Witness Statement of CAPT Brett Crozier, USN
On 8 May 2020, I was interviewed via video teleconference in connection with a command
investigation concerning chain of command actions with regard to the COVID-1 9 outbreak
onboard USS THEODORE ROOSEVELT (CVN 71).
What follows is a true and accurate representation of my statement for this investigation.
Witness Name: CAPT Brett Crozier, USN
Position:
Former Commanding Officer, USS THEODORE ROOSEVELT (CVN 71)
Email Address: ) 6)
Phone(s):
(b) (6)

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Introductory statement:
In late March 2020 COVID-19 was rapidly spreading onboard the USS THEODORE
ROOSEVELT. I, along with the medical professionals and fellow warfare commanders, was
growing more concerned with the ongoing process to isolate Sailors individually off ship. We
knew any delay in isolating Sailors greatly increased the risk of transmission in a shipboard or
open bay environment on base. We determined that the only way to effectively limit the spread
of COVID-1 9 was to place as many Sailors as possible in individual isolation rooms ashore.
Due to limitations on base, local hotels in Guam were viewed as the only viable option and best
way to eliminate the vims, clean the ship, and rapidly return the TR to sea when required.
At that time the operational chain of command was discussing all possible options to
combat the spread of the virus. The extended deliberations were causing delays to a fmal
decision, and fighting this invisible enemy presented a situation where the decisive action I
wanted to take was an unavailable action at my level.
My intent in sending the email on 30 March was to bring a sense of urgency to a rapidly
deteriorating and potentially deadly situation onboard the TR and avoid a larger catastrophe and
loss of life . Although my method may have been imperfect, I reached out to those in my Chain
of Command whom I believed were in the best position to provide immediate assistance to
expedite the necessaiy decision and action. Despite possible long te1m repercussions to my
career, I acted in what I believed was in the best interest of the Sailors aboard TR.

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 The Following is a Summary of the Interview conducted on 08 May 2020​:
I assumed command of THR in November 2019, just before THR entered Composite Training
Unit Exercise (COMPTUEX). The XO (CAPT (b) (6) ) arrived via COD just prior to the Da
Nang visit.

Vietnam

The decision to execute the Da Nang port visit (PVST) was planned and approved prior to my
taking command in November. The schedule of deployment port visits was provided to CSG-9
and THR by C7F. There were only 16 reported cases of Coronavirus Disease 2019 (COVID-19)
in Vietnam prior to THR pulling in on 5 March, and all of those ​were clustered up in Hanoi ​over
500 miles away. The risk of transmission under those facts seemed low. No one above me in
the chain of command asked for our assessment of the COVID-19 risks in Da Nang, but as a
command, THR took a conservative approach to minimize risk to THR personnel.

The THR provided an advance team to Vietnam. The team arrived on the 27​th​ of February; they
flew from Tokyo to Da Nang. The Team had to take a different flight than previously planned to
avoid a connection through Seoul, Korea, because Korea was considered a high risk area at the
time.

We took Vietnam’s total of 16 reported cases of COVID-19 in Hanoi at face value. We had no
indication the numbers were high, low or the locations were accurate or not. We were skeptical
that there were no cases outside of Hanoi. From what we knew of the cluster growth around the

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 world at that time, we attributed the lack of cases to a possible lack of testing. The Country team
for Vietnam was working closely with Vietnamese officials, and said they (the Vietnamese
officials) were very proactive in preventing the spread of COVID-19 in the country and
reiterated that the only known cases were in Hanoi.

Prior to pulling into Da Nang, THR put in place a formal screening process for incoming COD
flights that brought Vietnamese Distinguished Visitors out to the THR for an underway visit.
The THR released a Da Nang liberty instruction, and also created and provided a liberty brief for
the crew that was looped on Ship’s TV. There was a piece on COVID information and concerns
- washing hands and general coughing and sneezing protocols was part of our continuous
education piece that we also discussed in our weekly printed THR news magazine. XO and
medical were participants in the video brief. It was about 30 minutes in length and was required
that all hands review and document completion prior to being permitted to depart THR on
liberty. In addition, I addressed the crew via the 1MC regularly to communicate concerns I had
heard regarding our schedule, the upcoming port visit, or anything else the Sailors had been
discussing. Prior to pulling in to Da Nang, most of the Sailors' concerns were about liberty,
hotels, and ferry transport to the pier from the ship. The THR also provided liberty information
cards to all Sailors that departed the ship in Da Nang. These cards had information regarding off
limits locations, local sites, emergency THR contact information, and other general information.
I don’t recall now whether there was any COVID info on the liberty cards.

Hotels used by THR Sailors were pre-screened by the Vietnamese Government and the US
Country team (including NCIS). Sailors were required to get hotel reservations at a prescreened
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 hotel prior to leaving the ship if they wanted to spend the night ashore. Hotels weren’t approved
by the Vietnamese government until the day prior to PVST. All Sailors needed to have a hotel
voucher verifying their reservation. The crew’s shore liberty was confined to Da Nang proper, no
one was allowed to leave that area unless they were on an approved MWR trip.

The biggest impact to liberty during the Da Nang PVST was the sea state while at anchor; it
delayed getting Sailors to shore and many MWR tour events were cancelled as a result. Prior to
arriving, I cancelled all planned medical and culinary professional exchanges following the
recommendations of the THR Medical Department due the potential risk of COVID-19 and
exposure to high risk areas like local hospitals or commonly used galleys both ashore and
onboard the THR. I informed CCSG-9 at a Warfare Commanders Board (WCB) prior to pulling
in. He did not express any issues with cancelling these events.

The C7F TASKORDs concerning COVID-19 and mitigations throughout the AOR were
discussed and followed. I directed the SMO to review and provide a brief for the THR and to
forward a copy to the CSG staff to be further disseminated to other members in the strike group.
The SMO is the informal ‘Force Surgeon’ but doesn’t get a concurrent fitness report from
CCSG-9.

Prior to pulling in (for those Vietnamese and US Country Team visitors to THR underway) and
while in port in Da Nang, non-THR personnel were allowed onboard only after a medical
screening. They were given questions about travel in the last 14 days, personal medical
symptoms, and contact with any foreign travelers from specific areas; if “yes” was given to any
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 questions, then their temperatures were taken and further diagnostics were completed prior to
coming on board. Certain previous travel locations or contact with foreign travelers from
specific high risk COVID-19 areas precluded visitation to the THR and was in compliance with
all protocols. A total of around 55 Vietnamese guests visited the ship while at anchor, much less
than normal for a CVN foreign port visit. A similar screening was done for returning THR
Sailors, where they were asked about symptoms or contact with anyone from a COVID-19 high
risk country. Vietnam officials were also concerned about transmission from our Sailors and
placed additional procedures in place to monitor our Sailors going ashore on liberty.

The Big Top event on 6 March was moved from the THR to a local hotel due to sea states and
concerns with the safety of Sailors and guests. The hotel conducted personnel screenings; the
US Navy did not have control of access to the hotel due to the large number of guests at the hotel
that were not attending the event. Hotel screening was similar to the ship with published
screening questions and Hotel staff standing by for follow-up questions and to take temperatures
if required.

On 6 and 7 March, some MWR tours were cancelled due to sea states and the delays in getting
Sailors ashore. On 8 March, I cancelled all MWR tours ashore as well as Vietnamese tours to
the THR upon notification that two British citizens out in town tested positive for COVID-19.
Our records and inquiries identified 39 THR and BKH Sailors that either were currently staying
at the Vang Hotel in Da Nang, or had stayed there previously during the PVST. These persons
under investigation (PUI’s) were assessed to have possibly been within 6 feet of either of the two
British Citizens for more than 10 minutes at some point during their stay at the Vang Hotel. This
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 contact could have taken place at the hotel bar, restaurant or pool area; or any common area of
the hotel. Although their proximity to the British Citizens was not confirmed, we took this
conservative approach in order to reduce future risk. Because any of them might have come in
contact with either of the two British citizens, we decided to screen all of them and perform a
COVID-19 test prior to them getting back onboard the THR. Those Sailors still ​in the hotel
remained in isolation there until​ they could be tested later in the afternoon. By the end of 8
March, all 39 Sailors were isolated on the pier, had tested negative, and showed no symptoms of
COVID-19.

As a result of the positive cases of COVID-19 in Da Nang, I cancelled further liberty on 8
March, though I did not order a blanket recall because of sea states and concerns with our ability
to get everyone back onboard the ship safely that day. My intent was to get everyone back to the
ship over the next 24 hours in an orderly and safe process. I didn’t want over 2,000 Sailors
sequestered on the pier, and not able to maintain social distance, due to liberty boat delays as a
result of the challenging sea states.

Overall, the Sailors were frustrated because of the delays in departing the ship on liberty during
the PVST, and the cancellation of some MWR tours. However, throughout the PVST, they
behaved better than I could have expected. We had zero liberty incidents ashore and the crew
performed above average considering all the challenges and restrictions.

When it came time to depart anchorage at Da Nang, though we didn’t need a harbor pilot, it was
required that we have one by the Da Nang port authority. The harbor pilot did wear a mask, but
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 the rest of the crew did not wear masks while the pilot was on the bridge. The pilot also
completed a pre-screening protocol prior to coming onboard. He was onboard for about 30
minutes.

COVID-19 Mitigation Aboard THR

Prior to the THR getting underway on 9 March, all 39 PUIs identified in Vietnam were
segregated to two separate berthing areas (Male/female) with their own heads. Some BKH
Sailors, who were from the initial 39 PUIs identified, also stayed on THR (approximately 5 of
the 39) due to the larger spaces available on a CVN. ​The THR leadership (Triad and Heads of
Departments - HODs) had discussed and prepared isolation procedures prior to entering port.
We made decisions about the berthing locations should it be necessary. However, 39 Sailors
was a far higher number that we had planned for. ​Our original plan anticipated fewer people
such that we could have placed them in single person staterooms with a limited access head. The
goal initially was to keep the PUIs together to minimize exposure to the rest of the crew, and
ensure we could provide adequate medical and logistical care to them for the next 14 days. Their
only personnel contact was with medical department Sailors who were wearing proper PPE. The
crew was aware of PUIs on board, and I confirmed with them on the 1MC to heighten awareness
of potential risks to COVID-19. I believe CMC spoke with and emailed the CPO Mess, and the
XO was also communicating with all Khaki. We utilized the Ship TV to focus on mitigation.
e.g., reiterate the need to wash hands, cover your face when sneezing or coughing, and go to
medical if you have any of the known COVID-19 symptoms. These messages, along with
directions regarding the use of diluted bleach to clean commonly touched areas of the ship, were
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 also recurring themes discussed on the 1MC, and at various departmental meetings and
discussions. There was ​no specific guidance or objection from the CSG about our response plan
or crew messaging.

I am not sure which official guidance we used to identify the PUI’s, but we took a conservative
approach initially in identifying the 39 Sailors from Da Nang. The Senior Medical Officer
(SMO) was very proactive about reaching outside the ship, e.g., big Navy Medicine, the
C7F/CPF Surgeons. The Fleet guidance was changing pretty rapidly as we were going through
this and adapting to the changing environment. I directed the SMO to attend WCBs in order to
provide medical updates and recommendations on the current COVID-19 situation. We tested
all 39 PUIs on day 14 (22 March) and all tested negative. A Navy bio-med team joined the ship
after the port call and they were able to conduct the tests on 22 March, as well as all subsequent
testing done onboard.

CCSG-9 did not provide specific guidance for the isolation of the 39 PUIs, and no concerns were
voiced with the response plan we developed and implemented. Everyone believed we were
implementing the best response options considering the limitations we had onboard while
underway.

Departing Vietnam on 8 March, Guam had been discussed as our next port call in lieu of
Thailand due to growing COVID-19 concerns in the region and THR maintenance requirements.
The THR had a couple major maintenance items to complete (steering and propulsion related)
and Guam provided the best support to accomplish them. We also wanted to complete some
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 ESF operations with AMA ESG, e.g. a PHOTOEX and integrated flight operations, and we
would be able to do that while transiting towards Guam.

COVID-19 Mitigation for COD flights

On 7 March, the VRC detachment left Da Nang and arrived at Clark AFB, Philippines. The
​
CODs flew back onboard on 11​ March
bringing the US Navy infectious disease medical
​
personnel. We continued COD operations until 18​ March,
when they flew to Kadena AFB,

Okinawa.

We considered CODs as a potential risk vector, and THR and CVW-11 put measures in place to
mitigate that risk. All COD passengers had to answer specific COVID-19 screening questions,
and would be denied boarding or evaluated further if necessary. Due to the increasing number of
COVID-19 cases in the Philippines, we made an internal decision to push all future passengers
and parts to Kadena AFB, or Andersen AFB to avoid further flights to PI.

Managing COVID-19 Aboard THR

We received our first positive test for COVID-19 on March 24th at 0200 for two sailors who had
earlier reported to medical for COVID-19 symptoms. A third Sailor tested positive later that
morning. These three Sailors were not from the original 39 PUIs identified departing Da Nang.
The entire crew was informed of the positive cases in an effort to enhance basic preventive
measures (hand washing, sanitization efforts, etc..). We immediately instituted ‘bleachapalooza’
utilizing a recommended bleach water mixture to wipe down all high contact areas (handrails,
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 door knobs, ladder rails, etc..). We performed bleaching 2-3 times a week after Vietnam and
before 24 March. After 24 March, we bleached 1-2 times a day with all hands. I believe this
continued twice a day until I left the ship.

As soon as the positive tests were reported, we knew our schedule would change. We began
steaming towards Guam to be within range to medevac those Sailors that tested positive. CAG
and I cancelled all other flight operations. ​There was no question or objection to this plan ​or
other direction from CSG-9 or C7F. We initially discussed the utilization of CODs to fly Sailors
to Anderson AFB; however, the Air Force Base was concerned with the transport of COVID-19
positive Sailors. Accordingly, we delayed medevac flights until the next day to fly helicopters to
Naval Base Guam for further transport to Naval Hospital Guam. Utilizing contact tracing, we
identified close contacts with our known positive Sailors, and medically screened and tested
them with the intent to quarantine and limit further contact. Those that were identified as having
been in contact with the known positive cases were initially isolated to berthing in the aft portion
of the ship, and we used the CPO mess exclusively for the feeding of these Sailors. Once we
pulled into Guam the morning of March 27th, we transferred additional Sailors who had tested
positive ashore.

Alternate Port Options

Prior to pulling in to Guam, there were a number of informal discussions at my level with the
Warfare Commanders and “Bubbas,” as well as discussions with CSG-9, about pulling into a
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 different port. We looked at San Diego, Hawaii, and Okinawa. There were time/distance
problems with a high SOE – 10-12 days to San Diego. The final decision to pull in to Guam was
made by C7F. There were no formal COA briefs and no CSG guidance or direction regarding
other possibilities – just RFIs from CPF, C7F, and CSG-9 as we explored options prior to
arriving in Guam.

There were weekly C7F Commander Update Briefs (CUBs) held via VTC. The format was
unchanged and included weather, Intel, Force laydown, and then major events. The Warfare
Commanders or our representatives would attend. There was no discussion about specific THR
COVID-19 COAs post Guam at the CUBs, and I don’t know if CCSG-9 talked to C7F about
possible COAs outside of those meetings.

At the regularly scheduled CSG Warfare Commanders’ Board we discussed the current number
of positive COVID-19 cases, the possible exponential growth of future positives, and various
ways to mitigate the risk of COVID-19 to the crew. This included an analysis of the minimum
number of Sailors required to operate the THR safely at sea, and who to prioritize getting off the
ship if the decision was made to subsequently move the THR to another port. Various studies
from the Navy Marine Corps Public Health Center ​and current world and U.S. trends were used
to predict the spread and possible fatalities as a result of COVID-19. When discussing these
various COAs of steaming towards or sending Sailors to far more distant ports and the obvious
limits of each, there was a sense of concern due to the time it would take to execute any of these
plans. We had no information on the matter, but had we been aware then, that housing Sailors
individually in hotels in Guam was a viable and realistic COA, we may have had less concerns
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 because we knew at our level that moving Sailors ashore into hotels was the quickest and most
effective way to combat the spread of COVID-19. At one of the WCBs we were reminded by
CCSG-9 to review our command Casualty Assistance Calls Officer procedures to ensure we
were prepared for a possible fatality.

Managing the Spread of the Infection onboard THR

A copy of NAVADMIN 064/20 dtd 11 March (regarding social distancing and tracking
measures) was sent to all Khakis for further dissemination to the entire crew. We noted,
discussed and tried to resolve the differences between CDC and the NAVADMIN. We thought
the NAVADMIN might not address actual risk, and the CDC was the “gold standard.” The
NAVADMIN focused on COVID across the fleet, and was not ship specific. The NAVADMIN
was helpful to bound the problem; it was clear that the NAVADMIN said to – “do best you can.’
The NAVADMIN was definitely reviewed by all, but the subsequent NAVADMINs became
more useful as the Navy was better able to understand the complexity of the threat.

As additional members of the THR crew tested positive, they would remain isolated in medical
until we could get them off the ship. Once they departed the ship, they would be screened by
Naval Hospital Guam personnel and placed in designated quarters on base. In most cases that
meant several positive Sailors co-located in a house on base. We would also identify PUIs based
on contact tracing that medical conducted. We would attempt to isolate those Sailors onboard
until we could eventually get them tested and off ship into facilities ashore. Contact tracing
became difficult as we considered the close proximity all Sailors were to one another while
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 onboard. We generally tried to use 10 feet proximity as a guideline to identify Sailors that might
be bunking together, working in the same shop together, or eating next to a positively tested
Sailor. As noted earlier, PUIs were initially moved to berthing areas in the aft portion of the
ship. We used the CPO Mess as the designated isolation area to feed them away from the rest of
the crew. The SMO and Bio-medical team were heavily involved in our mitigation planning,
and ultimately concurred with the plan. I am aware of NTRP 4-02.10 (Shipboard Quarantine
and Isolation) and all the governing NAVADMINs and instructions released at the time, and we
applied what we could to the best of our ability with the limitations we had onboard.

The other immediate actions taken onboard were to close dental, gyms, the barber shop, and stop
self-serve in the mess lines. (Sailors with proper PPE would serve food to the dining Sailors).
Required meetings, duty section turnover, and events such as church services were only held on
the Flight Deck or Hangar Bay in open air to maximize social distancing. The XO was doing a
good job highlighting COVID-19 updates for all the khaki and informing them of steps we were
taking across the ship, to be further disseminated to the crew. I would also utilize the 1MC to
inform the entire crew of the efforts that we were taking onboard and explain why we needed to
take some of these steps. THR leadership was focused on COVID-19 throughout the day and
looking for new ways to maximize social distancing across the ship. The HODs were also
messaging and communicating to Sailors on a daily basis. However, even with all of these
measures implemented, we simply could not mitigate the risk that berthing compartments, heads,
and open messing presented to almost everyone onboard. Most of the crew worked in close
quarters, lived in close confines in large shared berthing areas with common heads, and dined in
extremely large messing areas.
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 We had a limited number of medical masks onboard and had to prioritize their use for Sailors
that had tested positive for COVID-19, medical personnel, food service personnel, and those
Sailors that were deemed to have been in close contact with positive cases. Thousands of masks,
gloves, and face shields were on order but there were no estimated shipping or arrival dates. We
began to encourage Sailors to utilize DC flash hoods as impromptu masks to help protect
themselves from exposure. Additionally, we continued with our education measures, the XO
made morning announcements and I made 1MC calls every other day. My primary message was
that the health and welfare of the crew is my number one priority and is key to warfighting. I
also told everyone to think of cleaning and sanitization as important as an aircraft pre-flight, a
pre-fire weapons check, or 3M check on a critical system. I also reiterated that this is an all
hands fight and that I needed everyone to do their part to maximize their distance from one
another, stay clean, and report to medical if they weren’t feeling well. Overall, I felt that we
were doing everything we could to protect the crew, but there were still many limitations
onboard a ship that would ultimately put them at risk.

Communications and Battle Rhythm

Following the departure from Da Nang, we continued routine carrier operations at sea (flight
ops, underway replenishments, etc…). In addition to safely executing these operations I met or
spoke daily with the XO, CMC, and THR HODs about COVID-19 mitigations. Initially
following our first positive cases on 24 March, SMO and the medical department were tasked
with the tracking of necessary medical information and providing updates to the CSG and THR
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 leadership. As we approached Guam and the number of positive COVID-19 cases increased, I
stood up an Emergency Coordination Center (ECC) headed by the CDCO (O-5, Commander) to
answer RFIs, track movement of Sailors off ship, and liaison with NBG staff to coordinate care
for Sailors ashore. The ECC quickly became a 24/7 operation to meet the growing information
demand signal and coordinate Sailor movements. Additionally, once pierside we began daily
meetings with the THR Triad, SMO, OPSO, ECC lead, and other key THR personnel. I also
conducted a daily meeting with the Warfare Commanders (CAG, DCAG, SMO, DESRON, and
XO) to ensure we were all aligned and addressed any concerns. Although these were
challenging times, I had a decent sleep schedule prior to 24 March, after which I was probably
averaging 4-5 hours of sleep a night.

My primary point of interaction on the CSG Staff during this time was the COS, and he was
extremely busy answering RFIs for HHQ and running the staff. I often also spoke with the N3 to
discuss the numerous planning efforts.

During the month of March, there had been little internal communication between the CVNs or
other ships about COVID-19. I directed the THR leadership to start collecting lessons learned
and forward them to their counterparts on the RRN, but there had not yet been any discussion
with fellow CVN COs at my level due to the rapid development of the situation.

Two days prior to pulling in to Guam we released the LOGREQ, inside the normal timeline
requirements, that focused primarily on the logistics necessary to safely pull pier side. Tugs,
pilots, line handlers, and other crucial elements were addressed. I spoke separately with the
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 NBG CO about the necessary arrangements for offloading both positive and negative Sailors
once pier side.

Guam

When we approached Guam, the harbor pilot embarked and wore a mask while onboard. All
THR Sailors on the bridge were also wearing masks. Guam personnel ashore set up a number of
shore services. Our personnel stayed behind a line on the pier until Guam personnel retreated to
prevent cross contamination with the shore side. Mail delivery was halted and only critical parts
and provisions were swung by crane onto the aircraft elevator. Sailors leaving the ship and those
assisting all wore PPEs, i.e., face masks and gloves. I spoke daily with the Naval Base Guam
CO to coordinate movements and assess our process. Once safely pierside in Guam, our primary
focus shifted from safe operations at sea, to the health and well being of our Sailors. Sailors
departed later that day for berthings ashore. The process began in a slow but deliberate manner
to avoid creating large groups on the pier.

In addition to their COVID-19 status, we also prioritized Sailors going ashore based on their job.
We prioritized COVID-19 positive Sailors first, then key reactor watchstanders that we wanted
to isolate to ensure they remained healthy and available for future reactor plant operations (one
reactor plant had to remain online – no shore power available in Guam), and then PUIs. The
high prioritization of reactor watchstanders was to ensure we had a virus free team to reboard
and assume the watch should a rapid underway tasking arrive. Testing had to be done before
Sailors were allowed to debark the ship. Both the negatives and positives were segregated. The
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 initial plan was to anticipate and be prepared to account for up to 500 positives ashore, many of
which could stay at NGIS or unused base houses. Negative tested Sailors would be housed off
the ship in various large gyms on base (e.g. base gym, unused school gyms). The NBG was
doing a good job configuring spaces, but we were challenged by support logistics for our Sailors
ashore since our Sailors on THR couldn’t go ashore to help the ones who had been removed
from the ship (e.g., medical testing, food delivery).

During the early phase in-port Guam, I was in direct communication with both the Base CO and
Hospital CO. At that time, the hospital CO expressed concerns about social distancing with the
negatively tested Sailors who were housed in the open spaces in gyms. 2-3 days after our
arrival, CMC and THR Chaplain were allowed to travel around to visit and inspect our Sailors
that had moved on base and provide direct feedback about the conditions ashore.

Due to either prior exposure, or due to the close quarters and open-bay berthing in the gyms, and
the 80% confidence/accuracy rate of the negative tests, Sailors housed in these facilities began
showing symptoms and many subsequently tested positive. The Naval Base Guam Hospital also
conducted routine checks of all ashore facilities to ensure they were in compliance with current
instructions. The Hospital CO conveyed to me on several occasions that her team was concerned
with the limited space between cots, as well as the ventilation that was inadequate to prevent the
spread of the virus.

Once pierside, moving Sailors ashore was a challenging and delicate balance between risk of
transmission and adequate conditions ashore. Reports we received initially indicated that over
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 the first couple days there were inadequate facilities ashore. While NBG was doing all they
could on short notice, living necessities were lacking, social distancing was often insufficient,
food was becoming an issue, and the Sailors were growing frustrated. I made a decision that, as
a rule of thumb​, if we determined that there were adequate and available cots ashore, proper
social distancing space, and confirmed suitable feeding and medical care, then we sent as many
Sailors ashore as we could. This helped reduce the number of Sailors aboard and therefore
increase our social distancing.

I knew the local hotels were largely empty, but I was unaware that the Navy had officially stated
that they did not need assistance from Guam outside of base facilities. I was aware, anecdotally,
of the difficulties in obtaining permission for cruise ships to dock in the United States, as well as
the time consuming and high level coordination that would be needed to move THR Sailors to
Naval Base Guam facilities outside of the main base. These constraints were limiting, led to
slow progress, and consequently increased the overall risk to Sailors as we tried to combat
COVID-19.

I was aware that there was a COA being discussed that involved III MEFs offering up to 5,000
individual isolation rooms for potential occupancy on Okinawa. This COA necessarily meant
busing Sailors to Anderson AFB, flying them on Navy transport planes to Kadena, and then
busing them to USMC facilities on Okinawa before they could begin isolation. In addition to the
extended timeline required to move up to 4,000 THR Sailors to Okinawa, this would limit our
ability to get underway quickly if required in Guam, and we had concerns with the actual
number of individual isolation rooms available. I spoke to the senior Navy Captain at Kadena
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 AFB and he expressed the same concern to me about the berthing availability. I passed on that
information to CCSG-9. When this concern was relayed to C7F during a VTC, it was reported
that the initial offer was actually for 500 vice 5,000 rooms. In the end, this was discounted as a
viable COA due to logistical challenges, distance from THR, and likelihood of insufficient
isolation rooms.

During discussions with the Base and Hospital CO and the CMC, the term “FEMA shelters” was
used to describe facilities ashore. This term wasn’t meant as a derogatory comment, but a
description of the open bay spaces ashore that provided adequate shelter from the elements as
would be necessary following a natural disaster and managed by FEMA. However that didn’t
spread out our Sailors far enough to be effective isolation against the spread of COVID-19
considering the protocols being developed and implemented in response to the pandemic.

The XO submitted a Memo for the Record via email on 28 Mar, and the XO and I were aligned
in our concerns. The XO wanted to document our attempt to push for better facilities. THR did
not have the ability to fully comply with all COVID-19 NAVADMINs and other guidance issued
as of 30 March. I relayed these concerns to CCSG-9 and indicated that THR was still going to
strive for compliance despite our limitations.

The THR crew was generally frustrated and concerned by the lack of space, food, and facilities
ashore. Some members of the crew ashore began ordering pizzas from an on base restaurant
because the food provided was insufficient. Those on the ship were eager to get ashore into
better isolation quarters. Many of them had their cell phones and had ready access to the TV and
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 internet news and COVID-19 coverage. The USO in Guam did a great job of providing some
basic supplies to Sailors ashore, and the NEX eventually set up a way for Sailors to order
supplies online. I received information and feedback about conditions ashore from the
ombudsman, social media, direct reports from the CMC and THR Chaplain, and various social
media postings from Sailors.

The Warfare Commanders discussed the study of the COVID-19 outbreak on the cruise ship
Diamond Princess. We realized the cruise ship study was not a perfect comparison to our
situation - but it was useful information. Ultimately, we felt that while the THR had a more
resilient demographic to fight the virus than the Diamond Princess, the THR had a worse
configuration with communal berthing and head facilities and limited isolation quarters onboard.
Therefore, we projected a higher infection rate but much lower mortality rate. We also
considered other outbreak models to include the one referenced in the email.

At the regularly scheduled Warfare Commanders’ Board we discussed the current number of
positive cases, the possible exponential growth of future positives, and various options to
mitigate the risk of COVID-19 to the crew. SMO, THR was not normally at these briefs, but
began attending them following the first positive case onboard. Various studies ​from the Navy
Marine Corps Public Health Center ​and current world and U.S. trends were shared with the
WCB and they were used to predict infection and possible fatalities of our crew as a result of
COVID-19.

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 CVW 11 email/document of 28 Mar 20 to CCSG 9 (Subj: PROPOSED PAPER / COURSE
OF ACTION FROM WARFARE COMMANDERS)
This email was unsolicited from anyone up the chain of command; we weren’t asked for it. The
pace of action was troubling to us, and Warfare Commanders were formally in writing pushing
information up the chain of command in hopes of​ breaking the bureaucratic logjam ​and get the
decisive action necessary to protect our Sailors. It was a place to put our thoughts, ideas, and
concerns together. All Warfare Commanders’ inputs, including my own, were included –
making it a collective opinion. Our intent was to send through CCSG-9 to the operational chain
of command. There was no specific response from CCSG-9 that I was aware of or told about,
and no action from above flowed down to our level. As a result, we felt that we didn’t move the
ball forward with the document.

I was informed by the CSG-9 Battle Watch Captain that there was a scheduled phone call with
the CNO, however it was cancelled for reasons that I was not aware of. The phone call might
have provided a more thorough understanding of wider Navy efforts to combat the virus onboard
and with our crew, allowed me to communicate our desire to get Sailors into effective isolation
quarters ashore, and instilled confidence that the situation was being rapidly addressed at the
appropriate levels.

My email and letter of 30 March (Subj: REQUEST FOR ASSISTANCE IN RESPONSE
TO COVID-19 PANDEMIC)
I sent the email with the intent to bring a sense of urgency to what was a rapidly deteriorating
and potentially deadly situation. We estimated having at least 500 - 600 positive COVID-19
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 cases at the current pace of infection (​this estimate was low and less than half the actual number
of positive cases​). Even at a significantly lower mortality rate of 1% (compared with current
3-4% trends throughout the world at the time), we estimated that five to six Sailors could die if
we didn't take immediate decisive action. I was clear that if we had to, we could and would fight
the ship at sea in our current condition, but we wouldn’t have to do that if we took immediate
action against the spread of the virus. I believe everyone involved was well intentioned, but
some up the chain of command were proceeding more slowly than I would have liked and
getting unnecessarily wrapped up in the status quo of COA development. From my perspective,
even just one more week of routine planning would have resulted in another week of exponential
growth in positive cases and greater risk to more Sailors. We wanted to stop the administrative
bureaucracy (e.g., debating whether to put the SSN or DODI number on testing kits) and quickly
bring focus back to what we thought was the best, and only viable COA (getting people off ship
and into effective isolation quarters). My perspective was that we were tackling this problem
relying on normal routine staff work, and as a result a ​critical decision was not forthcoming in a
timely and decisive manner ​ – so I sent up a red flare. Flag Officers always say, “if you need
help, let us know.” I sent it to the flag officers on the email because I know they are biased
towards action, can make quick decisions, and I knew they could solve the problem on behalf of
the Sailors. The Air Boss replied immediately and said thanks for “the red flare” and implied
that he would assist in getting the help needed - that was my intent.

I didn’t include C7F on the 30 March email because I wanted to send it to flag officers in my
chain of command that I know. C7F staff was still trying to bound the problem, and information
flow there suggested they might see the email as a hindrance to normal staff work vice see it as a
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 red flare. In hindsight, there was no good reason for not including C7F and I suspect that he
would have been as responsive as everyone else was.

In paragraph 4 of my letter, it states that there were “limited measures to slow spread of disease.”
What I was explaining is that we were in fact doing all we could at that point with the resources
and spaces available to us, hence, “limited measures.” We had very limited resources such as
masks and gloves, and limited spaces that would enable proper social distancing. Nonetheless,
we continued to see increased positive cases both onboard and in shore facilities.

I used the NIPR (unclassified network) to send the email on 30 March because we had been
working everything on the unclassified net, to include the NAVADMINS, and daily COVID-19
reports on the number of positive cases. The Diamond Princess case study and other COVID-19
products were also generated on the unclass side. I wanted a longer format to capture that
information; not something from the correspondence manual. The request was urgent in nature
and quicker to read on a government smartphone. I didn’t think everyone would be up on SIPR
and a timely response was desired. The email and attachments were only sent to those
individuals listed in the initial email, and subsequently forwarded to the JAG I was in contact
with after I was relieved of command. In hindsight, there was higher risk that the letter would
end up in the open press by sending it on an unclassified network, but that was not my intent. It
was not a classified document, and it could have still made its way to the press once it was
released on either platform. I also didn’t anticipate it would create difficulties with the Governor
of Guam who ultimately approved the request to move Sailors ashore. The isolation of Sailors

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 ashore in hotel rooms would have seemed to assist the Governor and Guam considering the vast
vacancies in hotel rooms on the island and resulting unemployment.

USS THEODORE ROOSEVELT (CVN 71) Medical Department ltr (TR med letter) of 31
Mar 20 (Subject indicating situation regarding COVID-19 on USS THEODORE
ROOSEVELT)
The SMO and the other signatories met with me to show me the signed copy of the letter. I
expressed my concerns to them about the letter and told them I thought may be viewed as
contentious and probably a little alarming. However, I also told them that, “I can’t tell you not
to send it if you believe you have a moral imperative to,” but asked them not to send it because I
thought that my letter from the day before would address their concerns. I didn’t know it was
sent outside the ship to a larger audience until sometime later. There were medical personnel
onboard THR who did not sign the letter - ​I have no personal knowledge why.

I am not aware of any friction between SMO and C7F Surgeon or others, besides the challenges
from the amount of RFIs the THR received. There did not appear to be anything unusual in the
professional or personal relationship between them. The SMO and his entire staff were
professional throughout in their support to me and the WCB in understanding the rapidly
changing information about the virus and developing response plans. They also did tremendous
work providing medical care to the 5,000 Sailors onboard.

I tested positive for COVID-19 on 2 April. The testing procedure for everyone was invasive and
included a swab inserted deep into one nostril. If the swabs were tested on board and evaluated
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 by THR Medical, results were available within a couple of hours. If swabs were tested and
evaluated in South Korea, results were available in 48-72 hours. Once I was evaluated as
positive I departed the ship and was housed in an individual isolation quarters in the Naval Base
Guam housing area. CTF 75 Sailors brought me three meals a day, and I received daily medical
checks and afternoon phone calls from the III MEF medical personnel. I ended up testing
positive two additional times throughout the month of April, and was finally cleared on
Saturday, 2 May.

Contact with the Acting Secretary of the Navy’s office

I was contacted by the A/SN CoS – Mr. Bob Love. He initially wanted to arrange a 1 April visit
for the A/SN. I had reservations as I believed a DV visit at that time would be a distraction and
risk A/SN to infection. I don’t know what A/SN would have accomplished by visiting. I asked
if this was like “Patton on the front line to provide motivation,” and was told, “yes.” I told him
we could make it work if required, but recommended “No.” I thought it would do more harm
than good and we could look at other ways he might communicate with the crew (letter, video
message on Site TV, etc..). Mr. Love later contacted me via email to cancel the visit. I spoke
with Mr. Love again and during that discussion I told him that I wanted to get as many Sailors
off the ship as possible and into effective isolation spaces. Mr. Love stated he would try to help.
The NBG CO later told me he was ordered to find space for a total of 4,000 Sailors ashore, the
vast majority of which would have to be in cots in large berthing areas and warehouses, and
would take some time to set up. A few days later Mr. Love called me and I thanked him for
assisting with support ashore, and followed up with an email a couple days later. Following the
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 news release of my 30 March letter, I spoke with A/SN by phone and he was angered that I had
not reached out to him personally about my continuing concerns.

When I sent the email on 30 March, I did not expect that I would be relieved of command. I
knew that my action would likely result in consequences down the road regarding future flag
selection, but I had planned on remaining in command to lead the THR through the current fight
and back out to sea. I sent the email because I was concerned for my Sailors and I was frustrated
that the decisive action that was needed was unavailable action at my level. A/SN told me in
person when he visited me in quarantine in Guam on 6 April that I was relieved because he lost
trust and confidence in me. However, based on incorrect comments he made to the press and
onboard the THR to the crew earlier that day, where he said I sent the email to 20-30 people, and
that I panicked as a leader and raised alarm bells unnecessarily, I think his decision was
premature.

I certify that the information in the statement above is true to the best of my knowledge or belief.

​, CAPT USN (Name)

15 May 2020​ ​(Date)

Name of Interviewer: RDML Paul C. Spedero, USN

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2000​ ​(Time)

 news release of my 30 March letter, I spoke with A/SN by phone and he was angered that I had
not reached out to him personally about my continuing concerns.

When I sent the email on 30 March, I did not expect that I would be relieved of command. I
knew that my action would likely result in consequences down the road regarding future flag
selection, but I had planned on remaining in command to lead the THR through the current fight
and back out to sea. I sent the email because I was concerned for my Sailors and I was frustrated
that the decisive action that was needed was unavailable action at my level. A/SN told me in
person when he visited me in quarantine in Guam on 6 April that I was relieved because he lost
trust and confidence in me. However, based on incorrect comments he made to the press and
onboard the THR to the crew earlier that day, where he said I sent the email to 20-30 people, and
that I panicked as a leader and raised alarm bells unnecessarily, I think his decision was
premature.

I certify that the information in the statement above is true to the best of my knowledge or belief.
(Name)

IS-~~ate)

ame o ~
"er:Kl)MC Paul c. Spedero, USN

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"'l..'l.£> S>

(Time)