back to sea. We could still safely manoeuvre the ship within the

port limits and get her back to sea. 30

COMMISSIONER: Did she alert you that the ship may need to go back to sea?

MR BUTCHART: She was going to speak to her supervisor and call me back.

35

COMMISSIONER: Did she alert you that the ship may need to go back to sea?

MR BUTCHART: No. I was - - -

COMMISSIONER: Well, have a look at your document, please. Do you see the 40

entry, the second entry for 2.15? Its second line.

MR BUTCHART: Yes.

COMMISSIONER: Did she or did she not, as you recall her words, alert you that 45

the ship may need to go back to sea?


MR KIRBY

MR BUTCHART: Yes, she did.

COMMISSIONER: Why did you tell me just not a minute ago that she didn’t?

MR BUTCHART: To the best of my knowledge, that’s what the phone call was. 5

But I was - - -

COMMISSIONER: Well, now, I don’t have an interest one way or the other. I

want to know your memory. Does your memory include her saying something that

you’ve understood as an alert to you that the ship may need to go back to sea, or not? 10

MR BUTCHART: No, it was – look, I don’t recall. It was definitely stated that I

could send that ship back to sea. Look - - -

COMMISSIONER: Did you tell her in effect to act as soon as possible because the 15

ship was within port limits?

MR BUTCHART: That’s right, yes.

COMMISSIONER: Do I understand that as meaning although it was not too late for 20

the ship to go back to sea, it soon would be in terms of safety and manoeuvrability?

MR BUTCHART: We – it had a limited scope of passage. Once it reached Fort

Denison, it would have got quite difficult to do the manoeuvre, so I was looking at it

purely from it’s at Bradleys now, we should be able to do that manoeuvre with one 25

tug and spin her at Circular Quay back to sea. If I hadn’t have received that phone

call back, I would have – we would have – we could have held that ship with one tug

off Circular Quay anyway. The phone call came back quick enough, and she said

keep going. That was it.

30

COMMISSIONER: The way that reads in your typed summary, it was a call from

Border Force as to whether the ship would come alongside or not. Do you agree?

MR BUTCHART: It was definitely Border Force. Yes.

35

COMMISSIONER: Before that first telephone call from Border Force, what was

your personal understanding in your professional position of the authority that

Border Force had in relation to permitting or prohibiting a ship coming alongside

MR BUTCHART: In my professional opinion, it’s – everything Border Force does 40

is – is once the ship is alongside. That’s where documents - - -

COMMISSIONER: I don’t know that that’s an answer to my question. Would you

like to answer my question, please.

45

MR BUTCHART: Can you please ask it again.


MR KIRBY

COMMISSIONER: What was your understanding of the authority of ABF to permit

or prohibit a ship coming alongside?

MR BUTCHART: My understanding is – no. It’s – it’s – none. It’s just passenger

control. 5

COMMISSIONER: So why didn’t you tell this person from ABF, “You can deal

with these passengers when they’re disembarking, but I’m the person in control of

vessel traffic. This ship is cleared to dock and so it is going to do”?

10

MR BUTCHART: That’s not what I told her.

COMMISSIONER: No. I know it’s not. Why – why is it not what you told them

if, as you’ve just told me, you didn’t think ABF had any authority to stop it from

docking? 15

MR BUTCHART: Because I could tell at this stage there was a – a serious – she

had concerns of the amount of people in isolation, and I – I don’t have – in all my

time as a harbourmaster, I – I don’t deal with ABF or Health. That’s a process that’s

not – that I’m not across. 20

COMMISSIONER: All the more reason for me trying to find out from you why did

you pay her any attention that night?

MR BUTCHART: Because she had a – she had a concern about these people in 25

isolation, and I – the best thing I felt I could do was say, “Well, if you’re not ready

for it, I can send this – this back to sea.”

MR KIRBY: Mr Butchart, you had given some indication before of your time as a

seaman on the bridge of large vessels. 30

MR BUTCHART: Yes.

MR KIRBY: You mentioned that whenever you came into port, the first people on

the ship, I think you said, were Customs or Border Force or something like that. 35

MR BUTCHART: Generally both, yes.

MR KIRBY: Right. So you understood the notion of pratique.

40

MR BUTCHART: Yes, I did.

MR KIRBY: Who do you think had the power to grant or withdraw that?

MR BUTCHART: Agriculture. 45

MR KIRBY: Pardon?


MR KIRBY

MR BUTCHART: The Department of Agriculture.

MR KIRBY: Right.

COMMISSIONER: The biosecurity people. 5

MR BUTCHART: Biosecurity, yes.

COMMISSIONER: By that, do you mean and not ABF?

10

MR BUTCHART: My – my – my opinion – how I – how I – how I believe it occurs

is that Health would be advising – this is totally my opinion – would be advising

Border Force that those – that they meet the criteria to disembark the vessel.

COMMISSIONER: And when you say “Health”, you mean agriculture biosecurity 15

or do you mean human biosecurity officers or - - -

MR BUTCHART: The names change so many times, but - - -

COMMISSIONER: Simplifies - - - 20

MR BUTCHART: Agriculture - - -

COMMISSIONER: Agriculture, yes.

25

MR BUTCHART: - - - would be advising ABF. It would be a lot like my process

that I have. If – if the ship has tugboats, linespeople, agency in place, pratique has

been cleared, I – I allow the vessel to enter the port. I – I strong believe that Border

Force probably acted in the same manner, that certain – once certain criteria was met,

that they allow people to disembark a vessel, but it’s not something that – we move 30

6000 ships a year. It’s not something that I have ever been drawn into.

COMMISSIONER: Did you think this ship had pratique before ABF rang you?

MR BUTCHART: It had been cleared pratique inside our SHIPS – SHIP system. 35

Yes.

COMMISSIONER: And does it follow from that that you did not regard ABF as

affecting pratique?

40

MR BUTCHART: Yes, but I – as I – I believe that ABF were probably making the

final call based off what they got from Health.

COMMISSIONER: What do you mean by “final call” after pratique has been

granted? 45


MR KIRBY

MR BUTCHART: Well, I – I – I guess that they’re not going to stamp somebody’s

passport and let them off the ship if for some reason they’re a hazard to – or they

shouldn’t be off the ship.

COMMISSIONER: But you don’t understand pratique as involving passport 5

control, do you?

MR BUTCHART: No, but I understand that – I’m sure Border Force would need

certain mechanisms before they do passport control, but - - -

10

COMMISSIONER: Yes, but passport control arrives – arises upon disembarkation.

Isn’t that right?

MR BUTCHART: I believe so, yes.

15

COMMISSIONER: Pratique is the permission that permits the ship to come

alongside before disembarkation. Isn’t that right?

MR BUTCHART: Yes.

20

COMMISSIONER: And then to proceed to disembark: correct?

MR BUTCHART: I don’t – don’t fully understand the pratique process. Sorry.

COMMISSIONER: Isn’t that your understanding of what “pratique” means? 25

MR BUTCHART: Yes, that it meets - - -

COMMISSIONER: Permission – permission to dock and disembark or unload.

30

MR BUTCHART: It meets their criteria to disembark, yes, whatever that may be.

COMMISSIONER: But you understand passport control is a matter for Border

Force distinct from pratique. That has always been your understanding, hasn’t it?

35

MR BUTCHART: Yes.

COMMISSIONER: I’m still interested to know, and so far haven’t been told by

you, in what sense you thought that Border Force had the final word on whether the

ship could come alongside. Are you able to help us about how you thought about 40

that on that night?

MR BUTCHART: I was willing to address her concerns. She had concerns about

the amount of people in isolation. I was willing to address her concerns and – if she

had have called back and said, “I’ve spoken to my superior, and do not bring that 45

ship alongside. We have issues,” I would have sent that ship back to sea.


MR KIRBY

COMMISSIONER: Why? As a matter of law, what authority would you think you

were exercising in so doing?

MR BUTCHART: I – I certainly would have run it through our CMT, but I - - -

5

COMMISSIONER: Well, let me – I don’t know if this will make it easier or not.

Did you think you had any authority with respect to health clearance?

MR BUTCHART: No.

10

COMMISSIONER: Did you think ABF did?

MR BUTCHART: No.

MR KIRBY: Well - - - 15

COMMISSIONER: You hesitated with that last answer. Are you unsure?

MR BUTCHART: I – I – I was of the opinion that ABF wouldn’t be clearing

passengers unless they had some kind of reassurance from Health that they’re 20

suitable to be – suitable to be cleared.

COMMISSIONER: You mean that’s for the safety of ABF personnel?

MR BUTCHART: I honestly don’t understand 100 per cent, but I would have 25

thought as well the safety of releasing them into the community and things like that.

I was – I was of the opinion there must be very good processes happening shoreside

to disembark these passengers, and then I’m getting alerted at 2 am that there’s all

these concerns with – with isolation and health and the best thing I can do is offer,

“Well, if – if you don’t want the ship, we can send it back to sea.” 30

COMMISSIONER: Now - - -

MR BUTCHART: “I can remove that for you.”

35

COMMISSIONER: The second call that you think came about five minutes later.

You recollect that it sounds as if it was the same person who had spoken to you?

MR BUTCHART: It was the same person. Yes.

40

COMMISSIONER: Yes. And how long did the second call take?

MR BUTCHART: Very - - -

COMMISSIONER: Well, I suppose your phone records will tell us that, but - - - 45


MR KIRBY

MR BUTCHART: Very short of – “I’ve spoken to –” she had made inquiries

internally and – and to please bring it alongside.

COMMISSIONER: And did she tell you of whom she had made inquiries?

5

MR BUTCHART: No. I don’t – don’t – there was – no. I don’t - - -

COMMISSIONER: You say “internally”. Do you mean at the Commonwealth

level, at the State level, onshore, what?

10

MR BUTCHART: I don’t – I don’t know. I didn’t – I didn’t – did not ask. I - - -

COMMISSIONER: What are the words you remember, doing the best you can, that

lead you now to paraphrase that as “internally”?

15

MR BUTCHART: Well, she – she was unable to make the decision to send the

vessel back to sea, so she needed to speak with somebody who, I believe, probably

could have made that decision. And she called back and said, “I’ve – keep – please

keep it coming.”

20

COMMISSIONER: Did she tell you who it was - - -

MR BUTCHART: No, she didn’t.

COMMISSIONER: - - - if anyone else, to whom she had spoken? 25

MR BUTCHART: No, she – she didn’t. It was – I was in bed. It was – I – I think

she understood I was in bed. It was just a quick phone call, and I think - - -

COMMISSIONER: Thank you. 30

MR KIRBY: Mr Butchart, you mentioned before when you were talking about

health that you meant Agriculture and Biosecurity.

MR BUTCHART: Mmm. 35

MR KIRBY: And you thought that there might be some communication between

biosecurity and ABF. Do – do you remember giving that answer before?

MR BUTCHART: Yes, I do, yes. 40

MR KIRBY: Is it the case that instinctively when you got a call from ABF,

knowing that that’s a commonwealth authority and knowing – and – and – well, I

withdraw that last bit. Knowing it’s a Commonwealth authority and who they are,

did you just instinctively defer to them without really thinking it through about 45

powers or whatnot and would have, if they had asked you to stop the ship and turn it

around, done that and then work out any difficulties later? I’m just wondering about


MR KIRBY

your thought process. When you got the call from ABF, was it the fact of – that

they’re a commonwealth agency that you thought may have some power to order the

ship not to dock. Is that what you were – in your mind, deferring to?

MR BUTCHART: Yes. 5

COMMISSIONER: What, you’re suggesting some pervasive appreciation of

section 109 of the constitution? Don’t – don’t - - -

MR KIRBY: Well, it’s hammered into us, Commissioner. 10

COMMISSIONER: Don’t worry, Mr Butchart. I shouldn’t have said that. Can I –

can I ask you this, please, did you in your answers to what I understand to be a

different woman from calling herself from Home Affairs, did you explain in the

course of the conversation that you’ve summarised as advising them of everything 15

above, did you explain that so far as you understood from the New South Wales

Health point of view it was fine for the ship to come alongside and commence

disembarkation?

MR BUTCHART: I would have - - - 20

COMMISSIONER: That is, New South Wales Health had deemed it low risk.

MR BUTCHART: That – that’s – that - - -

25

COMMISSIONER: Do you recall saying that to the person from Home Affairs,

supposedly? I’m trying to understand. You see, your summary form reads as

follows:

CB advises them of everything above. 30

I don’t take that literally, but that’s not a criticism. But do I – I imagine it includes,

does it?

MR BUTCHART: I’m just not - - - 35

COMMISSIONER: That there’d been a problem about the ambulance

understanding of the position and the ship’s view of the position, but the New South

Wales Health had deemed it low risk.

40

MR BUTCHART: Well, that’s – that – that was the information I had. I can’t see

why I wouldn’t of advised - - -

COMMISSIONER: That’s right. That’s fine. But you - - -

45

MR BUTCHART: Advised them of – of that at the time and everything that I knew

at – at that stage.


MR KIRBY

COMMISSIONER: Righto. That’s right ..... did you have a similar – did you

impart similar information to this different person from border force?

MR BUTCHART: I – I alerted that we had the – I can’t a hundred – recall 100 per

cent if I said New South Wales Health, but I certainly alerted her to what had 5

happened earlier with the ambulances. But her number one concern was the people

in isolation.

COMMISSIONER: Now, with Home Affairs contact to you - - -

10

MR BUTCHART: Mmm.

COMMISSIONER: - - - how did that conversation end so far as you were

concerned? Did you – the person - - -

15

MR BUTCHART: It was just a sit-rep basically. It was just a – what – I don’t even

know how they got my number. I’m suspecting they got it from the water police. It

was just a - - -

COMMISSIONER: So a situation report? 20

MR BUTCHART: Just a – a sit-report of what was going on at that – after that time

and - - -

COMMISSIONER: You weren’t told, were you, anything to the effect of that 25

they’d get back to you - - -

MR BUTCHART: No.

COMMISSIONER: - - - they’ll think about it or - - - 30

MR BUTCHART: Nothing.

COMMISSIONER: There didn’t appear to be unfinished business as far as you

were concerned, is that right? Or not? 35

MR BUTCHART: Look, I – I – I - - -

COMMISSIONER: This is Home Affairs, not Border Force.

40

MR BUTCHART: Yes. I – I alerted that everything had happened and it was our

understanding that it was a miscommunication with the ambulance authorities.

MR KIRBY: Commissioner, I don’t know whether it’s the witness’s best

recollection or the circumstances in which it was taken, but the witness has very 45

recently, as you’re aware, given a statement to the police.


COMMISSIONER: Yes.

MR KIRBY: And this matter is dealt with in paragraph 44 where there’s a version

given, and the latter matter with ABF is in paragraph 52, just in case you want to

explore that with Mr Butchart today. 5

COMMISSIONER: No. But Mr Kirby may want to. I’m not suggesting you

should.

MR KIRBY: There was only one more question that I wished to ask for today’s 10

purpose, Commissioner.

COMMISSIONER: Yes. Thank you.

MR KIRBY: And that, Mr Butchart, is you don’t mention in your statement, and I 15

just want to know whether it is the case, that you had no direct communications with

either the ship or anyone from Carnival, including its port agents, on – about the

Ruby Princess on 18 and 19 March.

MR BUTCHART: I very, very rarely ever have a contact aboard the ship. I always 20

deal directly with the ship’s agent. I did try to notify various agents that night, which

I could not.

COMMISSIONER: But Mr Kirby’s question was did you have any contact with

anybody on the ship or at the company. 25

MR BUTCHART: No, I could not raise anybody. Our VTS raised the ship, but not

myself personally.

MR KIRBY: Yes. Thank you. 30

COMMISSIONER: Thank you. Now, you’re excused from the summons for today,

but it is quite likely that you will be called back to give what might be called a more

complete version.

35

MR BUTCHART: Okay. Thank you.

COMMISSIONER: And thank you very much for your assistance this afternoon.

MR BUTCHART: Thank you. 40


45

MR BEASLEY: I think Mr Hutchings has mentioned preparing a chronology to

assist, which might be helpful.

.RUBY PRINCESS INQUIRY 1.5.20R2 P-243 K. RESSLER XN

MR BEASLEY SC

MR HUTCHINGS: Commissioner, we’ve wrestled with the issue of the time

stamps, and we’ve actually worked it out, so if we could provide a copy of assistance

to the Commission.

COMMISSIONER: That would be extremely helpful. I would be much obliged. 5

MR BEASLEY: Can we adjourn for five minutes, Commissioner - - -

COMMISSIONER: Yes.

10

MR BEASLEY: - - - given (a) the time and (b) I would like to have a brief

discussion with you about something else before we do anything.

COMMISSIONER: Yes. So we will adjourn for about five minutes.

15

ADJOURNED [4.22 pm]

RESUMED [4.27 pm] 20

COMMISSIONER: I will just repeat that, earlier this afternoon, I made directions

that this hearing be private and that until further order, there be no publication of the

evidence given at it and that, for clarity’s sake, means there is to be no 25

communication to anybody not in this room of that evidence, again, until further

direction. I’ve also directed that there may be present during this private hearing Ms

Furness of Senior Counsel and Ms Lindeman for New South Wales Health and

Messrs Woodhouse and Cessario from the solicitors, as well as Mr Ressler and

Deanne Tadros. Mr Beasley. 30

<KELLY-ANNE RESSLER, AFFIRMED [4.28 pm]

35

<EXAMINATION-IN-CHIEF BY MR BEASLEY SC


40

MR BEASLEY: Thank you. Ms Ressler, my name’s Richard Beasley. I’m one of

the counsel assisting with the inquiry. And you’ve just heard from Mr Kirby and

neither of – neither of us are responsible for the fact that you’ve been delayed. But

we apologise anyway.

45

MS K.A. RESSLER: That’s fine.


MR BEASLEY SC

MR BEASLEY: I understand that you have a – I should say, I’ve been supplied this

afternoon with a copy of a statement that you’ve given dated today’s date. I have

only skimmed through that and skimmed through the annexures that were provided

to it. Many of the annexures, though, I have seen before. Please don’t be concerned

if I don’t go through every single one of those annexures. I’m sure the 5

Commissioner will, but I may not today. And even he may not. Can I begin with

you have a Bachelor of Science Degree; is that right?

MS RESSLER: That’s correct.

10

MR BEASLEY: And Nutrition?

MS RESSLER: Yes.

MR BEASLEY: And a Masters of Public Health. 15


MR BEASLEY: And you have – how long have you been employed by the New

South Wales Department of Health in the South Eastern Sydney Public Health Unit. 20

MS RESSLER: 22 years in August.

MR BEASLEY: And you have, for some time, had particular responsibility in

relation to health issues involving cruise ships. 25

MS RESSLER: That’s right. Since 2004.

MR BEASLEY: Thank you. All right. I want to go straight to asking you some

questions about the Ruby Princess, which I’m sure is a vessel you’re familiar with. 30

MS RESSLER: Yes.

COMMISSIONER: Just before we do - - -

35

MR BEASLEY: Yes.

COMMISSIONER: I’ve read paragraphs 10 and 11 of your statement and you may

be assured that you will be given, in due course, any opportunity to supplement or

alter - - - 40

MS RESSLER: Okay.

COMMISSIONER: - - - parts of the statement that may arise after you’ve seen

more detailed records. Please don’t concern yourself about that. I will tell you, if 45

I’m administering a memory test, generally speaking, not. Otherwise, the statement

with that important qualification is true to the best of your knowledge and belief?


MR BEASLEY SC

MS RESSLER: It is.

COMMISSIONER: We’ll mark that for identification 3, please.

5

MFI #3 STATEMENT OF KELLY-ANNE RESSLER

MS FURNESS: Commissioner, might I just indicate that there’s a word missing at

– on page 21, paragraph 102, sub-paragraph (2), the second-last line. There should 10

be “and” between “arrival” and “should”.

MR HUTCHINGS: Sorry. I just missed which paragraph you’re - - -

COMMISSIONER: That’s where I’ve got a question mark. 15

MR HUTCHINGS: 102(2) - - -

MS FURNESS: Yes. Well picked.

20

COMMISSIONER: ..... checked again.

MR HUTCHINGS: Yes.

MR BEASLEY: And does the MFI assume, Commissioner, includes all the 25

annexures - - -

COMMISSIONER: So that’s and, a-n-d?

MS FURNESS: A-n-d. 30


MR BEASLEY: The MFI will include the annexures - - -

35

COMMISSIONER: Yes.

MR BEASLEY: - - - to the statement? Yes. Thank you. What I wanted to take

you to first, Ms Ressler, was – it’s in a different part of the documents I have, but

Commissioner, do you have the exhibits? 40

COMMISSIONER: I do.

MR BEASLEY: Yes. Exhibit 9.

45

MS RESSLER: Is that in this folder that was here?


MR BEASLEY SC

MR BEASLEY: No. Exhibit 9 of your statement.

MS RESSLER: My statement.

MR BEASLEY: Yes. I will try as far as possible to use that because - - - 5

MS RESSLER: Okay.

MR BEASLEY: - - - the other bundle isn’t paginated, which makes it a little bit

difficult to navigate around. If we go – right. But this is about the ship coming in – 10

prior to the ship coming in when it berthed on 8 March at the end of its 24 March

cruise. And I see that you have asked a series of questions of the ship’s doctor in an

email of 6 March sent at about 12.58 pm, correct? If you go to pages 4 and 5, you

will see - - -

15

MS RESSLER: Yes. I see.

MR BEASLEY: - - - a whole list of questions. Can I just ask that list of questions

and seeking information and including number 1, the full acute respiratory disease

log, etcetera. Were these questions formulated by New South Wales Health or are 20

they in conjunction with advice from the Federal Health Department or were they

questions formulated by you and the team you work in?

MS RESSLER: The questions were based on the policy document and I believe

that’s a New South Wales Health document. 25

MR BEASLEY: The COVID-19 - - -

MS RESSLER: That’s right.

30

MR BEASLEY: - - - document? There’s – I think there was one created on 19

February.


35

MR BEASLEY: Did you have a role in assisting in preparing that – they’re

guidelines, really, for cruise lines, correct?

MS RESSLER: And for health personnel.

40

MR BEASLEY: And for health personnel, but did you have a role in - - -

MS RESSLER: No. I don’t believe I did. I possibly was sent a version to comment

on - - -

45

MR BEASLEY: Right.


MR BEASLEY SC

MS RESSLER: - - - but I didn’t have a role in drafting it or a large role in any

comment made.

MR BEASLEY: All right. And although we’re out of chronological order, there

was some enhanced – an enhanced protocol on 9 March. Did you have any role in 5

- - -

MS RESSLER: No. I didn’t.

MR BEASLEY: - - - giving advice about how that should look? 10

MS RESSLER: I believe I was sent a draft for comment.

MR BEASLEY: Right. All right. Did you make any comments about it?

15

MS RESSLER: Can I just check that document that you’re talking about?

MR BEASLEY: Sure.

MS RESSLER: Sir. 20

MR BEASLEY: It’s probably in here. I’ll have it - - -

MS RESSLER: In - - -

25

MR BEASLEY: - - - in a different spot. But - - -

MS RESSLER: It’s in one.

MS FURNESS: It’s in tab – tab 1. 30

MR BEASLEY: - - - if she goes to tab – tab 1. Tab 1. Tab 1.5. 1.5.

MR ..........: Oh, sorry, this is in - - -

35

MS FURNESS: Tab one of the file.

MR BEASLEY: So tab - - -

MR ..........: Oh. 40

MR BEASLEY: - - - tab one of your annexures, I think, is the one – the first draft,

19 February 2020. Correct?

MS RESSLER: Yes. 45


MR BEASLEY SC

MR BEASLEY: Can I just – while we’re at it, this document – it’s not – it doesn’t

have page numbers. But if you go to the one, two, third page, its starts talking about

a risk assessment. Says:

High risk, medium risk, and low risk. 5

MS RESSLER: Yes.

MR BEASLEY: Both of the high risk and medium risk assessments, amongst other

things, talk about respiratory outbreaks affecting at least one per cent of those on 10

board. You see that?

MS RESSLER: Yes. Yes, I do.

MR BEASLEY: First of all, what is – what should the Commissioner understand by 15

the term, “Respiratory outbreak?”

MS RESSLER: My understanding is that a respiratory outbreak are cases of

influenza like illness.

20

COMMISSIONER: Why would respiratory outbreak as a matter of ordinary

English not include acute respiratory illness?

MR BEASLEY: Disease, I think it’s called.

25

COMMISSIONER: No. Acute respiratory illness.

MR BEASLEY: All right. ARI.

MR ..........: Yes. 30

MS RESSLER: I think it’s an unfortunate term that was used.

COMMISSIONER: It may well be. You may well think so. I – I want - - -

35

MS RESSLER: But in - - -

COMMISSIONER: - - - can you please answer my question. Why would it not

include acute respiratory illness?

40

MS RESSLER: Because acute respiratory illness isn’t a reportable condition for a

cruise ship, and - - -

COMMISSIONER: Why does that mean that the expression “respiratory outbreak”

would not include “acute respiratory illness”? 45


MR BEASLEY SC

MS RESSLER: So in my experience with the cruise ship program, we only ever

responded to influenza-like illness outbreaks.

COMMISSIONER: But you may be actually just rephrasing my question. I’m

asking you why. When the unfortunately precise threshold of one percent is being 5

deployed, I would like to know what is it I’m missing in all the documents I’ve read

that would explain to me why “respiratory outbreak” does not, to any reader, lay or

scientific, include “acute respiratory illness” as well as influenza-like illness.

MS RESSLER: Commissioner, it could do. 10

COMMISSIONER: Well, doesn’t it, as a matter of English, including medically

informed English?

MS RESSLER: If there was a respiratory illness outbreak on board a ship, we 15

would respond to it. It wouldn’t have to just be an influenza-like illness.

COMMISSIONER: I’m just asking about this language.

MS RESSLER: Yes. I didn’t write the language, sir, and I apologise - - - 20

COMMISSIONER: I understand that. And you understand that - - -

MS RESSLER: Yes.

25

COMMISSIONER: - - - part of my inquiry is whether those who write documents

should do so more carefully and those who read and use them should do so more

wisely. Please understand that’s a concern I have, an urgent one.

MS RESSLER: I understand. 30

COMMISSIONER: I need your help, because I have read your statement, I’ve read

a deal of documents in which you’ve had a hand, and I know that you will be able to

help me. So could you, doing the best you can – take all the time you like. I really

need to understand, because I don’t at the moment, why “respiratory outbreak” 35

doesn’t, as night follows day, include “acute respiratory illness”

MS RESSLER: I’m not sure the intention of the author of that document - - -

COMMISSIONER: Who is the author of the document? 40

MS RESSLER: It was New South Wales Health.

COMMISSIONER: So who is the author?

45

MS RESSLER: I am actually not sure, Commissioner.


MR BEASLEY SC

COMMISSIONER: Do you know how you would find out?

MR BEASLEY: If the answer is no, you’re allowed to say no. If you don’t know,

you’re allowed to say that.

5

MS RESSLER: I could ask Professor Ferson.

COMMISSIONER: You’re under no obligation to – please don’t go beyond what

you believe to be true.

10

MS RESSLER: Yes. I would ask Professor Ferson. He would probably know who

the author is.

COMMISSIONER: Thanks. We will do that. Thank you.

15

MS RESSLER: But can I please explain my experience?

COMMISSIONER: Yes, absolutely, please.

MS RESSLER: With respiratory illness, there has been a difficulty over my 17 20

years in the cruise ship surveillance program. There has been a difficulty in

understanding for cruise ships in reporting respiratory illness. The reporting

mechanism that we use to identify outbreaks is the Human Health Report that is

collected before a ship arrives.

25

COMMISSIONER: Yes.

MS RESSLER: Respiratory symptoms are not reportable in that, but a fever is. So

in my experience, we’ve responded to a fever and an acute respiratory illness doesn’t

include a fever unless it becomes an influenza-like illness. So it’s part of the case 30

definition for an influenza-like illness.

COMMISSIONER: And the way you’ve explained it there, fever becomes a

discriminating factor?

35

MS RESSLER: That’s right. And a fever is reportable by cruise ships before they

arrive.

COMMISSIONER: Yes.

40

MS RESSLER: And so I use that to question cruise ships who have reported a fever

as to the cause of the fever. And it’s an unfortunate situation in our surveillance

program that there is no definition for the cruise ships to report respiratory outbreaks.

Hence they don’t generally get reported.

45

COMMISSIONER: Now, in the - - -


MR BEASLEY SC

MR BEASLEY: Has this been a long term problem?

MS RESSLER: Yes.

MR BEASLEY: When you say – you use the word “unfortunate.” 5

MS RESSLER: It has.

MR BEASLEY: This distinction between acute respiratory illness on the one hand,

which might capture a range of symptoms. 10

MS RESSLER: Yes.

MR BEASLEY: And the distinction for an influenza-like illness is simply the

addition of a fever of 38 degrees or more. 15


MR BEASLEY: And do we take it by the use of the term “unfortunate” that you

would prefer – the Human Health form you’re talking about is a Commonwealth 20

document, correct?

MS RESSLER: Correct.

MR BEASLEY: By the use of the term “unfortunate,” should the Commissioner 25

understand that to mean that you think that reporting should be changed?

MS RESSLER: I do.

MR BEASLEY: And can you tell him in what way you think that process would be 30

– you would advise it being changed to?

MS RESSLER: The question on the Human Health Report should ask for the

number of people with an influenza-like illness and provide a case definition for an

influenza-like illness, being a fever plus one other respiratory system. 35

COMMISSIONER: Plus or alternatively?

MS RESSLER: Plus.

40

COMMISSIONER: Right. So always fever?

MS RESSLER: That is an influenza – yes.



MR BEASLEY SC

MS RESSLER: A proposal our unit has put forward prior to COVID is that there

are three questions added to the Human Health Report. One is asking the number of

influenza-like illness cases. The subset to that is the number of influenza positive

tests and then the number of cases of pneumonia diagnosed. We have proposed that

prior. 5

MR BEASLEY: When was that proposed; do you remember?

MS RESSLER: I have proposed it a couple of times.

10

MR BEASLEY: Well before March 2020?

MS RESSLER: Well before. Yes.

MR BEASLEY: Right. And has there been – you’ve proposed it to whom, firstly? 15

MS RESSLER: I have proposed it to Dr Sean Tobin and I have proposed it to Jillian

Hicks.

COMMISSIONER: And what is your understanding – please feel free to summarise 20

– what is your understanding of their response to your suggestion?

MS RESSLER: Initially I proposed it when the MARS platform was developed.

We have possibly proposed it before that but that was 2017 and they rolled out the

MARS platform and we sent to them the questions that we would like to see that 25

would help us in our cruise ship surveillance program to determine an outbreak on

board. At that time I recall there being a difficulty with changing the platform again.

COMMISSIONER: What do you mean by difficulty?

30

MS RESSLER: Technical difficulty.

COMMISSIONER: What, word processing?

MR BEASLEY: IT. 35

COMMISSIONER: IT. Is that what you mean?

MS RESSLER: That’s my recollection at the time, because they had – I would have

to go back, I’m sorry. 40

COMMISSIONER: No, don’t apologise.

MR BEASLEY: This MARS platform must be using Apollo-type computer system.

45

COMMISSIONER: So your understanding is that it wasn’t a scientific or public

health concern, but rather a document concern, a data collection concern?


MR BEASLEY SC

MS RESSLER: At one stage, that is my understanding.

COMMISSIONER: That’s all right, thank you.

MS RESSLER: I proposed it again more recently in response to coronavirus when I 5

noticed that the MARS questions had changed and I questioned if we could add that

extra criteria in and I got an email from Dr Sean Tobin saying that they were unable

to reach consensus across the states.

COMMISSIONER: The joys of federation. 10

MS RESSLER: So I have good data about influenza-like illness and the background

rate of influenza-like illness on cruise ships, but I don’t have good data about

respiratory illness. So we could not base a threshold of 1 per cent on respiratory

illness. 15

MR BEASLEY: Why is there a threshold? Why is 1 per cent chosen?

MS RESSLER: I don’t understand why the 1 per cent was chosen in coronavirus,

but in my cruise ship program, we used 1 per cent as a threshold to start asking 20

questions of cruise ships. It was not an outbreak threshold. It was a threshold to start

asking questions.

MR BEASLEY: I’ve seen some statistics that the average ILI on cruise ships

recorded for a couple of year period up until February 2020 was about 0.17 per cent. 25

Does that sound about right as an average?

MS RESSLER: I would have the data and I could run the data for you, but I would

think that’s correct. I actually believe the 0.5 per cent that we think is a background

level is more related to gastrointestinal illness. 30

MR BEASLEY: Right.

MS RESSLER: Because we have good data on gastrointestinal illness, because it’s

a question on the Human Health Report specifically. 35

MR BEASLEY: Right.

MS RESSLER: So our data on influenza-like illness is not as complete and there is

a wider opportunity for under-reporting. 40

MR BEASLEY: Yes. If we look at the high risk and medium risk assessment and

the criteria for a respiratory outbreak, whatever that means, affecting at least one per

cent of those on board; if by respiratory outbreak it wasn’t restricted to just

influenza-like illness but included everyone, passengers and crew, for example, on 45

the ARD log, then forgetting what the precise numbers were, but when the Ruby


MR BEASLEY SC

Princess docked on 8 March and when it docked again on 19 March, the ARD log

recorded more than 100 passengers with acute respiratory disease.

MS RESSLER: Yes.

5

MR BEASLEY: If that was the trigger point, then it would have been about 3 per

cent, correct?


10

MR BEASLEY: Is there a reason why that’s – that group of passengers isn’t

included?

MS RESSLER: Yes. My reasoning, sorry - - -

15

MR BEASLEY: Give us your understanding first of why the broader group of those

with acute respiratory disease isn’t included in the one per cent assessment and only

those with influenza-like illnesses?

MS RESSLER: Because respiratory disease is very common and one would expect, 20

in a population of three and a half or 4000 people, for there to be a level of

respiratory illness on board, in any population.

MR BEASLEY: When we’re using the term acute respiratory disease, what

symptoms are we talking about? 25

MS RESSLER: Just a cough or a runny nose. They’re very minor, it’s common

cold type symptoms.

MR BEASLEY: Common cold type symptoms. 30

MS RESSLER: And we just - - -

MR BEASLEY: Some of those are associated – sorry to cut you off.

35

MS RESSLER: Yes.

MR BEASLEY: Some of those are, of course, associated with an influenza-like

illness too. Correct? With an influenza-like illness, you can have a runny nose.

40

MS RESSLER: Yes.

MR BEASLEY: Correct?

MS RESSLER: Yes. 45

MR BEASLEY: And a cough?


MR BEASLEY SC

MS RESSLER: But if you had a fever, you would be – you would fit the case

definition.

MR BEASLEY: Yes, for an ILI, with the fever.

5


MR BEASLEY: Okay. Sorry. Now, I cut you off. You were going to – or had you

finished?

10

MS RESSLER: So – so our difficulty at the time was that we don’t really know the

accurate number of respiratory illness onboard a cruise ship, and we had also insisted

- - -

MR BEASLEY: Can I pause there. 15

MS RESSLER: Yes.

MR BEASLEY: Why don’t you know the accurate – why can’t you rely on the log?

20

MS RESSLER: Because people don’t present to the doctor with respiratory – a

common cold.

MR BEASLEY: Right.

25

MS RESSLER: So they’re not always – or they’re less likely to be captured on the

log than somebody with an influenza-like illness.

MR BEASLEY: Is there some statistic that people are more likely to go to the

doctor if a fever is involved? That’s when they start going to the medical centre? If 30

you don’t know – I’m just speculating and almost - - -

MS RESSLER: I – I can only assume.


MS RESSLER: Yes.

MR BEASLEY: All right. Do you have a view now – no. I will withdraw that.

Thinking of what we knew as at either 8 or 19 March, but what we knew about 40

COVID-19 as at those dates, do you think it would have been a more prudent course

to, in terms with the one per cent assessment – to include all of those on the log with

acute respiratory disease, not just those with influenza-like illness?

MS RESSLER: It certainly would have been a more prudent approach. 45

COMMISSIONER: Now, we’re trying to avoid too much hindsight.


MR BEASLEY SC

MR BEASLEY: Yes.

MS RESSLER: Yes.

COMMISSIONER: Let me explain that. Of course, I’m applying hindsight 5

completely.

MS RESSLER: Yes.

COMMISSIONER: But in terms of what I report concerning, if you like, the merits 10

of conduct, I am going to try at least to resist the temptation simply to be wise after

the event.

MS RESSLER: Okay.

15

COMMISSIONER: Casting your mind back to, to be precise, the early hours of

19 March – I hope you were asleep at the time, but as at that time do you recall to

what extent it was considered that fever was a necessary indicator of possible

COVID?

20

MS RESSLER: In my mind, I understood well at that point that there was mild

illness associated with coronavirus and even asymptomatic illness.

COMMISSIONER: So that you may not even have fever.

25

MS RESSLER: True.

COMMISSIONER: You could - - -

MS RESSLER: Well, I was – I thought that was possible. Yes. 30

COMMISSIONER: It’s just that most of us have seen on the television the

temperature measurers being aimed at people’s foreheads.

MS RESSLER: Yes. 35

COMMISSIONER: Presumably because however inexact, it is considered to be a

useful public health screen for possible COVID, that is, a fever; correct?

MS RESSLER: Correct. 40

COMMISSIONER: I had understood – please correct me – I’m asking for you to

help me here. I had understood, however, that certainly by 19 March thinking had

progressed in the public health field to the point of accepting that people could be

both infected and, therefore, contagious who were asymptomatic to the extent that 45

they were not apparently suffering fever. Is that right?


MR BEASLEY SC

MS RESSLER: That’s my understanding as well. Yes.

MR BEASLEY: Did you – was your understanding – I think – tell us if this

knowledge didn’t come to you, but you’re, I take it – would have been aware of the

Diamond Princess being quarantined in Japan. 5

MS RESSLER: Of course, yes.

MR BEASLEY: And a huge number of people on that ship, maybe everyone, was

tested for COVID during the course of the time that ship was quarantined. Were you 10

aware that a number of people that tested positive for COVID-19 on that ship, and

I’m talking hundreds, were at that point of time still asymptomatic?

MS RESSLER: I believe I was aware, though I didn’t have any - - -

15

MR BEASLEY: Precise data.

MS RESSLER: Yes.

MR BEASLEY: Okay. 20

MS RESSLER: Exactly. I wasn’t informed specifically.

MR BEASLEY: Do you want me to continue, Commissioner, or are you still - - -

25

COMMISSIONER: Of course.

MR BEASLEY: You went onboard the ship on 8 March.

MS RESSLER: Yes. 30

MR BEASLEY: The Ruby Princess. Prior – the reason you went onboard the ship

was because, as a result of the email chain I had taken you to, information was

conveyed, including the log, to the health assessment panel. Correct?

35


MR BEASLEY: And they assessed it as medium risk.


MR BEASLEY: And did you provide any assistance to that health panel in their

deliberations as to how – whether they would assist at high, low or medium?

MS RESSLER: I believe I was involved in the teleconference, and I would have 45

produced some documents for them, but I was not a decision-making member.


MR BEASLEY SC

MR BEASLEY: Sure. And doing the best I can from memory and your statement,

the reason – was it the driving reason for a medium assessment something to do with

two passengers from Singapore?

MS RESSLER: That’s correct. There were two passengers onboard who had 5

respiratory symptoms and had travelled to Singapore.

COMMISSIONER: When you say “respiratory symptoms”?

MS RESSLER: They did not have a fever. 10

COMMISSIONER: So that would not have been counted as influenza-like illness?

MS RESSLER: That’s true, yes, but because they had a positive travel history and

they had any respiratory symptom, they were of concern. 15

MR BEASLEY: Singapore was some sort of higher-risk country.

MS RESSLER: It was at that time.

20

MR BEASLEY: Yes. All right. Now, there was something like 360 people in a

dining room. Is that right?


25

MR BEASLEY: And what was your role onboard the ship on that day?

MS RESSLER: I was team lead.

MR BEASLEY: That doesn’t tell me your role. That tells me your title. So go 30

ahead and tell me what you did.

MS RESSLER: So we were operating in ICS structure, an incident - - -

COMMISSIONER: In a what, sorry? 35

MS RESSLER: An ICS structure, an incident command structure. So we had three

teams. We had an operations team, a logistics team and a planning team, and there

would be a team lead who would lead the three teams, and I was the team lead.

40

MR BEASLEY: Just pausing there, there’s 360 people in this room. They were

sitting at tables.


45

MR BEASLEY: Were they physically distancing – that was - - -


MR BEASLEY SC

MS RESSLER: No.

MR BEASLEY: Was it set up that way? No?

MS RESSLER: No. 5

MR BEASLEY: So there was – like, as an example, was there, like, 10 people at

any particular table? They were crowded together. Is that the general gist of it?

MS RESSLER: That’s correct. Yes. 10

MR BEASLEY: Were they wearing masks?

MS RESSLER: We had asked for everybody to be wearing masks, but when we

walked in they weren’t. 15

MR BEASLEY: Right.

MS RESSLER: So we put masks on everybody.

20

MR BEASLEY: Right. Okay.

MS RESSLER: The first thing. After putting our own PPE on, we made sure

everybody - - -

25

MR BEASLEY: So you carried that sort of gear on.

MS RESSLER: We did.

MR BEASLEY: Yes. All right. What I wanted to ask was, these 360 people in the 30

dining room, because they’ve responded to a message from the ship saying, if you’ve

got respiratory type illness symptoms like a cough or a cold, please go to the dining

room, whatever one was allocated – the da Vinci room, was it?

MS RESSLER: I’m not sure what it was called. 35

MR BEASLEY: Or can’t remember? Either the da Vinci room or the Michelangelo

room.

MS RESSLER: It was a big room. 40

MR BEASLEY: Had the other passengers disembarked?

MS RESSLER: No.

45

MR BEASLEY: Right. So everyone, passengers and crew, were still on board.


MR BEASLEY SC

MS RESSLER: Yes.

MR BEASLEY: You assessed passengers, and what is the purpose of your

assessment? Are you making a decision as to who would get a COVID test?

5

MS RESSLER: Yes.

MR BEASLEY: And that was based on?

MS RESSLER: An announcement was made for anybody with any respiratory 10

illness or travel to one of those countries with no symptoms - - -

MR BEASLEY: Yes.

MS RESSLER: - - - to come for assessment. Their temperatures were checked. 15

MR BEASLEY: Yes.

MS RESSLER: They had a traveller record form. They completed their travel

history and all their symptoms. They were assessed by a nurse. If they had a fever 20

they went to a separate spot where they were assessed by the doctor and a second

temperature was taken. If they remained febrile they were taken down to the medical

centre. They were given an influenza test, and if the influenza test was negative,

they were swabbed for coronavirus.

25

MR BEASLEY: I see.

COMMISSIONER: What was the thinking about screening by fever and negative

influenza, if you could – it was then appreciated you could have COVID without

fever and you could have COVID and influenza? Is it about chances or what? 30

MS RESSLER: It didn’t – sorry, Commissioner. It didn’t happen on that cruise, but

if somebody had any respiratory illness and a positive travel history, they would also

have been considered by the doctor for testing.

35

COMMISSIONER: I’m sure.

MS RESSLER: yes.

COMMISSIONER: But leave aside the - - - 40

MS RESSLER: And the doctor made those decisions.

COMMISSIONER: Yes. Leave – I’m sure about that, too. Leave aside the travel

history, the suspect countries or whatever. I’m just asking about are you able to help 45

me in relation to the rationale of the screening that you’ve described? It’s the sort of

sorting of the initial hundreds of passengers, isn’t it?


MR BEASLEY SC

MS RESSLER: Yes.

COMMISSIONER: Why, as you understand it, would fever be a useful

discriminating feature if you were trying to detect COVID?

5

MS RESSLER: At that time, fever was still thought to be a very common symptom

of coronavirus.

COMMISSIONER: I think it still is, isn’t it?

10

MS RESSLER: Yes, it is. And that was – it was not my decision.

COMMISSIONER: I promise you - - -

MS RESSLER: Yes. 15

COMMISSIONER: - - - I am - - -

MS RESSLER: And I - - -

20

COMMISSIONER: I will tell you – I will make it crystal clear, if I want you to

respond to something that might sound a criticism of your conduct. You will know

plainly. This afternoon I’m really trying to get your assistance in understanding both

the language and the concept of these screening approaches, because they are

important to my inquiry. Now, do you know – I know you’re not a medical 25

practitioner, but I also know what experience and expertise you do have. Do you

know why it is that – you’ve told me about fever. Why it is that a negative influenza

test, as opposed to a positive influenza test, was seen as a useful screening in relation

to those who would then be swabbed for COVID?

30

MS RESSLER: I see.

COMMISSIONER: As at 8 March. I suppose one way of asking is this, was it then

believed that if you were lucky enough to have influenza you would not be unlucky

enough to have COVID as well? 35

MS RESSLER: We recognised that you could have the co-infections.

COMMISSIONER: That’s what I thought. I thought that was common knowledge.

40

MS RESSLER: Yes, you’re right.

COMMISSIONER: So why would I – as a screener for public health, community

safety, why would I put – as a useful factor to decide how we would then proceed to

test people for COVID, why would I put any weight on whether you’ve tested 45

positive for influenza?


MR BEASLEY SC

MS RESSLER: My - - -

MR KIRBY: If there are other people that have tested negative with the same

symptoms? Is that - - -

5

COMMISSIONER: No, just - - -

MS RESSLER: My understanding is that one would believe that influenza was

causing your fever, not coronavirus.

10

COMMISSIONER: Why would you start with the proposition that you don’t have

co-infection? I mean, there may be an answer to that that may be beyond your

expertise - - -

MS RESSLER: Yes. I think it is - - - 15

COMMISSIONER: - - - and certainly beyond mine.

MS RESSLER: I think it is beyond my expertise.

20

COMMISSIONER: I’m trying to say - - -

MS RESSLER: And that was the testing criteria that was being used - - -

COMMISSIONER: No, I know. 25

MS RESSLER: - - - in hospitals at the time.

COMMISSIONER: I know that. I’m trying to - - -

30

MS RESSLER: And I – yes, I’m sorry, it’s - - -

COMMISSIONER: No, that’s – don’t apologise. Mr Beasley has then gone – noted

the next important thing we’re – I’m interested in. I gather that the same kind of

reasoning that saw positive influenza as a contraindication against COVID also saw 35

negative influenza test as indicating it would be worth making further inquiries about

COVID. Have I got that correct?

MS RESSLER: Yes.

40

COMMISSIONER: All right. Reported – I’m jumping now to the 19th.

MS RESSLER: Okay.

COMMISSIONER: Reported on this ship was 48 influenza tests and, by whatever 45

fluke, 24 positive, 24 negative.


MR BEASLEY SC

MS RESSLER: Yes.

COMMISSIONER: You may assume that I’m a glass half empty sort of person.

Why wouldn’t you – why wouldn’t one – I don’t mean you actually. Why wouldn’t

a person devising these screening tests say of such a situation, “Well, that certainly is 5

not reassuring about COVID.”

MS RESSLER: If you look at the number of people who had influenza-like illness.


MS RESSLER: That was 36. And, of those, 24 were positive - - -

COMMISSIONER: So you’re talking about that extra 12 who were tested, as it

were, as a base approach; is that right? 15

MR KIRBY: Just pause there on that figure of 36.

COMMISSIONER: I’m sorry.

20

MS RESSLER: Yes.

MR KIRBY: That’s 36 as from the log supplied by the ship in the morning of – let’s

forget the exact time – the morning of the 18th of March.

25

MS RESSLER: Yes.

MR KIRBY: That’s the number the Health Assessment Panel assesses on; correct?


MR KIRBY: The ship doesn’t get in for, let’s say, 20 hours later and we know more

people came became unwell with influenza-like illness. Is that a problem with the

system in terms of assessment that people are continuing to get ill in relation to using

a criteria like one per cent? 35

MS RESSLER: Yes.

COMMISSIONER: I think you’ve expressed, in reflection, as you put it, views

about this at the end of your statement; is that right? 40


COMMISSIONER: We don’t have time for that now.

45

MS RESSLER: Okay.


MR BEASLEY SC

COMMISSIONER: Could you help me with this: as you – I don’t know what tab it

is. I’m looking for the 19th of February 2020 draft of the assessment procedure. I

don’t know what version you’ve got that in.

MS FURNESS: The draft protocol, Commissioner? 5

COMMISSIONER: Is that number 1, is it?

MS FURNESS: The protocols are in number 1.

10

COMMISSIONER: Yes. That’s number 1. Thank you. Although it’s headed

Draft, it was understood to be operative although it was undergoing constant re-

evaluation; is that correct?


COMMISSIONER: At the foot of the second page, there’s a heading Pre-

disembarkation. Do you see that?

MS RESSLER: Yes. 20

COMMISSIONER: And there’s that phrase I asked you about earlier “a respiratory

outbreak”. Do you see that?

MS RESSLER: Yes. 25

COMMISSIONER: Where that is identified and informed to the jurisdictional

health authority, there is a requirement – do you see the words:

The ship must” - - - 30

MS RESSLER: Yes.

COMMISSIONER:

35

…to identify passengers and crew –

that means all persons – and it says:

…who require screening by the assessment team – 40

I won’t apologise for being critical of the English. Does that require a separate

judgment or are the three categories separated by the two bold use of the word “or”.

Are they – do you read that as being people who require screening by the assessment

team? 45

MS RESSLER: Yes.


MR BEASLEY SC

COMMISSIONER: Right. So the first one is simply “anyone with current

respiratory symptoms”.

MS RESSLER: Yes.

5

COMMISSIONER: That will certainly include everyone on the ARD log - - -

MS RESSLER: Yes.

COMMISSIONER: - - - with what we call ARI, won’t it? 10

MS RESSLER: Yes.

COMMISSIONER: The second one is what I will call suspect travel history.

15

MS RESSLER: Yes.

COMMISSIONER: Yes. And you will see that it’s separated – it’s not “and”, it’s

“or”. These are self-sufficient as indicators, aren’t they?

20

MS RESSLER: Yes.

COMMISSIONER: And the third one is “anyone who has been seen during the

cruise with fever”, and then that linguistic barbarism, “and/or”. Do you see that?

25

MS RESSLER: Yes.

COMMISSIONER: That means fever and ARI or fever or ARI, doesn’t it?

MS RESSLER: Yes. 30

COMMISSIONER: So one way or the other, I think probably two ways, ARI gets

into this list of criteria for screening by the assessment team. Isn’t that right?

MS RESSLER: Yes. 35

COMMISSIONER: And that’s – this is all about COVID.

MS RESSLER: Yes.

40

COMMISSIONER: Yes. Given that this is all about what happens when a

respiratory outbreak has been identified and informed to the authority, wouldn’t that

encourage somebody like me to read the expression “respiratory outbreak” as

including ARI?

45

MS RESSLER: Yes.


MR BEASLEY SC

COMMISSIONER: Then if you turn the page. It says:

Where a respiratory outbreak is reported, the ship must also provide a report –

etcetera: 5

…copy of the full ARD log, and that will include presentation with fever or –

and I stress the word “or” –

10

ARI.

Correct?

MS RESSLER: Yes. Yes. 15

COMMISSIONER: And then suspect travel history and result of flu tests. Is there

some reason why I should not read that as suggesting that relevant to the state of

affairs made interesting for public health officials called a “respiratory outbreaks” are

reports during the cruise of ARI? Am I misreading something? 20

MS RESSLER: I’m not sure, Commissioner. I - - -

COMMISSIONER: You know, of course – Mr Beasley has done the arithmetic for

you. 25

MS RESSLER: Yes.

COMMISSIONER: If you include ARI - - -

30

MS RESSLER: Yes.

COMMISSIONER: - - - as well with ILI, Ruby Princess is absolutely not low risk.

Correct?

35


COMMISSIONER: And - - -

MS RESSLER: And so - - - 40

COMMISSIONER: I really would appreciate your help because I’m trying to think

about - - -

MS RESSLER: Yes. 45


MR BEASLEY SC

COMMISSIONER: - - - the proper way to investigate this. I need your help as to

why I’m – am I on the wrong path in asking myself, look, these protocols clearly

concern themselves with ARI? They don’t require fever. They don’t require - - -

MS RESSLER: Yes. 5

COMMISSIONER: - - - negative influenza testing. I may well have considerable

criticisms of the one per cent in due course. I may have even more criticisms of a

slavish application of it.

10

MS RESSLER: Yes.

COMMISSIONER: But I’m not interested in that at the moment. I’m concerned, as

a medical layman, that I’m getting this nomenclature wrong.

15

MS RESSLER: No, you’re not. You’re not, Commissioner. You have it right.

And we ourselves weren’t sure what to make of an ARD rate and so that is why we

included both in our risk assessments, so that the panel could also consider the rate of

ARI.

20

COMMISSIONER: It sounds to me and it reads to me from your statement that for

some time you’ve not been professionally entirely satisfied with the form of this

protocol. Is that right?

MS RESSLER: I understood the basis for the protocol and – and I was okay with 25

the protocol. As coronavirus moved through the population, I became more nervous

that we would miss something and that it was inevitable that this would happen and

- - -

COMMISSIONER: When do you roughly – I’m not asking for exact dates. When 30

do you roughly date your growing apprehension as reaching that state?

MS RESSLER: When we started to see community transmission in Sydney.

COMMISSIONER: All right. 35

MS RESSLER: And prior to that we had been looking very closely at cruises that

had come from an international port or who had international – people who’ve

travelled internationally on board. But that was becoming less relevant because it

was in Sydney, it was in New Zealand, it was in these places. And I – we were all 40

nervous. We were all worried.

MR BEASLEY: Did you get a chance to consider or read the Federal Australian

Government Department of Health national protocol that was put out about

coronavirus disease on 6 March, relating to cruise ships? 45

MS RESSLER: I did read it, but I don’t have it in front of me.


MR BEASLEY SC

MR BEASLEY: The only reason I’m raising it, this isn’t so much of a question, but

that does use – like, doesn’t use the term - - -

COMMISSIONER: It does.

5

MR BEASLEY: - - - respiratory disease or respiratory outbreak. It uses ILI, which

is - - -

MS RESSLER: Yes. And this should have too.

10

MR BEASLEY: So there’s a disparity in the language between the Federal

document and the New South Wales document.

MS RESSLER: Yes.

15

COMMISSIONER: Just so that everyone knows what we’re talking about, it’s on

page 4 of that document.

MR BEASLEY: Yes.

20

COMMISSIONER: Footnote 3 has the clarification. In your understanding, was

there anything – in the New South Wales documents, the protocol that I’ve been

asking you about, was there anything which would require one to read respiratory

outbreak as the Commonwealth footnote describes it?

25

MS RESSLER: I hadn’t considered it at the time.

COMMISSIONER: If I may say so, not surprisingly, because the Commonwealth

uses that footnote to describe a different expression altogether. A more precise one,

influenza-like illness. 30

MS RESSLER: Yes.


35

MS RESSLER: I hadn’t realised that before.

COMMISSIONER: Yes. By the way, the word “outbreak” – I’m sorry to appear

pedantic, probably because I am. Doesn’t an outbreak start before it reaches 1 per

cent? 40

MS RESSLER: Outbreaks are defined as – in different ways - - -

COMMISSIONER: I know.

45

MS RESSLER: - - - by different cruise ship companies.


MR BEASLEY SC

COMMISSIONER: Yes.

MS RESSLER: And our program would count an outbreak if it had been responded

to as an outbreak on board. So a lot of the cruise ships would use eight cases in 24

hours or 12 cases in 48 hours. So if we noticed on the human health report that there 5

were cases that approached – well, that were close to or over 1 per cent, we would

send an email to the ship to ask for the ARD log and to ask them if they had

instituted response protocols to an outbreak on board.

MR BEASLEY: Dr Watzdorf, I think told you on the – by an email of 15 March, 10

that she thought the ship was in the beginnings of an influenza outbreak. What did

that mean to you then?

MS RESSLER: It meant that she had identified the pathogen as influenza A and

was instituting outbreak response protocols on board. However, my belief is that 15

cruise ships were operating at a heightened level regardless.

COMMISSIONER: Well, now, we’re talking about contagious infections.

MS RESSLER: Yes. 20

COMMISSIONER: Which by definition means that the number of cases is liable to

increase. Correct?


COMMISSIONER: Depending, of course, on both incubation and recovery

durations. But assuming that recovery takes longer than incubation, then your cases

are going to increase. Isn’t that right?

30

MS RESSLER: That depends on the response taken.

COMMISSIONER: True. That is, if you – if you don’t intervene and recovery

takes longer than incubation, inevitably your numbers are going to go up. Correct?

35


COMMISSIONER: And 1 per cent is counting numbers of what I will call putative

cases, because there’s no lab tests on the ship; is that right?

40

MS RESSLER: There’s a flu test on the ship.

COMMISSIONER: There’s a flu test, but there’s no lab tests for COVID, I mean.



MR BEASLEY SC

COMMISSIONER: Yes. So in terms of a respiratory outbreak, it’s accepted that

there may be more than one recognised disease entity - - -

MS RESSLER: Yes.

5

COMMISSIONER: - - - constituting the class. Is that right?


COMMISSIONER: It strikes me, as a medical layman, as sort of really silly to say 10

there’s no outbreak at the – when you’re counting cases and you’re one short of one

per cent and there is an outbreak when you count the cases and it’s now one per cent

or more.

MS RESSLER: We didn’t use one per cent as an outbreak. 15

COMMISSIONER: I’m pleased to hear it, but some of these documents do.

MS RESSLER: Yes.

20

COMMISSIONER: I am right, am I? It would be really silly to say there’s no

outbreak; now one more case, there is, because obviously, in biological terms, the

contagion of the infection increasing cases is already in train as you progress towards

the number that constitutes one per cent of the relevant population. Isn’t that right?

25

MS RESSLER: Yes.

COMMISSIONER: So the biological phenomenon which requires the professional

and social interventions to slow it down or prevent it is already in train.

30

MS RESSLER: Yes.

COMMISSIONER: And you say you don’t use one per cent to define outbreak.

MS RESSLER: No. 35

COMMISSIONER: I won’t hold you to this late in the week and the day, but how

would – how should I, in your preference, understand what an outbreak is then?

MS RESSLER: An increase above the expected rate of illness. 40

COMMISSIONER: Well, you know what my next question is. So how do you

ascertain what the expected level is for COVID?

MS RESSLER: We – we can’t. 45


MR BEASLEY SC

COMMISSIONER: But that might be as convenient a time as any bearing in mind

how late it is.

MR BEASLEY: Can I just ask very short – couple of other questions.

5

COMMISSIONER: Yes, of course.

MR BEASLEY: I just want to know something that’s not clear from the documents.

I’m certainly not going to take the witness through all these documents we’ve got

now. 10

COMMISSIONER: No. No. No.

MR BEASLEY: Now, I understand from skimming through your report that you

had played no role in relation to the health panel’s assessment of low risk for the 19 15

March disembarkation. Correct?

MS RESSLER: I provided documents to them.

MR BEASLEY: Outside of providing documents. 20

MS RESSLER: I didn’t make the decision.

MR BEASLEY: And there was no telephone hook-up for a discussion. It was all

done by email. Correct? 25

MS RESSLER: Yes.

MR BEASLEY: Can you assume for – just assume that, for whatever reason, the

log is different, whatever – or the panel just decided to go a different way. Say it 30

said this is meeting risk and you were sent back on the ship.

MS RESSLER: Yes.

MR BEASLEY: And you did the COVID testing and – and we know – would it 35

likely have been a similar process to 8 March, people in the room, or would you have

done it differently or - - -

MS RESSLER: It would have been very similar.

40

MR BEASLEY: All right. And we know it’s likely if the same people were

swabbed, that the results would have been that there’s people onboard that have got

COVID-19.

MS RESSLER: Yes. 45


MR BEASLEY SC

MR BEASLEY: Do you have an understanding what would have happened at that

point?

MS RESSLER: If we had taken the same approach that we did on 8 March, we

would have gone onboard and we would have identified anybody with a fever. So 5

we would have tested 15 people.

MR BEASLEY: Yes.

MS RESSLER: 13 of those we did already have swabs for. 10

MR BEASLEY: Yes.

MS RESSLER: We possibly would have identified a few more people.

15


MS RESSLER: Those people would have remained onboard.

MR BEASLEY: Yes. 20

MS RESSLER: And the other 3000 – three and a half thousand people would have

been free to disembark.

MR BEASLEY: Just pause there. Would they have been free to disembark before 25

the swabs were back?

MS RESSLER: Yes. They would have been free to disembark once we had

assessed all of the people who had presented for assessment. The ship was cleared

once we had finished our assessment. 30

MR BEASLEY: What’s the reason that everyone would have been let go before

you had a test result back for the COVID swabs?

MS RESSLER: We operated according to the protocol. There was no reason to 35

keep people onboard who were not symptomatic. We only would have kept the

people onboard who were tested. There was at no time a plan to keep people

onboard, only in a high risk where we knew already that somebody was positive, and

then we would have made arrangements for everyone to disembark as soon as

possible. 40

MR BEASLEY: Yes.

MS RESSLER: We did not want people staying on a cruise ship any longer than

they had to. 45


MR BEASLEY SC

MR BEASLEY: When you say there was no plans for people who were in this

medium-risk scenario, you’ve gone on the ship - - -

MS RESSLER: Yes.

5

MR BEASLEY: New South Wales Health has gone on the ship. The swabs are in

the process of going to the lab and being tested, but people allowed off. The plan not

– the plan not to keep the rest of the passengers that are asymptomatic on board

while that process is undertaken was because of what?

10

MS RESSLER: Because - - -

MR BEASLEY: What were you concerned about of keeping people on board?

MS RESSLER: We had no reason to keep those people on board if they were well 15

and had been assessed as well and as long as we had a full list of their contact details,

we would get the testing done, keep the people on board who were symptomatic and

tested and we could then begin contact tracing of people who had been disembarked

home.

20

MR BEASLEY: Just pause there. Say the decision, though, was everyone stays on

board until we get the COVID test back.

MS RESSLER: Yes.

25

MR BEASLEY: And they come back and there’s positives. What would happen

then?

MS RESSLER: An incident management team would be formed.

30

COMMISSIONER: No – yes, no doubt but - - -

MR BEASLEY: Would the people be allowed off?

MS RESSLER: Yes. People would be organised to disembark to somewhere where 35

we could quarantine them, was my understanding of the plan if that were to happen.

MR BEASLEY: By quarantining, you don’t mean self isolate, you mean

compulsory lockdown quarantine?

40

MS RESSLER: Yes. That was the plan for high risk. It was for - - -

COMMISSIONER: That’s even if – that’s even the asymptomatic people who have

been on board the same ship, isn’t it?

45

MS RESSLER: Yes.


MR BEASLEY SC

COMMISSIONER: In the protocol, what does “symptomatic people” mean, where

it talks about:

Symptomatic people can on-travel safely home with a mask, fact sheet and

hand rub before the results are known. 5

What does “symptomatic” mean?

MS RESSLER: So they would be the people who had some respiratory symptoms,

but weren’t assessed as requiring coronavirus testing. 10

COMMISSIONER: So with or without fever, or doesn’t that matter?

MS RESSLER: If they had a fever, they would have been tested and kept on board.

15

COMMISSIONER: So I should read in that final prompt in this protocol, I should

read that as meaning people with respiratory symptoms not selected by the earlier

steps you and I talked about for further COVID testing; is that right?

MS RESSLER: Yes, and that would depend on the date and what countries were of 20

concern.

COMMISSIONER: I understand, yes. Thanks. So this is a protocol which for

COVID accepted a risk that not only people with respiratory symptoms but also

people with no symptoms, already infected with COVID, would not go into 25

quarantine, even though you had yet to discover whether there was in fact COVID-

19 on the ship?

MS RESSLER: Yes.

30

COMMISSIONER: What’s the thinking behind that, as you now recall it? If you

don’t know, don’t speculate.

MS RESSLER: Sure. I don’t know. Yes, I don’t know.

35

MR BEASLEY: When you mentioned a plan, is this a written plan you had seen?

MS RESSLER: Yes. That’s the protocol, yes.

MR BEASLEY: About compulsory quarantine. I couldn’t see anything in there. Is 40

there something in there about that?

MS RESSLER: Yes.

MR BEASLEY: Just tell me where that is. 45


MR BEASLEY SC

MS FURNESS: I don’t think it’s behind this statement but it’s behind the Ruby

Princess report. It’s the process for confirmed cases.

COMMISSIONER: Yes. Arrangements, it says, will be made.

5

MS FURNESS: Yes, arrangements.

MR BEASLEY: I see. Just on that, could I ask you, and this going to wrap it up for

me. Have you been given a copy of the – what is titled the New South Wales Health

Report on the Ruby Princess cruise of 8 to 19 March 2020? 10

MS RESSLER: I have only seen a draft copy.

MR BEASLEY: By “only seen a draft copy” do we take it that you were consulted

in the preparation of that? 15

MS RESSLER: No.

MR BEASLEY: Did you provide any commentary about it?

20

MS RESSLER: No.

COMMISSIONER: Why were you looking at a draft?

MS RESSLER: It was sent to me for information. I was not asked to comment. 25

COMMISSIONER: Right. And you didn’t.

MS RESSLER: And I didn’t.

30


MR BEASLEY: I think for the purposes of today - - -

COMMISSIONER: Yes, so do I. I’m sorry about the late hour. 35

MS RESSLER: That’s okay.

COMMISSIONER: You are excused from the present occasion but it is certain that

you will come back to give evidence at a public hearing. 40

MS FURNESS: Commissioner, I thought that had already been arranged.

COMMISSIONER: Yes.

45

MR BEASLEY: It has.


MS FURNESS: It has?

COMMISSIONER: Things can change but it is certain.

MS FURNESS: Things may change, that’s true. 5

MR BEASLEY: It is certain.

COMMISSIONER: I’m very grateful for the assistance you’ve given this afternoon.

Thank you. 10

MS RESSLER: Thank you, Commissioner.

COMMISSIONER: That concludes today’s hearing.

15


MATTER ADJOURNED at 5.27 pm ACCORDINGLY20


Index of Witness Events

SARAH MARSHALL, AFFIRMED P-152

EXAMINATION-IN-CHIEF BY MR BEASLEY SC P-152

THE WITNESS WITHDREW P-196

CAMERON TREVOR BUTCHART, AFFIRMED P-196

EXAMINATION-IN-CHIEF BY MR KIRBY P-197


KELLY-ANNE RESSLER, AFFIRMED P-243

EXAMINATION-IN-CHIEF BY MR BEASLEY SC P-243


Index of Exhibits and MFIs

MFI #1 KEY DOCUMENTS VOLUME 1 P-155

MFI #2 STATEMENT OF SARAH MARSHALL TO NEW SOUTH

WALES POLICE FORCE DATED 22.4.2020

P-155

MFI #3 STATEMENT OF KELLY-ANNE RESSLER P-245

TRANSCRIPT OF PROCEEDINGS · TRANSCRIPT OF PROCEEDINGS O/N H-1193678 MR B. WALKER SC, Commissioner...

Documents

Transcript of TRANSCRIPT OF PROCEEDINGS · TRANSCRIPT OF PROCEEDINGS O/N H-1193678 MR B. WALKER SC, Commissioner...