.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
.RUBY PRINCESS INQUIRY 1.5.20R2 P-151
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.
COMMISSIONER: Thank you.
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?
.RUBY PRINCESS INQUIRY 1.5.20R2 P-153 S. MARSHALL XN
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-154 S. MARSHALL XN
MR BEASLEY SC
COMMISSIONER: Thank you.
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
COMMISSIONER: Thank you.
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?
.RUBY PRINCESS INQUIRY 1.5.20R2 P-155 S. MARSHALL XN
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.
COMMISSIONER: Thank you.
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
COMMISSIONER: Thank you.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-156 S. MARSHALL XN
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?
.RUBY PRINCESS INQUIRY 1.5.20R2 P-157 S. MARSHALL XN
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.
MS MARSHALL: Yes. 10
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
.RUBY PRINCESS INQUIRY 1.5.20R2 P-158 S. MARSHALL XN
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?
MS MARSHALL: Yes. 25
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-159 S. MARSHALL XN
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-160 S. MARSHALL XN
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?
MS MARSHALL: Yes. 35
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-161 S. MARSHALL XN
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?
.RUBY PRINCESS INQUIRY 1.5.20R2 P-162 S. MARSHALL XN
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?
MS MARSHALL: Yes. 15
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 - - -
MS MARSHALL: Yes. 35
COMMISSIONER: - - - that they – that means the health people – wouldn’t know if
it was COVID until the ship had come in.
MS MARSHALL: Yes. 40
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.
MS MARSHALL: Yes. 45
.RUBY PRINCESS INQUIRY 1.5.20R2 P-163 S. MARSHALL XN
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-164 S. MARSHALL XN
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.
MS MARSHALL: Yes. 10
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
.RUBY PRINCESS INQUIRY 1.5.20R2 P-165 S. MARSHALL XN
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.
MS MARSHALL: Yes. 10
MR BEASLEY: That follows an email you had sent to Ms Ressler at 5.04 pm in the
afternoon - - -
MS MARSHALL: Yes. 15
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-166 S. MARSHALL XN
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-167 S. MARSHALL XN
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-168 S. MARSHALL XN
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?
MS MARSHALL: Yes. 40
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-169 S. MARSHALL XN
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-170 S. MARSHALL XN
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 - - -
.RUBY PRINCESS INQUIRY 1.5.20R2 P-171 S. MARSHALL XN
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?
.RUBY PRINCESS INQUIRY 1.5.20R2 P-172 S. MARSHALL XN
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-173 S. MARSHALL XN
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 - - -
MS MARSHALL: Correct.
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 - - -
MS MARSHALL: Yes. 45
MR BEASLEY: - - - of 18 March at 3.41 pm?
.RUBY PRINCESS INQUIRY 1.5.20R2 P-174 S. MARSHALL XN
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-175 S. MARSHALL XN
MR BEASLEY SC
MR BEASLEY: - - - you’ve got 3.26 from Cameron - - -
MS MARSHALL: Correct.
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.
MS MARSHALL: Yes. 15
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.
COMMISSIONER: Thank you.
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 - - -
.RUBY PRINCESS INQUIRY 1.5.20R2 P-176 S. MARSHALL XN
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
.RUBY PRINCESS INQUIRY 1.5.20R2 P-177 S. MARSHALL XN
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-178 S. MARSHALL XN
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-179 S. MARSHALL XN
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 - - -
.RUBY PRINCESS INQUIRY 1.5.20R2 P-180 S. MARSHALL XN
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?
MS MARSHALL: Yes. 20
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 - - -
.RUBY PRINCESS INQUIRY 1.5.20R2 P-181 S. MARSHALL XN
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-182 S. MARSHALL XN
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?
.RUBY PRINCESS INQUIRY 1.5.20R2 P-183 S. MARSHALL XN
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
.RUBY PRINCESS INQUIRY 1.5.20R2 P-184 S. MARSHALL XN
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
.RUBY PRINCESS INQUIRY 1.5.20R2 P-185 S. MARSHALL XN
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-186 S. MARSHALL XN
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 - - -
.RUBY PRINCESS INQUIRY 1.5.20R2 P-187 S. MARSHALL XN
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-188 S. MARSHALL XN
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?
MS MARSHALL: Yes. 30
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 - - -
.RUBY PRINCESS INQUIRY 1.5.20R2 P-189 S. MARSHALL XN
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
COMMISSIONER: Thank you.
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
MR BEASLEY: All right.
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 - - -
.RUBY PRINCESS INQUIRY 1.5.20R2 P-190 S. MARSHALL XN
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-191 S. MARSHALL XN
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.
MS MARSHALL: Yes. 20
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-192 S. MARSHALL XN
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.
MR BEASLEY: Right. 20
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 - - -
MR BEASLEY: All right.
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
.RUBY PRINCESS INQUIRY 1.5.20R2 P-193 S. MARSHALL XN
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 - - -
MS MARSHALL: Exactly.
35
MR BEASLEY: - - - actually arriving.
MS MARSHALL: Exactly.
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 - - -
.RUBY PRINCESS INQUIRY 1.5.20R2 P-194 S. MARSHALL XN
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.
MS MARSHALL: Yes. 25
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
MS MARSHALL: Correct.
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
.RUBY PRINCESS INQUIRY 1.5.20R2 P-195 S. MARSHALL XN
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 - - -
MS MARSHALL: Yes. 30
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
COMMISSIONER: Thank you.
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-198 C.T. BUTCHART XN
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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 BUTCHART: Yes. That’s correct. Yes.
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 BUTCHART: Yes. That’s correct. Yes.
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-199 C.T. BUTCHART XN
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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
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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 BUTCHART: Yes. 45
MR KIRBY: Or actually you say the Australian government rule change.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-201 C.T. BUTCHART XN
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
COMMISSIONER: Thank you.
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-202 C.T. BUTCHART XN
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-203 C.T. BUTCHART XN
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
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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
MR BUTCHART: That’s correct.
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
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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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-206 C.T. BUTCHART XN
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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?
MR BUTCHART: Yes. That’s 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 - - -
MR BUTCHART: Yes. 40
COMMISSIONER: - - - there is a risk assessment involved, I’m not suggesting by
you as a medical practitioner - - -
MR BUTCHART: Mmm. 45
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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
MR BUTCHART: That’s correct.
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 - - -
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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
.RUBY PRINCESS INQUIRY 1.5.20R2 P-209 C.T. BUTCHART XN
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?
.RUBY PRINCESS INQUIRY 1.5.20R2 P-210 C.T. BUTCHART XN
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-211 C.T. BUTCHART XN
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?
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MR BUTCHART: Yes. That’s correct.
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
MR BUTCHART: Yes. That’s correct.
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 - - -
.RUBY PRINCESS INQUIRY 1.5.20R2 P-213 C.T. BUTCHART XN
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 - - -
MR BUTCHART: Yes. 25
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-214 C.T. BUTCHART XN
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
MR BUTCHART: That’s correct. Yes.
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
MR BUTCHART: Yes. That’s correct.
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:
.RUBY PRINCESS INQUIRY 1.5.20R2 P-215 C.T. BUTCHART XN
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-216 C.T. BUTCHART XN
MR KIRBY
COMMISSIONER: And so it was at your direction that - - -
MR BUTCHART: Yes, that’s correct.
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
MR BUTCHART: That’s correct. Yes.
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-217 C.T. BUTCHART XN
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?
MR BUTCHART: Yes. 40
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?
.RUBY PRINCESS INQUIRY 1.5.20R2 P-218 C.T. BUTCHART XN
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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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-219 C.T. BUTCHART XN
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-220 C.T. BUTCHART XN
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
MR BUTCHART: That’s correct. Yes.
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?
.RUBY PRINCESS INQUIRY 1.5.20R2 P-221 C.T. BUTCHART XN
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
.RUBY PRINCESS INQUIRY 1.5.20R2 P-222 C.T. BUTCHART XN
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
.RUBY PRINCESS INQUIRY 1.5.20R2 P-223 C.T. BUTCHART XN
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?
MR BUTCHART: Yes. That’s correct.
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-224 C.T. BUTCHART XN
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
.RUBY PRINCESS INQUIRY 1.5.20R2 P-225 C.T. BUTCHART XN
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-226 C.T. BUTCHART XN
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 - - -
MR BUTCHART: Yes. 30
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?
.RUBY PRINCESS INQUIRY 1.5.20R2 P-227 C.T. BUTCHART XN
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?
MR BUTCHART: Yes. 40
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?
.RUBY PRINCESS INQUIRY 1.5.20R2 P-228 C.T. BUTCHART XN
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?
.RUBY PRINCESS INQUIRY 1.5.20R2 P-229 C.T. BUTCHART XN
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-230 C.T. BUTCHART XN
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
.RUBY PRINCESS INQUIRY 1.5.20R2 P-231 C.T. BUTCHART XN
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
MR BUTCHART: Yes, that’s correct.
COMMISSIONER: That’s why it had been set up, to deal with such things as they
occurred; is that correct? 30
MR BUTCHART: Yes, that’s correct.
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
.RUBY PRINCESS INQUIRY 1.5.20R2 P-232 C.T. BUTCHART XN
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-233 C.T. BUTCHART XN
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
COMMISSIONER: Thank you.
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?
.RUBY PRINCESS INQUIRY 1.5.20R2 P-234 C.T. BUTCHART XN
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-235 C.T. BUTCHART XN
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?
.RUBY PRINCESS INQUIRY 1.5.20R2 P-236 C.T. BUTCHART XN
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
.RUBY PRINCESS INQUIRY 1.5.20R2 P-237 C.T. BUTCHART XN
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-238 C.T. BUTCHART XN
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
.RUBY PRINCESS INQUIRY 1.5.20R2 P-239 C.T. BUTCHART XN
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
.RUBY PRINCESS INQUIRY 1.5.20R2 P-240 C.T. BUTCHART XN
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-241 C.T. BUTCHART XN
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-242
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
<THE WITNESS WITHDREW [4.21 pm]
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
COMMISSIONER: Thank you.
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-244 K. RESSLER XN
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
MS RESSLER: That’s correct.
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?
.RUBY PRINCESS INQUIRY 1.5.20R2 P-245 K. RESSLER XN
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
COMMISSIONER: Thank you.
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?
.RUBY PRINCESS INQUIRY 1.5.20R2 P-246 K. RESSLER XN
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.
MS RESSLER: That’s correct.
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-247 K. RESSLER XN
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
.RUBY PRINCESS INQUIRY 1.5.20R2 P-248 K. RESSLER XN
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
.RUBY PRINCESS INQUIRY 1.5.20R2 P-249 K. RESSLER XN
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-250 K. RESSLER XN
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 - - -
.RUBY PRINCESS INQUIRY 1.5.20R2 P-251 K. RESSLER XN
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
MS RESSLER: That’s correct.
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.
COMMISSIONER: Yes. 45
.RUBY PRINCESS INQUIRY 1.5.20R2 P-252 K. RESSLER XN
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?
.RUBY PRINCESS INQUIRY 1.5.20R2 P-253 K. RESSLER XN
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
.RUBY PRINCESS INQUIRY 1.5.20R2 P-254 K. RESSLER XN
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?
MS RESSLER: 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?
.RUBY PRINCESS INQUIRY 1.5.20R2 P-255 K. RESSLER XN
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
MS RESSLER: That’s correct.
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.
MR BEASLEY: Right. 35
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-256 K. RESSLER XN
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?
.RUBY PRINCESS INQUIRY 1.5.20R2 P-257 K. RESSLER XN
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
MS RESSLER: Correct.
MR BEASLEY: And they assessed it as medium risk.
MS RESSLER: Correct. 40
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-258 K. RESSLER XN
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?
MS RESSLER: That’s correct.
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.
MS RESSLER: That’s correct.
45
MR BEASLEY: Were they physically distancing – that was - - -
.RUBY PRINCESS INQUIRY 1.5.20R2 P-259 K. RESSLER XN
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-260 K. RESSLER XN
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?
.RUBY PRINCESS INQUIRY 1.5.20R2 P-261 K. RESSLER XN
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?
.RUBY PRINCESS INQUIRY 1.5.20R2 P-262 K. RESSLER XN
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-263 K. RESSLER XN
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.
COMMISSIONER: Yes. 10
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?
MS RESSLER: Correct. 30
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
MS RESSLER: Correct.
COMMISSIONER: We don’t have time for that now.
45
MS RESSLER: Okay.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-264 K. RESSLER XN
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?
MS RESSLER: Correct. 15
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-265 K. RESSLER XN
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-266 K. RESSLER XN
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
MS RESSLER: Correct.
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
.RUBY PRINCESS INQUIRY 1.5.20R2 P-267 K. RESSLER XN
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-268 K. RESSLER XN
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.
COMMISSIONER: Thank you.
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-269 K. RESSLER XN
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?
MS RESSLER: Correct. 25
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
MS RESSLER: Correct.
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.
MS RESSLER: Correct. 45
.RUBY PRINCESS INQUIRY 1.5.20R2 P-270 K. RESSLER XN
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?
MS RESSLER: Correct.
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
.RUBY PRINCESS INQUIRY 1.5.20R2 P-271 K. RESSLER XN
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
.RUBY PRINCESS INQUIRY 1.5.20R2 P-272 K. RESSLER XN
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
MR BEASLEY: All right.
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
.RUBY PRINCESS INQUIRY 1.5.20R2 P-273 K. RESSLER XN
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-274 K. RESSLER XN
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
.RUBY PRINCESS INQUIRY 1.5.20R2 P-275 K. RESSLER XN
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
COMMISSIONER: Thank you.
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.
.RUBY PRINCESS INQUIRY 1.5.20R2 P-276
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
<THE WITNESS WITHDREW [5.27 pm]
MATTER ADJOURNED at 5.27 pm ACCORDINGLY20
.RUBY PRINCESS INQUIRY 1.5.20R2 P-277
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
THE WITNESS WITHDREW P-242
KELLY-ANNE RESSLER, AFFIRMED P-243
EXAMINATION-IN-CHIEF BY MR BEASLEY SC P-243
THE WITNESS WITHDREW P-276
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