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APPENDIX D: FINDINGS OF FACT
Table of Contents
Planning and Execution of Port Visit to Da Nang, Vietnam . D-1
Background and General Planning for the Port Visit . D-1
Historical Data and Significance of this Da Nang Port Visit . D-3
Other Coinciding Engagements . D-4
Planning and Preparation for COVID-19 Prior to Da Nang Port Visit . D-5
The Da Nang Port Visit . D-1 1
Notification of Close Contact (March 8th and 9th) . D-1 5
Actions during Transit to and Arrival in Guam Departing Da Nang until the First
Confirmed Case of COVID-19 . D-1 6
First Confirmed Case of COVID-19 until Arriving at Guam . D-24
Arrival in Guam . D-30
Development of and Response to Commanding Officer Letter of March 30, 2020
Warfare Commanders White Paper . D-39
Development of CAPT Crozier’s Letter and Email . D-40
Reactor Officer Letter . D-42
Medical Department Letter . D-43
Media Release and Subsequent Actions . D-44
Planning and Execution of Port Visit to Da Nang, Vietnam
Background and General Planning for the Port Visit
1 . On November 1 , 201 9, Captain Brett Crazier, USN, assumed command of the
USS Theodore Roosevelt (CVN 71) (TR).1
2. On January 17, 2020, TR departed San Diego, California for deployment.2
3. The Da Nang, Vietnam port visit was scheduled for March 5th through 9th and was
the second port visit of TR’s deployment.3
1 Crazier, B. CAPT Statement dtd 15 May 20; CNAP Statement dtd 13 May 20; “USS TR Change of Command” Schwartz, D.J. AN
(01 Nov 19) https://www.cpf.navv.miI/news.aspx/1 1 0877
2 CNAP Statement dtd 13 May 20
3 TRNOTE 5050 TR and CVW-1 1 Liberty Plan dtd 22 Feb 20; CCSG-9 Statement dtd 1 5 May 20
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4. The Department of State, Office of the Secretary of Defense, U.S. Indo-Pacific
Command (INDOPACOM), Commander, U.S. Pacific Fleet (CPF), the Vietnamese
Ministry of Foreign Affairs, the Vietnamese Ministry of Defense and the U.S. Embassy
Vietnam were involved in the Da Nang port visit planning.4
5. In the Commander, U.S. 7th Fleet (C7F) area of operations (AOR), the usual port
visit planning process is as follows:5
a. CPF sends a Planning Order to C7F.
b. C7F conducts a risk assessment, determines which asset will go to which
port, and determines which carrier strike group (CSG) or expeditionary strike group
(ESG) will conduct the missions.
c. C7F provides CPF with a suggested plan and CPF identifies ports for
strategic engagement.
6. INDOPACOM directed that the approval for the Da Nang port visit be held at the
INDOPACOM level due to the potential impact of COVID-19.6
a. C7F provided a brief to CPF staff on the risk of the Da Nang port visit and
CPF called C7F directly to ensure that all mitigation requirements from the C7F
TASKORD were met, to include such measures as temperature checks and
screenings.7
b. CPF’s final risk analysis was that the Da Nang port visit was low risk
based off of World Health Organization (WHO), Center for Disease Control (CDC), and
Vietnamese government inputs.8
c. On March 4, 2020, CPF forwarded a final port visit decision
recommendation to INDOPACOM recommending to go forward with the Da Nang port
visit based on CPF’s final risk analysis.9
d. Commander, INDOPACOM concurred in the recommendation to move
forward with the port visit.10
4 TR AAR For 5-9 March Vietnam PVST dtd 17 Mar 20
5 CPF Statement dtd 1 7 May 20; (S) CPF EXORD DTG 081 135Z JAN 20; CPF EXORD DTG 252242Z JAN 20; (S) CPF OPORD
201 , TAB A to APPENDIX 38 to ANNEX C(C-38-A-5)
6 CPF Statement dtd 17 May 20; C7F COS Statement dtd 21 May 20; (S) CPF COVID 19 TR VNM PVST Decision Slide
25FEB2020-1
7 C7F Vietnam Port Visit Decision Slide of 25 Feb 20; CPF Statement dtd 1 7 May 20
8 Email - CPF Surgeon to TR SMO and C7F Surgeon - Discussion with CDC Director dtd 26 Feb 20; INDOPACOM J07 Country
Health Risk to Force for COVID-19 dtd 4 Mar 20; CPF Statement dtd 17 May 20
9 Email (SIPR) - CPF to USINDOPACOM - DECISION: Theater Posture Operations dtd 4 Mar 20; CPF Statement dtd 17 May 20
10 CPF Statement dtd 1 7 May 20
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7. Prior to the port visit in Da Nang, TR sent an advance detachment to Da Nang to
prepare for the ship’s arrival.11
a. The Advance Detachment travel was modified to avoid layovers in Korea
because Vietnam began a policy of placing all travelers from China and Korea into
quarantine for 16 days as a matter of course.12
b. Members of the Advance Detachment attended several meetings with the
Da Nang People’s Committee and COVID-19 was the primary concern discussed during
the course of those meetings.13
c. The Da Nang People’s Committee showcased the steps that they had
taken to mitigate COVID-19 in the country and relayed that there were no active cases
of COVID-19 in Vietnam, all prior cases had been located in the northern part of the
country, and that there had never been any cases of COVID-19 in Da Nang.14
d. The Da Nang People’s Committee showcased their public health
campaign that they used to educate the population on how the disease is spread,
proper hygiene, and reliable sources of information.15
e. As a precautionary measure, the Da Nang People’s Committee requested
the cancellation or limitation of participation for large public gatherings.16
f. The Advance Detachment provided daily formal updates to the TR’s
Executive Officer (XO) via email and phone call. The Senior Medical Officer (SMO) was
cc’d on the daily update emails.17
Historical Data and Significance of this Da Nang Port Visit
8. TR was the second aircraft carrier to pull into Vietnam since the Vietnam War.18
9. USS Carl Vinson (CVN 70) had previously visited Da Nang in March 201 8. 19
10. TR’s visit commemorated the 25th anniversary of bilateral relations between the
U.S. and Vietnam.20
11 ADVON Daily Report dtd 27 Feb 20
12 ADVON Daily Report dtd 27 Feb 20; TR JUDGE Statement dtd 1 1 May 20
13 ADVON Daily Report dtd 27 Feb 20
14 ADVON Daily Report dtd 27 Feb 20
15 ADVON Daily Report dtd 27 Feb 20
16 ADVON Daily Report dtd 27 Feb 20
17 ADVON Daily Reports dtd 27 Feb 20, 28 Feb 20, 2 Mar 20, and 3 Mar 20; TR JUDGE Statement dtd 1 1 May 20
18 TR AAR For 5-9 March Vietnam PVST dtd 1 7 Mar 20
19 TR AAR For 5-9 March Vietnam PVST dtd 1 7 Mar 20
20 CPF Statement dtd 1 7 May 20; TR AAR For 5-9 March Vietnam PVST dtd 1 7 Mar 20
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1 1 . Presence in the Pacific region is routine and has helped maintain peace for more
than 70 years.21
12. Operating in the region supports regional security, stability, and prosperity.22
13. Operating in accordance with international laws, rules, standards, and norms
across the region enables the United States to reassure our allies and partners, and
keeps global trade flowing.23
Other Coinciding Engagements
14. On February 7, 2020, TR arrived in Guam and USS Bunker Hill (CG 52) (BKH)
arrived in Saipan for scheduled port visits.24
15. On February 10, 2020, TR and BKH departed Guam and Saipan.25
16. On February 15, 2020, Carrier Strike Group Nine (CSG-9) and USS America
(LHA 6) ESG conducted Expeditionary Strike Force operations in C7F AOR.26
17. Between February 22, 2020 and March 8, 2020, the USS America, the USS
Green Bay (LPD 20) (GBY), and the USS Blue Ridge (LCC 19) (BLR) were in Thailand
to support COBRA GOLD, a multinational combined joint training exercise.27
18. At the time of COBRA GOLD, Thailand was rated “yellow” by the INDOPACOM
risk matrix signifying moderate risk where COVID-19 cases occur in the community
without known contacts or exposures and/or with small outbreak clusters, swiftly
handled by public health interventions that limit disease transmission.28
19. Over 4,500 personnel were involved in COBRA GOLD. None of the personnel
who participated in COBRA GOLD contracted COVID-19 as a result.29
21 TR AAR For 5-9 March Vietnam PVST dtd 1 7 Mar 20
22 TR AAR For 5-9 March Vietnam PVST dtd 1 7 Mar 20
23 TR AAR For 5-9 March Vietnam PVST dtd 1 7 Mar 20
24 “USS Theodore Roosevelt, Pinckney Arrive in Guam for Port Visit” INDOPACOM (07 Feb 20) www.pacom.mil/Media/News/News-
Article-View/Article/2078206/uss-theodore-roosevelt-pinckney-arrive-in-guam-for-port-visit/ ;
“USS Bunker FHill Visits Saipan on Indo-Pacific Deployment” INDOPACOM (10 Feb 20)
www.pacom.mil/Media/News/News-Article-View/Articie/2079862/uss-bunker-hill-visits-saipan-on-indo-pacific-deployment/
25 Email - CCSG-9 BWC - TR Command Investigation dtd 12 May 20
26 “Theodore Roosevelt, America Str ke Groups Conduct Joint Operations In U.S. Indo-Pacific Command” INDOPACOM (18 Feb 20)
www.pacom.mil/Media/News/News-Article-View/Article/2086675/theodore-roosevelt-america-strike-groups-conduct-joint-operations-
in-7th-fleet/
27 The 39th Iteration of Cobra Gold Concludes with a Combined Arms-Live Fire Exercise and Closing Ceremony U.S. Army Public
Affairs Office (6 Mar 20)
https://www.army.mil/article/233549/cobra_gold_20_the_39th_iteration_of_cobra_gold_concludes_with_a_combined_arms_live_fire
_exercise_and_closing_ceremonyMEmail - C7F COVID Response Cell to LT Belmont - Inquiry Into 7th FLT Port Visits dtd 15 May
20
28 C7F COS Statement dtd 21 May 20; PACFLT Country Public Health Risk for COVID-19 dtd 27 Feb 20; P AC FLT Operational Risk
Matrix for COVID-19 dtd 27 Feb 20
29 Email - C7F COVID Response Cell - Inquiry Into 7th FLT Port Visits dtd 15 May 20; C7F COS Statement dtd 21 May 20
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20. The week prior to the Da Nang port visit, CPF cancelled all South Korea port
visits due to the outbreak of COVID in Korea.30
21 . On March 1 4, 2020, BLR arrived for a port visit in Singapore.31
22. At the time of BLR’s arrival in Singapore, Singapore was rated “yellow” by the
INDOPACOM risk matrix signifying moderate risk where COVID-19 cases occur in the
community without known contacts or exposures and/or with small outbreak clusters,
swiftly handled by public health interventions that limit disease transmission.32
23. No BLR Sailors contracted COVID-19 as a result of the Singapore visit.33
Planning and Preparation for COVID-19 Prior to Da Nang Port Visit
24. On December 31 , 2019, the Wuhan Municipal Health Commission in China,
reported a cluster of cases of pneumonia in Wuhan, Hubei Province which was
eventually identified as novel coronavirus disease 2019 (COVID-19).34
25. On January 1 3, 2020, officials confirmed a case of COVID-1 9 in Thailand, the
first recorded case outside of China.35
26. On January 20, 2020, TR XO sent an email to TR leadership reminding them that
only six weeks remained on the Da Nang port visit.36
27. On January 23, 2020, there were two confirmed COVID-19 cases reported in
Vietnam.37
28. C7F began tracking COVID-19 planning and socialization began at the end of
January. On January 25, 2020, C7F began sharing their COVID-19 quad slide with all
CTF surgeons.38
29. Around January 26, 2020, COVID-19 information began being included on the
CSG-9 daily intelligence brief.39
30 CPF Statement dtd 1 7 May 20
31 Email - C7F COVID Response Cell- Response to RFI dtd 1 5 May 20
32 Email - C7F COVID Response Cell- Response to RFI dtd 1 5 May 20; C7F COS Statement dtd 21 May 20; INDOPACOM J07
Country Health Risk to Force for COVID-19 dtd 4 Mar 20; PACFLT Operational Risk Matrix for COVID-19 dtd 27 Feb 20
33 C7F COS Statement dtd 21 May 20
34 WPIO Timeline - COVID-19. World Health Organization, www.who.int/news-room/detail/27-04-2020-who-timeline-covid-19
35 WPIO Timeline - COVID-19. World Health Organization, www.who.int/news-room/detail/27-04-2020-who-timeline-covid-19
36 Email - TR XO to TR Leadership - Vietnam Planning dtd 20 Jan 20
37 ‘‘Vietnam Reports First Novel Coronavirus Infection Cases” VietnamPlus (23 Jan 20) https://en.vietnamplus.vn/vietnam-reports-
first-novel-coronavirus-infection-cases/1 67729.vnp
38 C7F Surgeon Statement dtd 23 May 20
39 CCSG-9 Statement dtd 1 5 May 20
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30. On January 30 2020, the WHO Director General declared the COVID-1 9
outbreak a “Public Health Emergency of International Concern.”40
31 . Between February 2, 2020 and February 22, 2020 TR had an outbreak of
norovirus.41
32. Noroviruses are very contagious and are the most common cause of
gastroenteritis in the U.S. - symptoms include diarrhea, vomiting, nausea, and stomach
cramping.42
33. Sometime soon after February 2, 2020, due to the norovirus outbreak, TR began
a “bleach-a-palooza” campaign aimed at the eradicating the norovirus, which included
education through the Departmental Leading Chief Petty Officers (DLCPO) and the TR
SMO about hand washing, cleaning the hard surfaces with bleach twice a day, and
distributing hand sanitizers throughout the key areas on the ship, including the galleys.43
34. On February 4, 2020 INDOPACOM directed CPF to execute its pandemic plan in
response to the COVID-1 9 outbreak in the INDOPACOM AOR and the C7F Fleet
Surgeon provided CPF a COVID-1 9 concept of operations (CONOP).44
35. In early February, the C7F Chief of Staff (COS) established a COVID-1 9 working
group in the maritime operations center that dealt with nothing but COVID-1 9 issues.45
36. In February, C7F had begun planning for a COVID-1 9 outbreak on a ship
operating in the C7F AOR:46
a. Okinawa, Yokosuka, and Guam were discussed as options for ships to
pull in to port if needed.47
b. White Beach in Okinawa was deemed the best choice by C7F, but C7F
identified that it would be difficult politically to bring a ship with COVID-1 9 cases to
Okinawa.48
40 “WHO Timeline - COVID-19" World Health Organization (27 Apr 20) www.who.int/news-room/detail/27-04-2020-who-timeline—
covid-19
41 TR Psychologist Statement dtd 18 May 20; Email: CSG-9 - Response to RFI dtd 17 May 20
42 NTRP 4-02.10
43 TR Psychologist Statement dtd 1 8 May 20
44 Naval Message (SIPR): USINDOPACOM, Response To Novel Coronavirus EXORD DTG 040649Z FEB 20
45 C7F COS Statement dtd 21 May 20
46 C7F COS Statement dtd 21 May 20
47 C7F COS Statement dtd 21 May 20
48 C7F COS Statement dtd 21 May 20
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c. Yokosuka was deemed to have limited capacity in the ability to bring
people on and off of the ships.49
d. C7F determined that Guam was a good candidate, but would also be
difficult politically to pull a ship with COVID-19 cases into Guam.50
e. However, C7F determined that Guam was the only location in the C7F
AOR where an aircraft carrier could pull into port if that aircraft carrier had COVID-19
outbreak.51
37. On February 13, 2020, C7F Surgeon provided the C7F Force Health Protection
against COVID-19 CONOP to the CPF Surgeon Office.52
38. On February 15, 2020, C7F published Tasking Order (TASKORD) 20-057 for
force health protection against COVID-19.53
39. As a result of the TASKORD, TR Medical Department prepared a CSG brief and
routed it to TR leadership.54
40. On February 16, 2020, C7F published Fragmentary Order 001 to TASKORD 20-
057, revising disease surveillance and screening requirements due to updated country
risk.55
41 . On February 1 9, 2020, C7F Surgeon provided a Guam-specific COVID-1 9
Shipboard Case Scheme of Maneuver to CPF Surgeon Office.56
42. On February 22, 2020, TR issued an initial liberty plan for Da Nang with no
mention of COVID-19.57
43. As of February 25, 2020, there had been 16 confirmed cases of COVID-19
reported in Vietnam, all located 30 miles outside of Hanoi, and more than 450 miles
from Da Nang and all individuals had successfully recovered and had been discharged
from the hospitals.58
49 C7F COS Statement dtd 21 May 20
50 C7F COS Statement dtd 21 May 20
51 C7F COS Statement dtd 21 May 20
52 Email - C7F COVID Response Cell - Response to RFI dtd 15 May 20
53 Email - C7F COVID Response Cell - Response to RFI dtd 12 May 20
54 TR SMO Statement dtd 1 7 May 20
55 Email - C7F COVID Response Cell - Response to RFI dtd 12 May 20
56 Email - C7F COVID Response Cell - Inquiry Into 7th FLT Port Visits dtd 15 May 20
57 TRNOTE 5050 TR and CVW-1 1 Liberty Plan dtd 22 Feb 20
58 “Summary of the COVID-1 9 outbreak in Vietnam - Lessons and suggestions.” National Center for Biotechnology Information (2
Apr 20) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7146658/
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44. On February 25, 2020, Vietnam suspended entry for all travelers from COVID-19
affected areas.59
45. On February 26, 2020, the CPF Surgeon had a discussion with the U.S. CDC
Country Director in Vietnam (USCDCVN) who informed the CPF Surgeon that there
was no direct or indirect evidence to suggest an undetected COVID-19 outbreak in the
country and that the USCDCVN believed that the port visit was “low risk.”60
46. On February 27, 2020, Vietnamese media reported that the CDC removed
Vietnam from its list of areas experiencing widespread or sustained community
transmission of COVID-19.61
47. In preparation for the growing pandemic, on February 29th, C7F requested
support from Navy Environmental and Preventive Medicine Unit (NEPMU) teams, with
equipment from Navy Medical Research Center (NMRC) for forward deployable
preventative medicine units to mitigate the potential outbreak of COVID-19 aboard
America Expeditionary Strike Group (AMA ESG) and CSG-9 ships. Based on this
assessment C7F concluded that COBRA GOLD was a higher risk than Vietnam and the
medical support was deployed to BLR and AMA ESG.62
48. Utilizing the Navy Tactical Reference Publication (NTRP) 4-02.10, CSG-9
conducted a tabletop exercise on COVID-19 to determine how CSG-9 would respond to
a COVID-19 case aboard TR.63
49. Prior to the Da Nang port visit, TR crew received training on COVID-19:
a. The SMO directed the medical training officer, who is the ICU nurse, to
draft basic guidance for COVID-19 to be included in the updated liberty brief.64
b. The Medical Department presented the script, recorded the guidance, and
drafted the slides in the brief utilizing CDC guidance, Navy and Marine Corps Public
Health Center’s (NMCPHC) Guidance for Underway Evaluation and Management of the
2019 Novel Coronavirus and C7F guidance.65
59 “Vietnam Suspends Entry from All Coronavirus-Hit Areas” VnExpress (28 Feb 20) https://e.vnexpress.net/news/news/vietnam-
suspends-entry-from-all-coronavirus-hit-areas-4060323.html.
60 Email - CPF Surgeon to TR SMO and C7F Surgeon - Discussion with CDC Director dtd 26 Feb 20
61 “Embassy of the Socialist Republic of Vietnam” Embassy of the Socialist Republic of Vietnam in the United States (27 Feb 20)
http://vietnamembassy-usa.org/news/2020/02/us-removes-vietnam-list-areas-vulnerable-community-spread-sars-cov-2
62 Email - C7F COVID Response Cell - Response to RFI dtd 12 May 20; C7F Surgeon Statement dtd 23 May 20
63 CCSG-9 Statement dtd 15 May 20; CSG-9 COS Statement dtd 18 May 20
64 TR SMO Statement dtd 1 7 May 20
65 TR SMO Statement dtd 1 7 May 20
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c. The liberty brief was promulgated throughout the ship prior to the arrival in
Da Nang via the ship’s ciosed-circuit television (CCTV) channel and in-house
magazine.66
d. The liberty brief had two slides on COVID-19 outlining that: COVID-19 is a
virus spread mainly person to person when an infected person coughs or sneezes; 82%
of COVID-19 cases are classified as a mild illness; it directed any Sailor experiencing
fever, body aches, cough, [or feels] sick to report to “medical” at Fleet Landing prior to
boarding the ship; and that the CDC does not recommend that people who are well
wear a facemask to protect themselves from COVID-19.”67
e. Concerns about COVID-19 were also discussed at various meetings,
including Heads of Department (HOD)/DLCPO meetings and quarters, as well as in
emails that went out to the entire crew.68
50. The Medical Department created a plan, although not a formal instruction that
prepared for the possibility individuals would return to the ship from the Da Nang port
visit who were infected with COVID-1 9. 69
a. The plan was outlined in a PowerPoint brief that the TR SMO discussed
with the TR XO, TR CMC, the HODs, and the TR Supply Officer.70
b. The Medical Department scouted out places that would function as
quarantine or isolation berthing onboard the ship with a goal to locate areas that had
two hatches between the main area of the ship and the isolation or quarantine area.71
c. Once an area was identified as a potential isolation or quarantine area, the
Medical Department had briefings with the affected HOD should medical have to utilize
those spaces over which that HOD has control.72
d. The Medical Department then identified the “flow” of services to the
spaces and determined how medical personnel would proceed to and from those
spaces, how food would be delivered, and how laundry would be cleaned.73
66 TR SMO Statement dtd 1 7 May 20
67 TR Da Nang PVST Crew Brief dtd Mar 20
68 TR SMO Statement dtd 1 7 May 20
69 TR SMO Statement dtd 1 7 May 20
70 TR SMO Statement dtd 1 7 May 20
71 TR SMO Statement dtd 1 7 May 20
72 TR SMO Statement dtd 1 7 May 20
73 TR SMO Statement dtd 1 7 May 20
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e. The TR SMO emailed the COVID-19 Fleet Forces Screening Form and
the TR COVID-19 screening plan to FIODs and DLCPOs, which outlined that all
personnel boarding the TR will be screened for COVID-19 symptoms prior to boarding
the ship, and again seven days after getting underway.74
f. The TR Da Nang Medical Treatment Plan called for inbound carrier
onboard delivery (COD) personnel to receive department-level screening in which
anyone who screened positive for flu-like illnesses were sent to medical for evaluation
immediately.75
g. The TR leadership (TR XO, TR Command Master Chief (CMC), and TR
SMO) made initial preparations for potential quarantine quarters aboard ship by
identifying appropriate berthing compartments and discussing the general plan for
execution.76
h. The three quarantine options discussed were:
(1) DV Row: six rooms (two-person racks), cots for additional patients
(2) Berthing: Chief Overflow Berthing (aft mess deck); admin male
berthing; medical quiet room (4 racks-isolated head)
(3) Brig: up to 20 individuals, not the most ideal.77
51 . TR CO cancelled all planned medical and culinary professional exchanges
scheduled for the Da Nang port visit as a result of recommendations of the TR Medical
Department due to the potential risk of COVID-19 and exposure to high risk areas like
hospitals or commonly used galleys both ashore and onboard the TR.78
52. On March 2, 2020, U.S. media outlets reported the first two U.S. deaths as a
result of complications due to COVID-19, that some individuals can be asymptomatic,
and that for the majority of individuals who do show symptoms of the virus, their
symptoms tend to be mild fatigue and a low fever.”79
53. At the time of the port visit, there were no State Department, DoD, or CDC travel
restrictions for U.S. citizens to Vietnam.80
74 Email - TR SMO to HODs and DLCPOs - COVID-1 9 Screening for CSG-9 Sailors After a Port Visit dtd 03 Mar 20
75 Da Nang Medical Treatment Plan
76 TR XO Statement dtd 16 May 20; TR CMC Statement dtd 17 May 20; TR SMO Statement dtd 17 May 20
77 TR XO Statement dtd 1 6 May 20; TR CMC Statement dtd 1 7 May 20; TR SMO Statement dtd 1 7 May 20
78 Crazier, B. CAPT Statement dtd 15 May 20
79 “America Has Suffered Its First Coronavirus Deaths-and First Infections of Health Care Workers.” Advisory Board- Daily Briefing
(02 Mar 20) https://www.advisory.com/daily-briefing/2020/03/02/corona-deaths
80 INDOPACOM J07 Country Health Risk to Force for COVID-1 9 dtd 4 Mar 20
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54. The March 4, 2020 INDOPACOM Country Health Risk to Force for COVID-19
indicated that Vietnam’s current risk status was “yellow,” signifying moderate risk where
COVID-19 cases occur in the community without known contacts or exposures and/or
with small outbreak clusters, swiftly handled by public health interventions that limit
disease transmission. The risk level was projected, in seven days, to be “green,”
signifying low risk classifying countries with no reported cases of COVID-19, or
countries that have cases that were imported from another country, or countries that
have isolated transmission exclusively attributed to travel, household contacts or
healthcare settings.81
55. On March 5, 2020, all reported cases of COVID-19 in Vietnam were reported as
clear.82
The Da Nang Port Visit
56. On March 2, 2020, TR’s prospective XO arrived aboard TR via a COD in order to
effect turnover with the outgoing XO.83
57. On March 3, 2020, TR facilitated two distinguished visitor (DV) daylight only
embarks.84
a. The first DV embark was for 1 7 Vietnamese nominated by the
Government of Vietnam.85
b. The second DV embark was for 14 U.S. country team members who
planned the carrier port visit.86
c. TR sent medical representatives to screen the DVs who disembarked from
the COD flights.87
d. The medical team used the COVID-19 Fleet Forces Screening Form that
primarily asked about symptoms and recent travel.88
81 INDOPACOM J07 Country Health Risk to Force for COVID-1 9 dtd 4 Mar 20; PACFLT Operational Risk Matrix for COVID-19 dtd
27 Feb 20
82 “Summary of the COVID-1 9 outbreak in Vietnam - Lessons and suggestions.” National Center for Biotechnology Information (2
Apr 20) https://www.ncbi. nlm.nih.gov/pmc/articles/PMC71 46658/
83 TR XO Statement dtd 1 6 May 20
84 TR AAR For 5-9 March Vietnam PVST dtd 1 7 Mar 20
85 TR AAR For 5-9 March Vietnam PVST dtd 1 7 Mar 20
86 TR AAR For 5-9 March Vietnam PVST dtd 1 7 Mar 20
87 TR OPSO Statement dtd 1 8 May 20
88 TR OPSO Statement dtd 1 8 May 20
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e. The DVs received a tour of the hangar bay, an aircraft elevator ride to the
flight deck, a tour of the flight deck, and an aircraft elevator ride back to the hangar bay
before departing.89
f. Both of the DV tours lasted less than one hour.90
58. On March 5, 2020 TR and BKH arrived in Da Nang.91
59. The pilot wore a mask and gloves when he came aboard TR.92
60. Upon arrival, a Vietnamese delegation formally received the U.S. Ambassador to
Vietnam, CPF, Commander, Carrier Strike Group NINE (CCSG-9), TR CO, and the
Commanding Officer, BKH - and the group posed for a photo pier side next to the
BKH.93
61 . The Vietnamese Ministry of Foreign Affairs then moderated the 60-minute press
conference that was attended by more than 100 reporters and focused on the visit’s
historical significance, the U.S. -Vietnam bilateral relationship, and naval operations in
the South China Sea.94
62. The U.S. Ambassador to Vietnam, CPF and CCSG-9 participated in the press
conference with the Vietnamese Director of Da Nang Department of Foreign Affairs and
the Vice Chairman of Da Nang People’s Committee.95
63. The U.S. Ambassador to Vietnam, CPF, and CCSG-9 attended office calls with
the Chairman of the Da Nang People’s Committee and Vietnamese Commander of
Navy Region 3. 96
64. TR was unable to support boat operations due to heavy swell in the harbor. As a
result, approximately 1,000 people toured the BKH instead.97
a. BKH implemented basic self-report screening procedures designed to turn
away anyone who felt ill.98
89 TR OPSO Statement dtd 1 8 May 20
90 TR OPSO Statement dtd 1 8 May 20
91 CPF Statement dtd 1 7 May 20; “Theodore Roosevelt Strike Group arrives in Vietnam” USS Theodore Roosevelt Public Affairs (4
Mar 20) https://www.cpf.navy.mil/news.aspx/130563
92 TR Navigator Statement dtd 1 6 May 20
93 TR AAR For 5-9 March Vietnam PVST dtd 1 7 Mar 20
94 TR AAR For 5-9 March Vietnam PVST dtd 1 7 Mar 20
95 TR AAR For 5-9 March Vietnam PVST dtd 1 7 Mar 20
96 TR AAR For 5-9 March Vietnam PVST dtd 1 7 Mar 20
97 BKH CO Statement dtd 1 7 May 20
98 BKH CO Statement dtd 1 7 May 20
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b. BKH did not use temperature checks of the individuals who toured the
ship."
c. Approximately 65 reporters received one hour of access to BKH for filming
standups and capturing still imagery and b-roll footage.100
d. Reporters toured BKH bridge, hangar bay, foc’sle, and aft missile deck.101
e. Outlets in attendance included Reuters, Channel News Asia, Dat Viet
Newspaper, Tuoi Tre Newspaper, VN Express, and Da Nang Newspaper.102
65. The sea state in Da Nang made it difficult for the crew to depart and return to TR
and many of the scheduled liberty boat trips between TR and Da Nang had be
cancelled.103
a. The unprotected harbor of Da Nang at anchorage caused difficulties with
loading the crew on liberty launches.104
b. Due to the sea state, the First Lieutenant had to collapse his duty sections
into a port and starboard team to safely conduct stern barge operations.105
c. High sea-states limited the ability of TR Sailors to maximize liberty events,
resulting in many cancelled tours and community relation events.106
d. Some morale, welfare, and recreation tours, professional exchanges and
all sporting events were cancelled.107
e. The U.S. Pacific Fleet band modified their performance schedule to
support Vietnamese direction to refrain from large public gatherings due to concerns
with COVID-1 9. 108
f. The band performed at the Vietnamese hosted dinner followed by the
Charity Center Community Relations Project (COMREL), U.S. Pacific Fleet hosted
reception, Hoa Mai Orphanage COMREL, and the Nguyen Huu Dinh Opera Theatre.109
99 BKH CO Statement dtd 1 7 May 20
100 TR AAR For 5-9 March Vietnam PVST dtd 1 7 Mar 20
101 TR AAR For 5-9 March Vietnam PVST dtd 1 7 Mar 20
102 TR AAR For 5-9 March Vietnam PVST dtd 1 7 Mar 20
103 TR AAR For 5-9 March Vietnam PVST dtd 1 7 Mar 20
104 TR XO Statement dtd 16 May 20
105 TR 1 LT Statement dtd 1 1 May 20
106 TR AAR For 5-9 March Vietnam PVST dtd 1 7 Mar 20
107 TR AAR For 5-9 March Vietnam PVST dtd 1 7 Mar 20
108 TR AAR For 5-9 March Vietnam PVST dtd 1 7 Mar 20
109 TR AAR For 5-9 March Vietnam PVST dtd 1 7 Mar 20
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g. All three planned professional exchanges (air traffic controller, firefighting
and meteorology) involving tours of TR were cancelled due to sea state and/or COVID-
19 concerns.110
66. There were many precautions taken as a result of the heightened awareness of
COVID-19 in Vietnam:
a. Liberty boats and piers were disinfected by the Vietnamese government
prior to being turned over to th TR and BKH for use.* 111
b. Vendors on the pier were curtailed and food vendors were cancelled.112
c. TR and BKH Sailors were limited to Embassy-vetted locations and
hotels.113
d. Every crew member leaving the ship was screened by medical personnel
and Vietnamese personnel conducted passive temperature checks using temperature
scanners of anyone leaving TR outside of the liberty pier.114
e. In Da Nang, there were signs at some of the businesses indicating they
were closed due to “virus” or “closed due to staff illness.”115
f. The Vietnamese government instituted temperature checks prior to going
into some hotels and upon checking into some hotels.116
67. More than 100 CSG personnel and country team members fulfilled all the other
COMREL obligations that had not been cancelled, included interacting with residents at
the Vocational Charity Center, Dorothea’s Project Legacy Charity Center, Agent Orange
Victims Center, Hoa Mai Orphanage and Dong A University.117
68. On March 7, 2020, the U.S. Pacific Fleet hosted a formal reception for
approximately 400 guests.118
a. The reception was originally scheduled to be held aboard TR, but due to
concerns with safely transferring guests to and from the carrier because of an increased
sea state - C7F approved the relocation to the Da Nang Golden Bay Hotel.119
110 TR AAR For 5-9 March Vietnam PVST dtd 1 7 Mar 20
111 TR JUDGE Statement dtd 1 1 May 20
112 TR JUDGE Statement dtd 1 1 May 20
113 TRNOTE 5050 TR and CVW-1 1 Liberty Plan dtd 22 Feb 20; TR SUPPO Statement dtd 1 8 May 20
114 TR JUDGE Statement dtd 1 1 May 20
115 TR Psychologist Statement dtd 18 May 20; TR Nurse Statement dtd 18 May 20
116 TR Psychologist Statement dtd 18 May 20
117 TR AAR For 5-9 March Vietnam PVST dtd 1 7 Mar 20
118 CCSG-9 Statement dtd 15 May 20
119 TR JUDGE Statement dtd 11 May 20; SUPPO Stmt dtd 18 May 20
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b. If the reception had been held aboard TR, the guest list would have
included approximately 600 attendees.120
c. The hotel instituted self-screening measures and selective temperature
checks outside of the hotel.121
d. All staff at the hotel wore surgical-style masks.122
e. CPF, the U.S. Ambassador to Vietnam, and the Vice Chairman of the Da
Nang People’s Committee provided formal remarks during the ceremony.123
f. The Navy Band sang the Vietnamese national anthem as well as popular
Vietnamese songs.124
69. On March 7, 2020, a select group of 30 reporters still in the area were brought
via liberty boat to TR for a tour of the hangar bay and flight deck. This was the only
group able to get out to TR for a tour of the ship during port visit.125
70. On March 8, 2020, the Government of Vietnam cancelled shipboard tours for 100
additional guests due to COVID-19 concerns.126
Notification of Close Contact (March 8th and 9th)
71 . On March 8, 2020, the U.S. Embassy notified TR/CSG-9 that Sailors may have
been exposed to COVID-19 during a hotel stay in Da Nang where two British citizens
tested positive for COVID-19.127
72. On March 8, 2020, at the request of Da Nang city government, TR and BKH
suspended liberty for remainder of the day.128
a. An initial email was sent to the crew members that recalled all crew
members to the TR.129
b. A follow-up email went out that clarified that the recall was cancelled, but
that once returning to TR, no one would disembark.130
120 CCSG-9 Statement dtd 15 May 20
121 BKH CO Statement dtd 17 May 20
122 TR JUDGE Statement dtd 1 1 May 20; CCSG-9 Stmt dtd 15 May20
123 TR AAR For 5-9 March Vietnam PVST dtd 1 7 Mar 20
124 TR AAR For 5-9 March Vietnam PVST dtd 1 7 Mar 20
125 TR AAR For 5-9 March Vietnam PVST dtd 1 7 Mar 20
126 TR AAR For 5-9 March Vietnam PVST dtd 1 7 Mar 20
127 CSG-9 COS Statement dtd 1 8 May 20
128 TR CDO Report dtd 8 Mar 20
129 TR Safety Officer Statement dtd 17 May 20; TR AIRBOSS Statement dtd 17 May 20
130 TR Safety Officer Statement dtd 17 May 20; TR AIRBOSS Statement dtd 17 May 20
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73. On March 8, 2020, all tours/professional engagements were cancelled.131
74. On March 8, 2020, an emergency command center was set up in Strike
Operations.132
75. On March 8, 2020, information was gathered to form a list of people who stayed
at or had interactions with the Vanda Hotel grounds.133
76. TR leadership identified the location of 37 Sailors known to have been at the
hotel and possibly come within six feet of the British citizens for more than 10
minutes.134
a. Of the 37, 1 1 TR Sailors identified as having stayed, and still present, at
the hotel were screened, tested on site and upon receipt of their negative test were
released to TR for quarantine.135
b. The 26 other TR Sailors identified as having stayed at the hotel were
removed from TR to the pier, screened, tested on the pier by the Vietnamese Ministry of
Health, and upon receipt of their negative test, returned to TR for quarantine.136
c. Two additional Sailors reported to TR medical staff that they had also
visited the hotel and were also tested by the Vietnamese Ministry of Health, and upon
receipt of their negative test, returned to TR for quarantine.137
77. Upon returning to TR, all other crewmembers were screened via a verbal
questionnaire.138
Actions during Transit to and Arrival in Guam Departing Da Nang until the First
Confirmed Case of COVID-19
78. On March 9th, TR got underway from anchorage in Da Nang Bay, Vietnam.139
79. As TR departed Da Nang, the 39 Sailors remained sequestered from the rest of
the crew.140
131 Crazier, B. CAPT Statement dtd 15 May 20
132 TR CDO Report dtd 08 Mar 20
133 TR CDO Report dtd 08 Mar 20; Crazier, B. CAPT Statement dtd 15 May 20
134 Crazier, B. CAPT Statement dtd 15 May 20
135 Crazier, B. CAPT Statement dtd 15 May 20
136 TR SMO Statement dtd 17 May 20
137 TR SMO Statement dtd 17 May 20
138 TR AIRBOSS Statement dtd 17 May 20
139 Crazier, B. CAPT Statement dtd 15 May 20
140 Email (SIPR) - CPF BWC TR Sailors COVID Screening dtd 9 Mar 20
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80. TR CO addressed the decision to quarantine Sailors over the ship’s public
address system (1MC); emphasizing that the quarantined Sailors were being monitored
and there was no cause for alarm.141
81 . TR Supply Department obtained food and water for the quarantined Sailors.142
82. TR increased cleaning measures, including twice-daily use of a shipboard
approved bleaching solution.143
83. The crew generally referred to these cleaning evolutions as “bleach-a-
palooza.”144
84. The TR XO delivered daily reminders via 1 MC to wash hands, maintain social
distancing, and to avoid face touching.145
85. The TR CO delivered reminders via 1 MC to wash hands, maintain social
distancing, and to avoid face touching every second day.146
86. The TR XO passed COVID-19 mitigation effort information to the HODs for
dissemination to the crew.147
87. The TR Medical Department created a COVID-19 video, which played on loop on
CCTV.148
88. After departing Vietnam, the Medical Department directed departments to send
Sailors to medical if they were experiencing influenza-like illness (ILI) symptoms.149
89. On March 9, 2020, the TR CO restricted self-service on the main galley lines.
Self-service remained an option for other food selections including the salad bar.
Specifically, no seats were removed, lines continued to form without six feet of
separation between Sailors and condiments were available for common use.150
141 TR Psychologist Statement dtd 18 May 20
142 TR PAO Interview Summary dtd 23 May 20
143 Crazier, B. CAPT Statement dtd 15 May 20; TR SMO Statement dtd 17 May 20; ATI Statement dtd 22 May 20
144 TR SMO Statement dtd 17 May 20; TR CMC Statement dtd 17 May 20; HM3 Statement dtd 15 May 20; CCSG-9 Statement dtd
15 May 20; ATI Statement dtd 22 May 20
145 TR XO Statement dtd 16 May 20
146 Crazier, B. CAPT Statement dtd 15 May 20; TR XO Statement dtd 16 May 20; TR SMO Statement dtd 17 May 20; TR RO
Statement dtd 18 May 20
147 Crazier, B. CAPT Statement dtd 15 May 20
148 TR SMO Statement dtd 17 May 20
149 CVW-1 1 Surgeon Statement dtd 1 8 May 20; TR PA Statement dtd 1 8 May 20
150 AME1 Statement dtd 13 May 20; CSC Statement dtd 17 May 20; TR CMC Statement dtd 17 May 20; TR SUPPO Statement dtd
1 8 May 20; CVW-1 1 Surgeon Statement dtd 18 May 20; Email - TR SMO to TR CO - Follow Up dtd 9 Mar 20; TR XO Statement dtd
16 May 20
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90. Following the Da Nang port visit, gyms, the main ship store, library, barbershops,
and chapel services remained open for common use.151
91 . From the time the ship left Da Nang on March 9th until March 23rd, seven COD
flights originating out of Clark Air Force Base in the Philippines brought a total of 29
passengers and COD detachment personnel to the carrier.152
92. Utilizing the screening protocols required by the February 23, 2020 C7F
Fragmentary Order, every individual arriving on TR via COD initially screened negative
for COVID-19 symptoms.153
93. Personnel arriving via COD to TR were required to stay on the flight deck and
maintain physical distance with the ship’s crew.154
94. NAVADMIN 064/20 issued on March 12, 2020, required social distancing
wherein individuals were required to remain out of congregate settings, avoid mass
gatherings, and maintain six feet or two meter distance from others when possible.”155
a. The TR CO and TR XO believed guidance within relevant COVID-1 9
NAVADMINs translated little to deployed aircraft carriers.156
b. Social distancing was not observed on TR during the transit from Da Nang to
Guam.157
c. The TR CO, TR XO, and TR SMO believed that social distancing would be
impossible onboard an aircraft carrier.158
d. CCSG-9 did not provide formal, supplementary guidance to TR regarding
COVID-19 mitigation.159
95. Upon leaving Da Nang, BKH took the following steps:
a. Sailors self-monitored for 1 4 days and were instructed to report to ship’s
medical staff upon presentation of ILI symptoms.160
151 AME2 Statement dtd 16 May 20; CMC statement dtd 17 May 20; TR SUPPO statement dtd 18 May 20
152 COD Completed Travel Log/Manifest
153 TR SMO Statement dtd 17 May 20; COD Completed Travel Log/Manifest (Four Sailors later tested positive for COVID-19 on
March 27th, March 28th, April 14th, April 21st.)
154 CCSG-9 Statement dtd 15 May 20
155 NAVADMIN 064/20 Navy Mitigation Measures in Response to Coronavirus Outbreak dtd 12 Mar 20
156 Crazier, B. CAPT Statement dtd 15 May 20; TR XO Statement dtd 16 May 20
157 CCSG-9 Statement dtd 15 May 20; TR RO Statement dtd 18 May 20; TR SMO Statement dtd 17 May 20; CSC Statement dtd 17
May 20; ATI Statement dtd 22 May 20
158 TR SMO Statement dtd 1 7 May 20; TR XO Statement dtd 1 6 May 20
159 Crazier, B. CAPT Statement dtd 15 May 20; TR XO Statement dtd 16 May 20; CVW-1 1 CAG Statement; CSG-9 COS Statement
160 Email - CSG-9 - Response to RFI dtd 24 May 20
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b. Cleaning efforts were increased with focus on disinfecting high-contact
touch areas with bleach and other cleaning solutions.161
c. Messaging was provided via the Plan of the Day, emails, and site TV on
proper personal hygiene162
d. A COVID-1 9 response plan instruction was developed and the ship
conducted an onboard outbreak response exercise163
96. BKH did not implement any social distancing measures onboard following the Da
Nang port visit.164
97. On March 1 1 , 2020, CAPT (b) (6)
completed turnover with CAPT
and officially assumed the role as TR XO.165
98. On March 1 1 , 2020, WHO declared COVID-1 9 a pandemic.166
99. On March 1 1 , 2020, OSD issued travel restrictions for DOD Components.167
100. On March 1 1 , 2020 personnel from the Biological Defense Research Directorate
(BDRD) of the Naval Medical Research Center embarked on TR with specialized
laboratory equipment for testing and diagnosing respiratory pathogens.168
101. On March 12, 2020, A-SN issued guidance on COVID-1 9 preventive measures,
and restricted official and personal travel and PCS orders to, from, or through CDC
Travel Health Notice (THN) Level 3 locations.169
102. On March 12, 2020, OPNAV issued guidance on preventive measures, travel,
PCS, and liberty restrictions to CDC Level 3 locations, and reporting requirements.170
103. On March 13, 2020, the TR CO sent letters to family members indicating the ship
had begun COVID-1 9 testing for select individuals.171
1 04. On March 1 3, 2020, OSD issued an order to stop travel within CONUS for all
DoD military, civilians, and families.172
161 Email - CSG-9 - Response to RFI dtd 24 May 20
162 Email - CSG-9 - Response to RFI dtd 24 May 20
163 Email - CSG-9 - Response to RFI dtd 24 May 20
164 Email - CSG-9 - Response to RFI dtd 24 May 20
165 Email - TR XO - Subject: TR Investigation dtd 7 May 20
166 WFIO Timeline - COVID-19 https://www.who.int/news-room/detail/27-04-2020-who-timeline-covid-19, accessed May 8, 2020
167 SECDEF Memo Travel Restrictions for DoD Components in Response to Coronavirus Disease 2019 dtd 1 1 Mar 20
168 (b) (6) LCDR Statement dtd 23 May 20
169 ALNAV 025/20 Vector 1 5 Force FHealth Protection Guidance for Department of the Navy dtd 12 Mar 20
170 NAVADMIN 064/20 Navy Mitigation Measures in Response to Coronavirus Outbreak dtd 12 Mar 20
171 Crazier, B. CAPT Ltr to families dtd 1 3 Mar 20
172 SECDEF Memo Travel Restrictions for DoD Components in Response to Coronavirus Disease 2019 dtd 1 1 Mar 20
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1 05. On March 1 3, 2020, the President of the United States declared the COVID-1 9
outbreak a national emergency.173
106. On March 14, 2020, the acting Secretary of the Navy (A-SN) issued a stop
movement order for all DON personnel beginning March 16, 2020. 174
107. On March 14, 2020, the Office of the Chief of Naval Operations (OPNAV) issued
a stop movement order for Permanent Change of Station and temporary duty orders,
and authorized local leave only.175
108. On March 14, 2020, members of the Navy Forward-Deployed Preventive
Medicine Units and Naval Medical Research Center embarked TR, BLR and AMA to
help combat the risk of COVID-1 9 and provide laboratory batch testing capability while
at sea.176
109. On March 14, 2020, medical personnel tested the 39 quarantined TR Sailors and
each tested negative.177
110. On March 1 4, 2020, BLR arrived in Singapore for a previously scheduled port
visit.178
111. On March 1 4, 2020, the Government of Guam issued a state of public health
emergency.179
112. On March 1 5, 2020, the TR SMO emailed the entire TR crew, clarifying
screening requirements after port visits, explaining self-monitoring, and passing
reminders about hand sanitization, hand washing, and cough etiquette.180
113. On March 1 6, 2020, the TR SMO emailed the entire TR crew updates about
COVID-1 9, including guidance for personnel arriving and/or leaving by COD.
Specifically, the email provided, “Personnel arriving via COD - HODs/DLCPOs are
notified (by TR Medical Department using the Air Transport Officer manifest) of those
173 Proclamation on Declaring a National Emergency Concerning the Novel Coronavirus Disease (COVID-19) Outbreak dtd 13 Mar
20 https://www.whitehouse.gov/presidential-actions/proclamation-declaring-national-emergency-concerning-novel-coronavirus-
disease-covid-1 9-outbreak/
174 ALNAV 026/20 Official and Personal Domestic Travel Guidance for Department of the Navy (CONUS Travel Guidance) dtd 14
Mar 20
175 NAVADMIN 065/20 Navy Mitigation Measures in Response to Coronavirus Outbreak Update 1 dtd 14 Mar 20
176 Navy Preventive Medicine Teams Embark Ships in 7th Fleet, INDOPACOM, (03 Mar 20)
https://www.pacom.mil/Media/News/News-Article-View/Article/2122302/navy-preventive-medicine-teams-embark-ships-in-7th-fleet/;
TR Psychologist Statement dtd 18 May 20
177 Email - TR SMO - Post-Danang Update dtd 1 8 Mar 20
178 Email - C7F COVID Response Cell - Response to RFI dtd 1 5 May 20
179 Government of Guam Executive Order 2020-03
180 Email - TR SMO to All Officers, All CPOs, All E-6 and below - 14 days of screening following port visits dtd 15 Mar 20
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individuals that require screening after arrival on a COD. Same screening concept
except that their 7+7 days of screening starts the day they arrive on the ship and results
are emailed to CAPT Ashman.”181
114. As TR transited to Guam, the C7F Fleet Surgeon and the TR SMO increased
communications.182
115. By March 17, 2020, COVID-19 reached all 50 United States.183
116. On March 1 7, 2020, the TR CO emailed the Commanding Officer (CO), Naval
Base Guam (NBG) CO to propose three possible courses of action (COAs) for liberty
during the TR’s upcoming Guam port visit:
a. Full Guam liberty, similar to the previous port visit,
b. NBG liberty with base access (busses to Navy Exchange (NEX), beach,
etc.), and limited off-base liberty (golf, small group tours, etc.), or
c. Pier liberty with limited access to NBG (busses to NEX, beach, etc.) and
MWR pier support (food/beer/entertainment/wifi).184
1 1 7. The NBG CO stated that only COA #3 was appropriate and that further mitigation
measures were needed to afford TR Sailors access to the NEX and that TR medical
personnel would be required to assist in screening and sanitization inspections.185
118. On March 1 9, 2020, the U.S. Department of State added Vietnam to the list of
countries on the Global Level 4 Health Advisory, recommending against traveling
there.186
119. By March 20, 2020, Guam had 12 confirmed cases of COVID-19.187
120. The TR XO and the TR Operations Officer were concerned that Sailors would
congregate elsewhere so TR’s gyms remained open until the ship arrived in Guam.188
181 Email - TR SMO - Coronavirus screening - Update dtd 15 Mar 20
182 TR SMO Statement dtd 1 7 May 20
183 CORONAVIRUS: DOD RESPONSE TIMELINE (15 May 20) https://www.defense.gov/Explore/Spotlight/Coronavirus/DOD-
Response-Timeline/
184 Email - NBG CO to TR CO - TR PVST dtd 20 Mar 20
185 Email - NBG CO to TR CO - TR PVST dtd 20 Mar 20
186 U.S. Embassy & Consulate in Vietnam: COVID-19 Information https://vn.usembassy.gov/u-s-citizen-services/covid-19-
information
187 Email - NBG CO to TR CO - TR PVST dtd 20 Mar 20
188 TR SMO Statement dtd 17 May 20; Crazier, B. CAPT Statement dtd 15 May 20; TR XO Statement dtd 16 May 20; TR CMC
Statement dtd 17 May 20
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121 . On March 22, 2020, the TR CO requested via email limited access to NBG
locations such as the NEX, Liberty Center, movie-theater, gym, ballfields, and hiking
areas.189
122. CO, NBG responded to the TR CO that his first priority was the safe mooring of
the ship and proper husbanding while in port, all while ensuring that the ship and crew
remained “clean.” CO, NBG stated further that “once we have that locked in we will
focus on the quality of life.” Additionally, CO, NBG attached the general schematic for
Kilo Wharf (Figure 2) and the potential Force Health Protection Enclave (FHPE) that
would be employed to enable the required separation for TR Sailors to base support
personnel.190
123. On March 22, 2020, 14 days after they had been placed in quarantine, all 39
close-contact Sailors were asymptomatic, tested negative and released from
quarantine.191
124. On March 23, 2020, the CDC reported the Diamond Princess and Grand
Princess cruise ships had more than 800 total COVID-19 cases, including 10 deaths.192
125. On March 23, 2020, the Secretary of Defense raised the Health Force Protection
Condition Level to Charlie for all DoD installations.193
126. On March 23, 2020, the Navy published definitions of quarantine and isolation,
derived from CDC guidance.194
127. On March 23, 2020, TR stopped receiving COD flights from the Philippines.195
1 28. The TR CO stated that due to the increasing number of COVID-1 9 cases in the
Philippines, an internal decision was made to re-route all future outbound passengers
and parts to Kadena Air Force Base (AFB) or Anderson AFB in order to avoid further
flights to the Philippines.196
189 Email - NBG CO to TR CO - RE TR PVST dtd 23 Mar 20
190 Email - NBG CO to TR CO - RE TR PVST dtd 23 Mar 20
191 C7F COS Statement dtd 21 May 20;; Crazier, B. CAPT Statement dtd 15 May 20; TR XO Statement dtd 16 May 20; TR SMO
Statement dtd 17 May 20; C7F Surgeon Statement dtd 23 May 20
192 Update Public Flealth Response to the Coronavirus Disease 2019 outbreak - United States (24 Feb 20)
https://www.cdc.gov/mmwr/volumes/69/wr/mm6908e1.htm
193 Statement by Department of Defense on Additional Access Restrictions for the Pentagon Reservation dtd 23 Mar 20
https://www.defense.gov/Newsroom/Releases/Release/Article/2122686/statement-by-department-of-defense-on-additional-access-
restrictions-for-the-pe
194 NAVADMIN 083/20 Restriction of Movement (ROM) Guidance 23 Mar 20
195 COD Completed Travel Log/Manifest
196 Crazier, B. CAPT Statement dtd 15 May 20
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129. Between the period of March 9 to March 23, 2020, 9 patients presented to TR
Medical with ILL197
a. The embarked BDRD personnel screened all ILI cases using the BioFire
Respiratory Panel-2 (RP-2) to rule out the most common respiratory pathogens.198
b. In all cases tested using the BioFire RP-2, a common respiratory
pathogen was identified and the diagnosis process halted.199
130. On March 24th, prior to Sailors testing positive for COVID-19 aboard TR, three
Sailors reported to the CVW-1 1 Surgeon that they had experienced a loss of taste
and/or smell and that they had been experiencing those symptoms for approximately
one week and had no other symptoms.200
a. The CVW-1 1 Surgeon had learned that day that there was the possibility
that the loss of taste and/or smell were a symptom of COVID-19, but determined that
evidence was anecdotal and was not predominant in COVID-19 literature at the time.201
b. The Sailors informed the CVW-1 1 Surgeon that there were one or two
other Sailors who had the same symptoms and the CVW-1 1 Surgeon requested these
Sailors report to the Medical Department.202
c. All Sailors who presented with the loss of taste and/or smell presented
with no other symptoms.203
d. Because these individuals had no other symptoms, the CVW-1 1 Surgeon
determined that these Sailors’ loss of taste and/or smell were not a diagnostic
symptom.”204
e. The CVW-1 1 Surgeon directed these Sailors not to return to their work
center and contacted the Industrial Hygienist onboard to inspect their work center.205
f. The Industrial Hygienist ran a RAD-57 test which demonstrated a normal
CO level.206
107
106
100
200
201
202
203
204
205
205
TR Sick
CVW-1 1
CVW-1 1
CVW-1 1
CVW-1 1
CVW-1 1
CVW-1 1
Call Log 5 Mar to 23 Mar 20
LCDR Statement dtd 23 May 20
LCDR Statement dtd 23 May 20
Surgeon Statement dtd 18 May 20
Surgeon Statement dtd 18 May 20
Surgeon Statement dtd 18 May 20
Surgeon Statement dtd 18 May 20
Surgeon Statement dtd 18 May 20
Surgeon Statement dtd 18 May 20
Surgeon Statement dtd 18 May 20
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g. The CVW-1 1 Surgeon believes that three of the Sailors eventually tested
positive for COVID-19.207
h. Subsequent investigation of the ship’s Sick Call Log revealed no patients
presented to TR Medical with a loss of taste or smell prior to the first confirmed positive
COVID-19 case.208
First Confirmed Case of COVID-19 until Arriving at Guam
131. In the early morning of March 24, 2020, TR confirmed three Sailors tested
positive for COVID-19; two from CVW-1 1 and one from the Reactor Department.209
1 32. The first three TR Sailors to test positive for COVID-1 9 were not close contacts of
the initial 39 Sailors quarantined on March 9th.210
133. Within 24 hours of positive cases, the TR SMO began basing initial projections
for the spread of COVID-19 aboard TR on similar circumstances on cruise ships, but in
“negative fashion” since cruise ships have individual berthing.211
1 34. After Sailors aboard TR tested positive for COVID-1 9, C7F considered directing
TR to Hawaii or San Diego; however, C7F ruled these ports out due to the limited
medical evacuation coverage of responding aircraft.212
1 35. TR was originally scheduled to execute a port visit to Guam from April 3 to April
10, 2020. 213
136. On March 24, 2020, TR sailed for Guam at BKH’s best speed based on
maximum allowable fuel burn rate for the planned transit.214
137. Guam had previously denied entry to cruise ship MS WESTERDAM on February
7, 2020, over COVID-19 concerns, even though there were no known COVID-positive
passengers on the ship.215
138. On March 24, 2020, Deputy Chief of Naval Operations (DCNO) for Operations,
Plans and Strategy (OPNAV N3/N5) informed C7F that the “crew of TR will not leave
207 CVW-1 1 Surgeon Statement dtd 1 8 May 20
208 TR Sick Call Log 5 Mar to 23 Mar 20
209 Email - TR SMO to CCSG-9 - COVID-1 9 Update dtd 24 Mar 20
210 CCSG-9 Statement dtd 15 May 20
2.1 TR SMO Statement dtd 17 May 20
2.2 C7F COS Statement dtd 21 May 20
213 Email - CSG-9 - Response to RFI dtd 20 May 20
214 Crazier, B. CAPT Statement dtd 15 May 20; C7F COS Statement dtd 21 May 20; TR XO Statement dtd 16 May 20; TR RO
Statement dtd 18 May 20
215 Guam denies entry to ship over coronavirus concerns, USA Today (07 Feb 20)
https://www.usatoday.com/story/news/local/2020/02/07/guam-denies-entry-ship-over-coronavirus-concerns/4687803002/
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pier, with the exception of Sailors testing positive for COVID-19, who will be
sequestered in base berthing facilities.”216
139. On March 24, 2020, C7F suggested to CCSG-9 that TR use the ship’s hangar
deck for segregated berthing and to consider moving the CSG-9 Command Element to
a command ship.217
140. On March 24, 2020, C7F considered flying CVW-1 1 off TR to Anderson AFB,
Guam.218
141 . CTF 75 offered C7F tents with air conditioning and cots for 400 Sailors to be
available on the pier in Guam if needed.219
1 42. After the third Sailor tested positive for COVID-1 9, TR CO conducted a 1 MC call
informing the crew that antiseptic wipes and hand sanitizer were available throughout
the ship, “bleach-a-palooza” would occur twice daily, dental services were limited, and
self-service was secured on the mess decks, the Chief Petty Officers’ mess, and
wardrooms.220
143. C7F was aware of the preventive measures taken aboard TR.221
144. On March 24, 2020, the Pentagon confirmed its first case of COVID-19.222
1 45. On March 24, 2020, USA Today reported TR had up to eight Sailors aboard who
tested positive for COVID-19.223
146. On March 24, 2020, TR Safety Officer stood up a COVID-19 Awareness Council
(CAC), which included dental staff, the TR’s staff judge advocate, and various CVW-1 1
representatives. The purpose of the CAC was to manage messaging. Specifically, the
CAC aimed to convert CDC and NAVADMIN guidance into a format easily accessible
and usable across the entire ship.224
216 Email (SIPR) - C7F to OPNAV N3/N5 - RE: (U//FOUO) FOR INFO: TR Recovery and Disposition Plan dtd 27 Mar 20
2,7 Email (SIPR) - C7F to CCSG-9, C7F CoS, CSG-9 CoS - RE: (S) Positive COVID tests on TR (Update #2) dtd 24 Mar 20 2313
(Guam time)
218 Email (SIPR) - C7F CoS to CSG-9 CoS, NBG CO - *** Urgent - Air Wing Fly Off? dtd 24 Mar 20
219 Email - (SIPR) CTF 75 to C7F - COVID-19 Commander's perspective 22 Mar dtd 24 Mar 20
220 Email - TR PAO to Crazier, B. CAPT - RE: TRSG RTQ dtd 24 Mar 20
221 Email - C7F PAO to TR PAO - FWD: Proposed Statement dtd 26 Mar 20
222 First Case of COVID-19 at the Pentagon dtd 25 Mar 20
https://www.defense.gov/Newsroom/Releases/Release/Article/2125774/first-case-of-covid-19-at-the-pentagon/
223 Eight sailors from USS Theodore Roosevelt have coronavirus, raising concerns about pandemic's strain on military, USA Today
(24 Mar 20) https://www.usatoday.com/story/news/politics/2020/03/24/coronavirus-3-sailors-test-positive-military-readiness-
affected/2910165001
224 TR Safety Officer Statement dtd 1 7 May 20
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147. TR spent most of March 24th in condition River City (limited communications on
and off the ship).225
1 48. Within the first 48 hours of TR’s first COVID-1 9 positive cases, the TR SMO
distributed the NTRP relating to shipboard isolation and quarantine to each of the
HODs.226
149. The TR CO stated that after March 24th, he was sleeping 4-5 hours a night.227
1 50. After the outbreak, the TR SMO had daily communication with C7F surgeon,
CPF surgeon, Naval Hospital Guam (NHG) CO, and 3D MEB.228
151 . After March 24, 2020, the TR Surgeon cancelled routine operations and began
screening patients.229
152. Positive crew members initially remained in ship’s Medical unless the member
was an officer with a single stateroom. Positive cases were then isolated and contact
tracing identified additional Sailors to segregate.230
153. At the time, NAVADMIN 083/20 defined a person under investigation (PUI) as
an individual with either a pending COVID-1 9 test or for whom a test would have been
ordered/conducted if one had been available.231
154. Close contacts were identified as having 10 minutes of contact or more within 20
feet of a positive case.232
1 55. The COVID-1 9 treatment plan included over-the-counter medications.233
156. The Medical Department was running low on testing kits, so anyone with a
common cold but no fever were treated for what the Medical Department suspected.234
157. Following positive cases of COVID-1 9, the TR Medical Department ceased
routine care, including mental health. The TR psychologist responded to routine
patients and handled “fleet administrative tracking” where COVID-1 9 test results were
recorded when known.235
225 TR Psychologist Statement dtd 18 May 20
226 TR Safety Officer Statement dtd 1 7 May 20
227 Crazier, B. CAPT Statement dtd 15 May 20
228 TR SMO Statement dtd 17 May 20
229 TR Surgeon Statement dtd 18 May 20
230 Crazier, B. CAPT Statement dtd 15 May 20
231 NAVADMIN 083/20 Restriction of Movement (ROM) Guidance dtd 23 Mar 20
232 Crazier, B. CAPT Statement dtd 15 May 20
233 TR PA Statement dtd 18 May 20
234 TR PA Statement dtd 18 May 20
235 TR Psychologist Statement dtd 18 May 20
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158. On March 25, 2020, TR transferred ashore the first four Sailors who tested
positive for COVID-19 via rotary wing.236
159. The TR XO stated he believed TR largely adhered to NTRP 4-02.10 guidance
prior to Sailors testing positive.237
160. The TR XO stated, “We were absolutely aware of the CPF and C7F OPORD and
FRAGORDs -- but as we got closer to Guam and cases increased, it appeared CPF and
C7F were not in alignment on NAVADMIN 083 - specifically the need for isolated
berthing. They continued to direct us to attempt group quarantine methods that were
not in compliance. We were getting a 1 0,000-yard screwdriver from BLR. We did it, but
it was frustrating.238
161 . Once TR Sailors tested positive for COVID-1 9, the TR SMO routinely sent
CCSG-9 updates and numbers, including prediction models for the virus’ spread.239
162. The TR SMO relied upon observations and data from the cruise ship Diamond
Princess sequestered in Japan, which had a different demographic than that of the
TR.240
163. The TR CO acknowledged studies about cruise ships influenced his decision¬
making.241
164. On March 25th, the TR CO sent letters to family members indicating “a few
Sailors” had tested positive for COVID-19, were been placed in isolation, and work was
in progress to fly those Sailors off the ship as soon as possible.242
1 65. Once Sailors aboard TR tested positive for COVID-1 9, TR closed the barbershop
and gyms but permitted PT in the hangar bay. Cooks served salad and self-serve food
options were removed from the mess deck. ATMS, vending machines, and the ship’s
store remained open (with a limited number of patrons at a time). Self-serve laundry
closed. TR XO implemented mandatory facemask wearing.243
236 CO NHG Statement dtd 18 May 20; Sailors tested positive on USS Theodore Roosevelt, extent of exposure unclear, Pacific Daily
News (23 Mar 20) https://www.guampdn.com/story/news/local/2020/03/26/sailors-tested-positive-uss-rooseveit-extent-exposure-
unclear/5084652002/#
237 TR XO Statement dtd 16 May 20 Addendum
238 TR XO Statement dtd 16 May 20
239 Email - TR SMO to CCSG-9 - RE COVID -19 update 28 March - Evening update dtd 28 Mar 20
240 Email - TR SMO to Warfare Commanders - Diamond Princess Article dtd 28 Mar 20
241 Crazier, B. CAPT Statement dtd 15 May 20
242 Email - Crazier, B. CAPT to TR Ombudsmen - (none) with Letter to TR Families and Friends dtd 27 Mar 20
243 TR SUPPO Statement dtd 1 8 May 20; TR XO Statement dtd 1 6 May 20
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166. While in transit to Guam, the TR CO authorized the use of damage control flash
hoods as face coverings because the ship lacked a sufficient number of face coverings
for the entire crew.244
167. Despite receiving direction to plan for using on-base resources, CCSG-9
believed that using Guam hotels was still an option.245
168. On March 25, 2020, CO, NBG compiled a scheme of maneuver brief that
detailed 150 isolation and 493 quarantine beds available in gyms and open bay
berthing.246
169. On March 25, 2020, the CSG-9 COS notified C7F COS of the need for 4,000
rooms to house Sailors in single isolation for two weeks.247
170. On March 25th, CCSG-9 requested 4,000 CDC-compliant rooms and believed
higher headquarters was working their request.248
171 . CCSG-9 received feedback that obtaining 4,000 CDC-complaint rooms was not
an option because A-SN had stated publicly that TR will be pierside in Guam and no
one on the crew would be allowed to leave other than pierside and that 100 percent
testing of the crew will occur to ensure that COVID-19 is contained.249
172. On March 25, 2020, Commander, Joint Region Marianas (CJRM) notified the
Governor of Guam that TR had three COVID-19 Sailors onboard and they were being
evacuated to NBG. The following day, CJRM notified the Governor of Guam an
additional 21 Sailors would be evacuated to NBG from TR.250
173. CJRM stated, “As the situation onboard the ship became more serious and the
medical response evolved [from March 27-29] my conversations with the Governor
became more frequent.”251
174. On March 26, positive COVID-19 cases aboard TR rose from eight to 33. 252
244 Crazier, B. CAPT Statement dtd 15 May 20
245 CCSG-9 Statement dtd 15 May 20
246 Email (SIPR) - CO NBG - NBG Task Force TR REVIVE dtd 26 Mar 20
247 Email - (SIPR) CSG-9 COS to C7F COS - HOTEL OPTION dtd 25 Mar 20
248 CCSG-9 Statement dtd 15 May 20
249 CCSG-9 Statement dtd 15 May 20; Transcript: Marine Corps Officials Hold a Defense Department News Briefing on COVID-19
Efforts dtd 26 Mar 20 https://www.defense.gov/Newsroom/Transcripts/Transcript/Article/2127585/marine-corps-officials-hold-a-
defense-department-news-briefing-on-covid-19-effo/
250 Email - CJRM - Follow Up to 13 May 20 Phone Call
251 Email - CJRM - Follow Up to 13 May 20 Phone Call
252 Email (SIPR) - CCSG-9 - Positive COVID-19 tests on TR (update #9) dtd 26 Mar 20
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175. On March 26, 2020, CCSG-9 informed C7F that TR would run out of
quarantine/isolation space ashore in Guam.253
176. On March 26, 2020, A-SN stated publicly that TR would not need assistance
from Guam and that TR’s crew will stay on the pier upon arrival.254
177. On March 26, 2020, CCSG-9 issued outbreak Commander’s Guidance for arrival
in Guam expressing the following priorities: (1) move all COVID-positive Sailors to
isolation quarters; (2) identify key groups needed to operate ship at sea in near-term; (3)
move key reactor supervisory personnel into isolation following testing; and (4) if
additional quarantine racks remain, prioritize personnel by function.255
178. On March 26, 2020, the TR XO sent an email to all officers and all Chiefs
outlining a plan to disembark TR’s crew upon arrival in Guam.256
179. On March 26, 2020, CPF sent the first of a series of TR Recovery and
Disposition Plan email updates to INDOPACOM and the Chief of Naval Operations
(CNO). CPF reported to CNO that the plan was to test the entire TR crew for COVID-
19.257
180. On March 26, 2020, C7F emailed DCNO (N3/N5) recommending Echelon I
engagement and support for additional resources for testing 1 00 percent of the TR
crew.258
181 . The C7F COS stated that testing before moving to quarantine was not required
and that C7F was clear to CCSG-9 that the intent was to move Sailors ashore as fast as
possible.259
182. On March 24, 2020, C7F emailed CCSG-9 providing testing protocol and the TR
Triage and Disposition Plan, a flow chart for testing all Sailors.260
183. On March 28, 2020, C7F corrected CCSG-9 in an email regarding testing
protocol and mandating him to “start over” with testing.261
1 84. At the request of CNO, it was CPF’s intention to test 1 00 percent of TR’s crew.262
253 Email (SIPR) - CCSG-9 - Positive COVID-19 tests on TR (update #9) dtd 26 Mar 20
254 UPDATED: USS Theodore Roosevelt Quarantines Sailors on Guam as Coronavirus Outbreak Spreads, USNI News (26 Mar 20)
255 Email (SIPR) - CCSG-9 to Crazier, B. CAPT, CVW-1 1 CAG - (S) OUTBREAK COMMANDER’S GUIDANCE dtd 26 Mar 20
256 Email: TR XO - Plan for Guam Day 1 dtd 26 Mar 20
257 Email (SIPR) - CPF to CNO and INDOPACOM - TR Recovery and Disposition Plan dtd 26 Mar 20
258 Email - (SIPR) C7F to OPNAV N3/N5 - RE: (U//FOUO) FOR INFO: TR Recovery and Disposition Plan dtd 26 Mar 20
259 C7F COS Statement dtd 21 May 20
260 Email (SIPR) - C7F- Positive COVID-1 9 Tests on TR dtd 24 Mar 20
261 Email (SIPR) - C7F to CCSG-9 dtd. 28 Mar 20 SUBJ: (S) 28 Mar TB - follow-up
262 Email (SIPR) - CNO to CPF - FOR INFORMATION: TR Recovery and Disposition Plan dtd 26 Mar 20, 2014
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185. In response, C7F stated that “100 percent [testing] was desired but likely not
possible.”263
186. In the same email thread the DCNO (N3/N5), who was responsible for Navy’s
overall plan to combat COVID-19, replied to C7F that the “Crew of TR will not leave
pier, with the exception of positive Sailors, who will be sequestered in base berthing
facilities.”264
1 87. The CNO stated that he understood CPF’s intent to test 1 00 percent of TR’s
crew.265
188. During a discussion with C7F, the Commanding General of III Marine
Expeditionary Force (III MEF) offered up to 5,000 rooms for potential TR crew
occupancy in Okinawa.266
Arrival in Guam
189. On March 27, 2020, TR arrived in Guam and moored pierside.267
190. As TR arrived in Guam, the ship had 36 COVID-19 positive cases.268
191. As of March 27, 2020, USS Ronald Reagan (CVN 76) had three COVID-19
positive cases.269
192. The TR SMO requested assistance from Navy Medicine upon arrival in Guam.270
193. The C7F and CPF Fleet Surgeons concurred with the TR SMO that as TR
arrived in Guam, “[A]nyone who is defined as [having influenza-like illness symptoms] is
a presumptive [positive for] COVID-19 and should be treated as such.”271
1 94. The TR medical team used the batch testing method to test Sailors for COVID-
1 9. 272
195. A batch test does not individually diagnose Sailors.273
1 96. As of March 27, 2020, TR was limited to 40 diagnostic tests per day.274
263 Email (SIPR) - CNO to CPF - FOR INFORMATION: TR Recovery and Disposition Plan dtd 26 Mar 20, 2014
264 Email (SIPR) - CNO to CPF - FOR INFORMATION: TR Recovery and Disposition Plan dtd 26 Mar 20, 2014
265 Email (SIPR) - CNO to CPF - FOR INFORMATION: TR Recovery and Disposition Plan dtd 26 Mar 20, 2014
266 C7F Statement dtd 18 May 20
267Facebook Post - Family and Friends of the Rough Riders, Crozier, B. CAPT (27 Mar 20)
https://www.facebook.eom/USSTheodoreRoosevelt/photos/a.4891 37065779/1 01 56700551 025780/?type=3&theater
268 Email (SIPR) - C7F - C7F COVID daily CDRs update (26 Mar) dtd 27 Mar 20
269 Email (SIPR) - C7F - C7F COVID daily CDRs update (26 Mar) dtd 27 Mar 20
270 Email - TR SMO to CPF and C7f surgeons - WARNORD for BUMED dtd 24 Mar 20
271 Email - CPF Surgeon to C7F surgeon and TR SMO - WARNORD for BUMED dtd 24 Mar 20
272 Email (SIPR) - CCSG-9 to C7F - POSITIVE COVID-19 TEST ON TR (update #3) dtd 25 Mar 20
273 Navy Preventive Medicine Teams Embark Ships in 7th Fleet, INDOPACOM, (03 Mar 20)
https://www.pacom.mil/Media/News/News-Article-View/Article/2122302/navy-preventive-medicine-teams-embark-ships-in-7th-fleet/
274 TR SMO Statement dtd 1 7 May 20; CCSG-9 Statement dtd 1 5 May 20
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197. NAVADMIN 092/20 urged commands to “continue random urinalysis specimen
collection from Sailors during the COVID-19 pandemic to the greatest extent possible,”
but also afforded Commanding Officers the approval authority to pause collections in
response to the strict enforcement of social distancing measures.275
198. Subsequent to TR’s arrival in Guam, TR’s Command Urinalysis Program
continued with assigned times for each department to report for urinalysis screening.276
199. As TR pulled into Guam, C7F’s priority was keeping TR mission capable.277
200. As the TR arrived in Guam, C7F was “crystal clear” to CCSG-9 that C7F wanted
as many Sailors off the ship as quickly as possible.278
201 . According to C7F COS, CPF directed 1 00 percent testing of TR’s crew because
CPF believed a lab in Korea could test 1 ,000 samples a day. C7F COS stated he
believed Korea was never able to test 1 ,000 TR Sailors in one day.279
202. TR leadership prioritized removing COVID-19 positive Sailors first, key reactor
watchstanders second, and PUIs last.280
203. The TR XO planned to keep approximately 700 Sailors aboard TR to run the
ship.281
204. According to the C7F COS, after TR arrived in Guam, the goal became
scattered: CPF wanted testing, C7F wanted Sailors off the ship, and TR wanted single
rooms.282
205. According to the C7F COS, Guam later required testing before Sailors could
enter hotels.283
206. On March 28, 2020, the C7F COS informed the CSG-9 COS that TR was not
following “protocol” because Sailors were going into quarantine without batch tests to
determine if the virus was present.284
275 NAVADMIN 092/20 Urinalysis Policy Update dtd 27 Mar 20
276 TR MA2 to TR Crew - URINALYSIS POLICY UPDATE dtd 29 Mar 20
277 C7F COS Statement dtd 21 May 20
278 C7F COS Statement dtd 21 May 20
279 C7F COS Statement dtd 21 May 20
280 TR XO Statement dtd 16 May 20
281 TR XO Statement dtd 16 May 20
282 C7F COS Statement dtd 21 May 20
283 C7F COS Statement dtd 21 May 20
284 Email (SIPR) - C7F COS to CSG-9 COS - Triage and Procedure dtd 27 Mar 20
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207. According to CCSG-9, securing hotel rooms in Guam was initially not an option
because A-SN stated publicly that the Navy would not require assistance from Guam.285
208. C7F believed that should hotels become available in Guam, Sailors would need
to test negative for COVID-19 before exiting NBG.286
209. As of March 27, 2020, the C7F COS explained to CSG-9 that testing was
required before personnel disembarked.287
210. On March 27, 2020, the TR SMO distributed “TR’s Triage and Disposition Plan”
promulgated by C7F, which contemplated 200 COVID-19 tests per day.288
21 1 . Because Guam declared a Public Health State of Emergency on March 1 4, 2020,
the C7F COS believed asking Guam for help was a “big ask.”289
21 2. TR CO stated, “Testing had to be done before Sailors were allowed to debark the
ship.”290
21 3. The TR XO stated that testing requirements “seemed to change daily.”291
21 4. The TR SMO stated, “There was some initial confusion as to whether or not the
Sailors had to be tested before they went to on-base facilities rather than the hotels out
in town.”292
21 5. The TR XO stated the information flow between C7F, CSG-9, and TR was “off”
and that TR XO believed the TR was “making decisions without the benefit of full
information.”293
216. The TR CO stated that “[the Warfare Commanders] 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 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.”294
265 CCSG-9 Statement dtd 15 May 20
286 C7F Statement (Addendum) dtd 19 May 20; C7F COS Statement dtd 21 May 20
287 Email - (SIPR) COS C7F to COS CSG-9 - Triage and procedure dtd 28 Mar 20
288 Email - TR SMO to CSG-9 Staff - Testing Planning Factors dtd 27 Mar 20
289 C7F COS Statement dtd 21 May 20; Email (SIPR) - CSG-9 COS to C7F COS - HOTEL OPTION dtd 25 Mar 20
290 Crazier, B. CAPT Statement dtd 15 May 20
291 TR XO Statement dtd 16 May 20
292 TR SMO Statement dtd 1 7 May 20
293 TR XO Statement dtd 1 6 May 20
294 Crazier, B. CAPT Statement dtd 15 May 20
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21 7. The TR SMO stated he was not fully aware of a Guam hotel plan and was not
briefed on the plan.295
21 8. CCSG-9 was aware of ongoing efforts by higher headquarters to negotiate for
the use of hotels on Guam and “by March 31, [we knew we] were making progress.”296
219. According to C7F, “the TR CO was briefed on the [hotel] option and the support,
voiced no concerns when asked, (but then sent his letter the same or following day, 29
or 30 March).”297
220. The TR SMO stated he did not get much sleep between March 24th and April
2nd.298
221 . The TR CO did not attend C7F COS COVID-19 working group meetings. As a
result, C7F was generally unaware of what was actually happening on the ship during
the first two days in Guam.299
222. As TR Sailors came ashore, complaints about available accommodations and
food arose.300
223. Sailors expressed their concerns on social media and this was relayed to the TR
CO and TR XO.301
224. The CSG-9 COS stated that in “daily meetings with the C7F Crisis Action Team,
we stated food supply was insufficient, and available racks were not spread out far
enough. C7F seemed concerned only with filling beds ashore. Ongoing dialogue
between C7F and CCSG-9 was contentious.”302
225. The TR SMO did not consistently attend or send a representative to the daily
C7F medical synchronization meetings.303
226. The TR CO stated that it was a constant balancing act between keeping the crew
in close quarters on the ship and sending the crew out to inadequate facilities where
they lacked proper living necessities and medical care.304
295 TR SMO Statement dtd 17 May 20
296 CCSG-9 Statement dtd 15 May 20
297 C7F Statement dtd 18 May 20
298 TR SMO Statement dtd 17 May 20
299 C7F COS Statement dtd 21 May 20
300 TR XO Statement dtd 16 May 20; AN Statement dtd 16 May 20; ATI Statement dtd 22 May 20
301 Crozier, B. CAPT Statement dtd 15 May 20; TR XO Statement dtd 16 May 20; TR PAO Interview Summary dtd 23 May 20
302 CSG-9 COS Statement dtd 1 8 May 20
303 CPF Surgeon Statement dtd 19 May 20
304 Crozier, B. CAPT Statement dtd 15 May 20
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227. The TR XO expressed concern sending “thousands of Sailors off the ship if there
were no acceptable showers, bathrooms, or food available.”305
228. The TR SMO stated the NHG public health emergency officer expressed to him
concerns over “communal berthing” on land.306
229. NBG does not have a galley. NBG CO coordinated with MWR (Club), NEXCOM,
and DoDEA cafeteria in order to serve 5000 - 6000 daily meals.307
230. On March 28, 2020, TR received new COVID-1 9 testing kits, but they required
12-14 days of preparation before use. 308
231 . On March 28, 2020, C7F, JRM COS and CJRM began initial discussions about
increasing isolation capacity via hotels. The same day, CJRM began discussing the
availability of hotel rooms with the government of Guam.309
232. On or about March 28, 2020, the Governor of Guam told CJRM, “we (Guam)
need to support the people who defend us. This is the humanitarian thing to do.”310
233. The Governor of Guam indicated to the CJRM COS that a formal request from
CPF or INDOPACOM would be necessary to secure hotels.311
234. After the initial concept of operations was developed the Guam Hotel and
Restaurant Association (GHRA) identified the first hotels for use by TR personnel and a
unified “walkthrough” of partner hotels was arranged between April 1st and 2nd at various
sites.312
235. On March 28th, CCSG-9 decided to move people off ship as quickly as possible
and test later.313
236. On March 28th, the TR SMO wrote an email to C7F and U.S. Pacific Fleet
(PACFLT) Surgeons stating the need to move 4,500 personnel into individual berthing
with single heads.314
305 TR XO Statement dtd 1 6 May 20
306 TR SMO Statement dtd 17 May 20
307 NBG CO Statement dtd 1 8 May 20
308 Email - (SIPR) CNO to CPF - INFO TR recovery and disposition update 27 Mar 20 dtd 28 Mar 20
309 Email - CJRM - Follow Up to 13 May 20 Phone Call
310 Email - CJRM - Follow Up to 13 May 20 Phone Call
311 C7F Statement dtd 18 May 20; Email - CJRM - Follow Up to 13 May 20 Phone Call
312 Email - CJRM - Follow Up to 13 May 20 Phone Call
313 Email (SIPR) - C7F to CCSG-9 - SUBJ: (S) 28 Mar TB - follow-up dtd 28 Mar 20
314 Email - TR SMO to C7F and CPF Surgeons - Reality dtd 28 Mar 20
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237. As positive cases mounted aboard TR, the TR CO stated that he relayed his
concerns about the ship’s inability to adhere to COVID related NAVADMINs to CCSG-
9. 315
238. On March 28, 2020, the TR XO acknowledged TR was not in compliance with
applicable guidance and believed quarantining Sailors in aft berthing aboard TR was
“only making the problem worse.” The TR XO recommended to the TR CO to end
segregated berthing on board the ship and declare] the entire crew and embarked staff
as ‘Close Contacts]. ’“316
239. On March 28, 2020, the TR SMO sent an email to CCSG-9 noting 44 total Sailors
had tested positive by midday. In an evening update, the TR SMO verified two more
Sailors tested positive, bringing the total to 46 total positive cases aboard TR.317
240. On March 29, 2020, the TR SMO sent an email to CCSG-9 noting 50 total Sailors
had tested positive by midday. In an evening update, the TR SMO verified three more
Sailors tested positive, bringing the total to 53 positive cases aboard TR.318
241 . On March 29, 2020, the TR SMO sent an email stating “we have lost” regarding
COVID-19 on TR.319
242. The TR XO suggested that the Ship Emergency Command Center (ECC) data
demonstrated the ship’s segregated berthing plan was making the rate of transmission
worse.320
243. During this time, C7F tasked CCSG-9 and TR to develop plans to airlift crew
members to Okinawa.321
244. C7F had arranged for III MEF to vacate their barracks in Okinawa located at
Marine Corps Air Station Futenma, Marine Corps Base Butler and outlying camps.322
245. On March 29, 2020, the TR CO emailed Commander, Fleet Activities Okinawa
(CFAO), to “get some fidelity on the latest proposal to get the TR 5,000 barracks rooms
3,5 Crazier, B. CAPT Statement dtd 15 May 20
316 TR XO Statement dtd 16 May 20; Crazier, B. CAPT Statement dtd 15 May 20
317 Email - TR SMO to CCSG-9 - COVID-19 update 28 March - Mid-day update dtd 28 Mar 20; Email - TR SMO to CCSG-9 - RE
COVID -19 update 29 March - Evening update dtd 28 Mar 20
318 Email - TR SMO to CCSG-9 - COVID-19 update 29 March - Mid-day update 29 Mar 20; Email - TR SMO to CCSG-9 - COVID-
19 update 29 March - Evening update dtd 29 Mar 20; Email - (SIPR) CPF to C7F - Evening Ops Update and COVID 29 Mar dtd 29
Mar 20
319 Email - TR SMO to C7F and CPF Surgeons - Reality dtd 28 Mar 20
320 TR XO Statement dtd 1 6 May 20
321 CCSG-9 Statement dtd 15 May 20
322 Email - C7F COVID Response Cell - RFI Follow-Up dtd 20 May 20
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in Okinawa.” CFAO replied, “Long story short, we don’t have 500p [sic] rooms but will
do whatever we can to support.”323
246. The TR CO discussed his conversation with CFAO with the TR XO and senior
Warfare Commanders. The group believed the C7F staff had wasted their time on a
non-viable COA. The TR CO did not attempt to verify the accuracy of this information
up the chain of command.324
247. The TR CO stated the Okinawa COA “was discounted as a viable COA due to
logistical challenges, distance from THR, and likelihood of insufficient isolation
rooms.325
248. The TR CO and CSG-9 Warfare Commanders later stated that they were
unaware of the intended movement of III MEF.326
249. On March 29, 2020, CPF rejected C7F’s plan for movement of the TR crew to
Okinawa based on the risk of accelerating infection spread on the aircraft during the 9-
hour flight to Okinawa, and complications with the government of Japan.327
250. CPF directed that no Navy personnel leave Guam until he personally reviewed
and approved that plan.328
251 . On March 29, 2020, CO, NBG and C7F COS acknowledged that if they could not
achieve better social distancing, more Sailors would contract the virus.329
252. As of March 29, 2020, the testing rates for TR were 1 20/day max and there were
4,389 untested crewmembers. At that rate, the TR SMO estimated it would take 37
days to test the entire crew.330
253. On March 29, 2020, there were 1 ,1 50 racks available on Guam with 535 racks
occupied.331
254. CSG-9 COS stated the TR SMO pushed hard for individual rooms. CSG-9 COS
stated C7F understood this, but pushed to quarantine Sailors 150-200 at a time.332
323 Email - CAPT Crozier to Commander, Fleet Activities Okinawa - Subj: New Normal dtd 29 Mar 20, 1818
324 CCSG-9 Statement dtd 15 May 20; Crozier, B. CAPT Statement dtd 15 May 20; TR XO Statement dtd 16 May 20
325 Crozier, B. CAPT Statement dtd 15 May 20
326 Crozier, B. CAPT Statement dtd 1 5 May 20; CVW-1 1 CAG Statement dtd 1 9 May 20; CDS-23 Statement dtd 1 9 May 20
327 Email (SIPR) - CPF to C7F - Evening Ops Update and COVID 29 Mar dtd 29 Mar 20
328 Email (SIPR) - C7F to CPF - Evening Ops Update and COVID 29 Mar dtd 30 Mar 20
329 Email (SIPR) - NBG CO to C7F COS - Quarantine - Social Distancing - getting to 4,000 dtd 29 Mar 20
330 Email - (SIPR) C7F COS - Numbers dtd 29 Mar 20
331 Email (SIPR) - CPF to C7F - Evening Ops Update and COVID 29 Mar dtd 29 Mar 20
332 CSG-9 COS Statement dtd 1 8 May 20
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255. On March 29, 2020, the TR’s Afloat Recreation Specialist closed all gyms aboard
TR.333
256. On March 29, 2020, with over 1 ,000 members of the crew onboard in quarantine,
the TR CO released 900-1 ,000 Sailors in aft quarantine based on the recommendation
of the TR SMO, TR XO, and TR CMC.334
257. The TR CO stated he felt it became prudent to begin considering all Sailors as
COVID-19 positive.335
258. The TR XO stated by March 29, 2020, there was “true human suffering” in aft
berthing.336
259. The TR SMO stated that a decision to quarantine large numbers of Sailors in aft
berthing was ineffective.337
260. CCSG-9 was not involved in the decision to break TR’s aft quarantine. The TR
CO informed CCSG-9 after he had already lifted the quarantine order.338
261 . After TR SMO notified CCSG-9 of the COVID-1 9 positive Sailors aboard TR,
CCSG-9 asked C7F for assistance in securing individual isolation rooms in compliance
with applicable NAVADMINs. At the time, CCSG-9 requested 200 rooms, but expected
that the number would grow.339
262. On March 29, 2020, TR CO established a policy that no Sailors would leave the
ship until guarantee of sufficient meal service was available. Additionally, the CO
requested the ability for ship’s company to inspect isolation/quarantine facilities for
suitability prior to moving Sailors (e.g., adequate meal service, heads, physical
separation).340
263. TR’s leadership was concerned about the practicality of the temporary open-bay
facilities because open bay facilities were not CDC compliant and did not allow for
appropriate social distancing.341
333 Email - TR Afloat Rec Specialist - Gym's Secured dtd 29 Mar 20
334 TR XO Response to RFI dtd 6 Apr 20
335 Crazier, B. CAPT Statement dtd 15 May 20
336 TR XO Statement dtd 1 6 May 20
337 TR SMO Statement dtd 17 May 20
338 CSG-9 COS Statement dtd 1 8 May 20
339 Email (SIPR) - CCSG-9 to C7F and C3F - POSITIVE COVID-19 TESTS ON TR (initial report) dtd 24 Mar 20; CCSG-9 Statement
dtd 1 5 May 20
340 Email - TR CO to NBG CO - NBG CMC Tour dtd 29 Mar 20; TR XO Statement dtd 1 6 May 20; TR CMC Statement dtd 1 7 May
20
341 Crazier, B. CAPT Statement dtd 15 May 20; TR SMO Statement dtd 17 May 20; CVW-1 1 CAG Statement dtd 19 May 20
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264. TR CO communicated regularly with CO, NBG, TR CMC and TR Chaplain about
conditions ashore.342
265. C7F believed that the TR CO and CSG-9 were resisting sending the crew ashore
because available facilities were not fully CDC-compliant.343
266. C7F did not view the temporary facilities at NBG as inadequate as C7F felt they
were a short-term improvement over shipboard conditions that would provide a bridge to
a longer-term solution.344
267. On March 30, 2020, TR Supply Officer acknowledged a gym was available
pierside for all hands.345
268. On March 30, 2020, TR CO halted the transfer of Sailors to off-ship berthing
because available rooms were not single occupancy.346
269. According to C7F COS, TR CO turned down short term cots in less than
desirable places like storerooms and warehouses.347
270. The pier area around TR had been designated a Force Health Protection
Boundary (FHPB), restricting movement of those Sailors beyond the pier.348
271 . TR CO stated that he intentionally left C7F off his email “TR request for
assistance”.349
272. In addition to CCSG-9, the TR CO, CVW-1 1 CAG, CDS-23, and CSG-9 COS
were regular attendees at C7F Commander’s Update Briefs conducted via VTC
regularly during the deployment.350
273. On March 30, 2020, A-SN COS advised TR CO that A-SN would not visit the
ship so TR “may focus on the health and welfare of [the] Sailors.”351
274. On March 31 , 2020, five members of the TR Medical Department signed a letter
advocating for disembarkation of all TR Sailors from the ship and expressed an intent to
release it to the public.352
342 Crazier, B. CAPT Statement dtd 15 May 20
343 C7F COS Statement dtd 21 May 20
344 C7F Statement dtd 1 8 May 20
345 Email - TR SUPPO to All Officers and Chiefs - Pier Gym Use dtd 31 Mar 20
346 Email - NBG CO and TR CO - "Please Call" dtd 30 Apr 20
347 C7F COS Statement dtd 21 May 20
348 Email - CO NBG to TR CO - RE: TR PVST 0529 (Guam time) dtd 24 Mar 20
349 Crazier, B. CAPT Statement dtd 15 May 20
350 C7F Statement dtd 18 May 20; CCSG-9 Statement dtd 15 May 20; Crazier, B. CAPT Statement dtd 15 May 20; CVW-1 1 CAG
Statement dtd 19 May 20; CDS-23 Statement dtd 19 May 20; CSG-9 COS Statement dtd 18 May 20
351 SECNAV COS email to TR CO - Support Requirements dtd 30 Mar 20
352 Medical Department letter dtd 31 Mar 20
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275. On March 31 , 2020, the President of GHRA passed along a string of emails
wherein an unknown person was looking to book hundreds of rooms in Guam for the
TR.353
276. When informed of the third party attempt to secure hotel rooms, the TR XO
emailed all leadership on TR to ask personnel to stop, as this was “counterproductive”
as Guam political leaders were “under tremendous pressure from their constituents to
contain [the TR COVID cases] to the base” and noted that currently there was “little
local support for moving” TR Sailors into hotels on the island.354
277. On March 31 , 2020, CPF formally requested Guam hotel options and
negotiations commenced for an undetermined number of hotel rooms.355
278. On or about March 30, 2020, eight local community groups sent a letter to Guam
Governor Leon Guerrero urging action to keep military patients on-base until the virus
was defeated.356
279. On March 31 , 2020, the TR CO received an email from the TR Ombudsman
expressing concern about “the overwhelming lack of medical treatment or check in for
Sailors who have been moved off the ship [and for their] [b]asic living necessities . . .
whether it be medicine, toiletries, etc.”357
Development of and Response to Commanding Officer Letter of
March 30, 2020 Warfare Commanders White Paper
280. On March 29, 2020, the CVW-1 1 CAG drafted a white paper, collaborating
between the other CSG-9 Warfare Commanders, presenting a COVID-19 analysis and
suggested courses of action for CSG-9 Warfare Commanders and TR senior leadership
review and revision with the intent of providing the final product to CCSG-9.358
281 . CVW-1 1 CAG sent the White Paper to CCSG-9 on March 30, 2020. 359
353 Email - TR PAO to JRM PAO et al. - RE: IMMEDIATE AWARENESS” » Fwd: 400 Rooms checking in ASAP dtd 131 Mar 20
354 Email - TR XO - Hotel Room inquires dtd CS1 Mar 20
355 C7F Statement dtd 18 May 20
356 "Governor: 'One Guam' approach needed to defeat virus" Pacific Daily News (31 Mar 20)
https ://www.guampdn.com/story/news/local/2020/03/31/governor-one-guam-approach-needed-defeat-virus/2938329001/
357 Email - TR Ombudsmanto TR CO, TR XO, TR CMC - Questions on medical treatment for affected Sailors dtd 131 Mar 20, 1 246
358 CVW-1 1 CAG Statement dtd 19 May 20; TR XO Statement dtd 16 May 20; CCSG-9 Statement dtd 15 May 20; Email - CVW-1 1
CAG to CCSG-9 - PROPOSED PAPER / COURSE OF ACTION FROM WARFARE COMMANDERS dtd 29 Mar 20
359 Email - CVW-1 1 CAG to CCSG-9 - PROPOSED PAPER / COURSE OF ACTION FROM WARFARE COMMANDERS dtd 29
Mar 20
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282. CCSG-9 directed the Warfare Commanders to distill the white paper into four
executable courses of action and CVW-1 1 CAG responded with four executable
courses of action:
a. 4,500 Sailors into individual isolation; 500 Sailors to remain onboard
b. 2,500 crewmembers into individual isolation; 2,500 crewmembers to
remain onboard and in group berthing off-ship
c. Maintain the status quo - utilizing group berthing off-ship using available
NBG facilities
d. Immediately get underway360
283. After preparing the four courses of action, the Warfare Commanders provided
them to CCSG-9.361
284. CCSG-9 did not consider using the Guam hotels as a viable option but kept the
use of Guam hotels as an available option.362
285. On the morning of March 30th, CCSG-9 recommended to C7F that the removal of
4,500 crewmembers to individual isolations rooms was the CCSG-9 recommended
course of action.363
286. C7F acknowledged the recommendation, but directed to continue batch testing,
identification of “clean” group, and development of a plan to get a “clean” ship.364
Development of CAPT Crozier’s Letter and Email
287. TR CO was unaware of any promises the U.S. Government had made to Guam
about the use of local resources to aid in the care of TR crewmembers.365
288. The TR CO acknowledged that the A-SN COS understood TR needed more cots
on base and attributed the acceleration of that delivery to his interaction.366
289. A-SN COS had not taken any action to accelerate the delivery of cots.367
360 Email - CVW-1 1 CAG to CCSG-9 - PROPOSED PAPER / COURSE OF ACTION FROM WARFARE COMMANDERS dtd 29
Mar 20
361 Email - CVW-1 1 CAG to CCSG-9 - PROPOSED PAPER / COURSE OF ACTION FROM WARFARE COMMANDERS dtd 29
Mar 20
362 CCSG-9 Statement dtd 15 May 20
363 CVW-1 1 CAG Statement dtd 1 9 May 20
364 CCSG-9 Statement dtd 15 May 20; C7F Statement dtd 18 May 20
365 Crazier, B. CAPT Statement dtd 15 May 20; TR XO Statement dtd 16 May 20
366 Crazier, B. CAPT Statement dtd 15 May 20
367 Email - TR Cl Team 3 Lead to TR Cl CoS - TELECON with (b) (6) dtd 1 8 May 20
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290. The CVW-1 1 CAG outlined that NBG facilities were insufficient to isolate
personnel in accordance with the TR SMO’s guidance, and securing hotels for the entire
TR crew was impractical upon arrival; however, the Warfare Commanders were careful
to ask for isolation, not specifically for hotel rooms.368
291 . On March 30th, the TR CO and TR XO expected a phone call from the CNO; that
phone call did not occur.369
292. CNO did not attempt to contact TR directly, nor did he intend to do so at any time
relevant to this investigation as he trusted the leadership in the TR chain of command to
discuss the immediate issues of the ship with the TR CO.370
293. The report of an incoming phone call from CNO to the TR CO was a
miscommunication resulting from CNO’s Battle Watch Captain (BWC) calling TR to ask
if the previous A-SN COS call had been completed.371
294. The TR CO directed the TR XO to draft TR CO’s letter based on input from the
Warfare Commanders’ White Paper.372
295. The TR CO reviewed the document and the email cover letter, signed it, scanned
the letter, attached the letter to his email and sent the letter to CPF, Commander, Naval
Air Forces Pacific (CNAP), and CCSG-9. The TR CO stated that his intent in sending
the letter was to stop the administrative bureaucracy and bring focus back to what he
thought was the best course of action to get people off the ship. Fie described the email
and letter as a “red flare.”373
296. C7F was not included on the email from the TR CO to CPF and CNAP.374
297. The TR CO received calls and emails from A-SN’s COS on March 30th
discussing an April 1st visit by A-SN to the TR; they did not discuss an immediate need
for 4,000 beds fully in compliance with CDC and Navy guidelines and the TR CO did not
specify that the current plans were not acceptable.375
see CVW-1 1 CAG Interview dtd 19 May 20
369 Crozier, B. CAPT Statement dtd 15 May 20; TR XO Statement dtd 16 May 20
370 Email - CNO Former EA to TR Cl Senior Legal Advisor - TR Investigation dtd 20 May 20
371 Email - CNO ABWC PTGN to BWC PTGN RE: Hot RFI.THEODORE ROOSEVELT RFI dtd 30 Mar 20; Email - CNO EA to BWC
PTGN FW: TR dtd 29 Mar 20
372 Crozier, B. CAPT Statement dtd 15 May 20; TR XO Statement dtd 16 May 20
373 TR CO Email and Ltr - Request for Assistance in Response to COVID-19 Pandemic dtd 30 Mar 20; Crozier, B. CAPT Statement
dtd 15 May 20
374 TR CO Email and Ltr - Request for Assistance in Response to COVID-1 9 Pandemic dtd 30 Mar 20
375 Crozier, B. CAPT Statement dtd 15 May 20
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298. On March 30th at 1 348, the TR CO sent an email with the letter drafted by the
TR XO to ten recipients on an unclassified network The email was sent to CPF, CNAP,
CSG-9, and copied to CVW-1 1 CAG, TR XO, CVW-1 1 Deputy CAG, Commander,
Destroyer Squadron (CDS) 23, TR SMO, CPF COS, and CNAP COS. The TR CO
stated that in hindsight that there was likely a higher risk of the letter being released to
press after being sent on the unclassified network, but at the time he did not realize this
risk or intend for the letter to be released to the press.376
299. The TR CO requested “all available resources to find NAVADMIN and CDC-
complaint quarantine rooms for my entire crew as soon as possible.”377
300. CCSG-9 did not have prior knowledge that TR CO was going to send this email
and was surprised that the CO did not talk to him about the email first.378
301 . CNAP, CPF, and CJRM responded to the CO’s email.379
302. The TR SMO forwarded the TR CO email with attachment to his personal email
account.380
303. The TR SMO also later forwarded the responses to the TR CO email from CNAP,
C7F, and CJRM to his personal email.381
304. CNAP and TR CO spoke on the phone following the email.382
305. CPF and CCSG-9 spoke on the phone following the email; TR CO was present
for this conversation.383
Reactor Officer Letter
306. The TR Reactor Officer (RO) discussed with the TR CO concerns about the
safety of the Reactor Department watch supervisors and the increase of positive
COVID-19 cases in berthing in the gym.384
307. On March 26th, the TR RO sent an email via the classified network to CNAP
Force Nuclear Propulsion Officer and the Special Assistant to the Director of Naval
376 Crazier, B. CAPT Statement dtd 15 May 20
377 TR CO Email and Ltr - Request for Assistance in Response to COVID-1 9 Pandemic dtd 30 Mar 20
378 CCSG-9 Statement dtd 15 May 20; Crazier, B. CAPT Statement dtd 15 May 20
379 See Email - CNAP to TR CO - RE: TR request for assistance dtd 30 Mar 20; Email - CPF to TR CO and CCSG-9 - RE: TR
request for assistance dtd 30 Mar 20
380 Email - TR SMO to Personal email account - FW: TR request for assistance dtd 29 Mar 20 (forwarding the TR CO original email
to SMO’s personal email account)
381 Email - TR SMO to Personal email account- FW: TR request for assistance dtd 6 Apr 20 (forwarding the responses to the TR
CO original email to SMO’s personal email account)
382 CNAP Statement dtd 1 3 May 20
383 CPF Statement dtd 17 May 20; CCSG-9 Statement dtd 15 May 20
384 TR RO Statement dtd 18 May 20
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Reactors for Carrier Operations outlining the current situation and way ahead for
operations.385
308. On March 30th, the TR RO drafted and sent a classified email to the TR CO
requesting off ship isolation rooms with separate bathroom facilities; the TR CO sent the
TR RO’s email to CNAP.386
Medical Department Letter
309. Junior Medical Department personnel drafted a letter and presented it to the TR
SMO, who was the last to sign it.387
31 0. In the letter, the signatories outlined their concerns over the situation on TR,
detailed the possibility of 50 fatalities onboard the TR based on their assessment of
published COVID-19 mortality rated at the time, and threatened to release their letter to
the media.388
31 1 . Not all members of the Medical Department signed the letter.389
31 2. The TR SMO and the other signers of the Medical Department letter presented
the Medical Department letter to the TR XO.390
31 3. The TR XO requested the signers not send the letter, and believed the letter was
not helpful, and the tone was unprofessional and overly combative.391
31 4. The TR SMO and the other signers of the Medical Department letter then
presented the Medical Department letter to the TR CO.392
31 5. The TR CO asked the signers not to send it to the media because he had sent
his email, with the attached letter, up the chain of command and thought it would
address their concerns.393
385 Email (SIPR) - TR RO to SA to NR for CVN Ops - CVN 71 COVID-19 Roll Up and Way Ahead dtd 26 Mar 20; TR RO Statement
dtd 18 May 20
386 TR CO Email and Ltr - Request for Assistance in Response to COVID-1 9 Pandemic dtd 30 Mar 20
387 TR SMO Statement dtd 17 May 20
388 Medical Department Letter dtd 31 Mar 20
389 See e.g., CVW-1 1 Surgeon Statement dtd 18 May 20 , (“We didn’t take the letter to the media and never intended to, and we
certainly had no reason to after what happened with [TR CO]’ s memo.”), but also TR PT Statement dtd 18 May 20 (“I believed only
two things would drive the Navy to act, the death of a Sailor or public opinion.”)
390 TR XO Statement dtd 16 May 20
391 TR XO Statement dtd 16 May 20
392 TR XO Statement dtd 16 May 20; TR SMO Statement dtd 17 May 20
393 See e.g., Crazier, B. CAPT Statement dtd 15 May 20; TR SMO Statement dtd 17 May 20; TR Surgeon Statement dtd 18 May 20;
CVW-1 1 Surgeon Statement dtd 18 May 20
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31 6. The TR SMO sent the Medical Department letter via email to the Surgeon
General copying CPF and C7F Surgeons and a few other senior leaders within Navy
medicine.394
31 7. Approximately three minutes later, the TR SMO sent the Medical Department
letter via email to over 160 recipients, none of whom were in TR’s operational or
administrative chain of command.395
Media Release and Subsequent Actions
31 8. As early as March 30th, a reporter for the San Francisco Chronicle received a
copy of the TR CO’s letter and subsequently contacted OSD Public Affairs for
comment.396
319. On April 1st, the San Francisco Chronicle posted a story entitled “Exclusive:
Captain of aircraft carrier with growing coronavirus outbreak pleads for help from Navy.”
The TR CO’s letter was included in this article.397
320. On April 1 , 2020, the Governor of Guam permitted the entrance of TR personnel
into Guam, subject to certain limitations. The Governor had intended to voice her
support during a press conference on April 1st, in order to convey the well-managed and
thoughtful civil-military response to the situation on TR. Publication of the TR CO’s
letter affected the Governor’s opportunity to shape the public narrative of Guam’s
partnership with the Navy398
321 . The TR CO’s email and letter of March 30th, did not increase support from CPF.
CPF stated, “I took no new actions as a result of Crozier’s email or memo because we
had already been examining all options to get Sailors off the ship safely, get them tested
quickly, and moved into appropriate locations efficiently.”399
322. The TR CO’s email and letter of March 30th, did not increase support from C7F.
C7F stated, “I can’t see how the letter didn’t slow things down.”400
394 Email - TR SMO to Navy Surgeon General - Letter from Medical Department on USS Theodore Roosevelt dtd 31 Mar 20
395 Email - TR SMO - Guam dtd 30 Mar 20
396 Email - TR PAO - FW: Urgent Media inquiry: USS Theodore Roosevelt COVID outbreak dtd 30 Mar 20
397 Exclusive: Captain of aircraft carrier with growing coronavirus outbreak pleads for help from Navy San Francisco Chronicle (31
Mar 20) https://www.sfchronicle.com/bavarea/article/Exclusive-CaDtain-of-aircraft-carrier-with-15167883.php
398 Governor of Guam Itr to CJRM, Subject: USS Theodore Roosevelt, dtd 1 Apr 20; CPF Statement dtd 1 7 May 20
399 CPF Statement dtd 17 May 20
400 C7F Statement dtd 1 8 May 20
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323. The TR CO’s email and letter of March 30th, did not increase support from
CCSG-9. CCSG-9 stated, “The letter had no impact on what echelon I, II, or III were
doing. The letter did have negative impact on our progress, which was frustrating.”
324. On April 1 , 2020, TR XO expressed to CJRM the need for surgical masks, stating
“1000’s [were] on order.” Without surgical masks, TR XO directed Sailors wear flash
hoods, bandanas, or some other face covering. He also mentioned Sailors were
restricted to their rooms and asked if Chaplains, CMCs and OICs could perform health
and wellness checks.401
325. On or about April 1, 2020, personnel transporting TR Sailors to hotels in Guam
denied entry of two TR Sailors onto transport trucks because the two presented with
COVID-19 symptoms.402
326. On April 2, 2020, Fleet Logistics Center Pearl Harbor approved 4,000 hotel
rooms in Guam for use by TR personnel.403
327. On April 2, 2020, the TR CO and CO, NBG coordinated transportation of over
300 TR personnel to hotel rooms.404
328. On April 2, 2020, TR XO distributed quarantine and release plan to all hands.405
329. On April 2, 2020, A-SN COS offered TR CO a “direct line to SECNAV.”406
330. During a phone call with CCSG-9, A-SN asked CCSG-9 whether or not the TR
CO should be fired; CCSG-9 stated he felt pressured to agree with A-SN and stated to
A-SN that the TR CO should be fired.407
331 . Immediately after that phone call with A-SN, CCSG-9 called C7F to voice his
concern.408
332. The Vice Chief of Naval Operations (VCNO) called CCSG-9 and directed him to
relieve the TR CO for cause by order of A-SN.409
333. On April 3rd, the TR CO was relieved by A-SN for “loss of confidence.”410
401 Email - TR XO email to JRM COS - SUBJ: Confidential dtd 1 Apr 20; C7F COS Statement dtd 21 May 20
402 Email - CJRM to TR CO - SUBJ: Day 1 dtd 1 Apr 20
403 Email - NAVSUP Fleet Logistics Center Pearl Harbor to TR Suppo - TR Lodging Awarded dtd 2 Apr 20, 1506
404 Email - NBG CO to TR CO - RE: 300 PAX (sic) tonight and other dtd 2 Apr 20
405 Email - TR XO to TR All Hands, CSG-9, CVW-1 1 , and COMDESRON 23 leadership - COVID-1 9 QUARANTINE PLAN dtd 2 Apr
20 1627
406 Email - SECNAV COS to TR CO - RE:TR Family Letter dtd 2 Apr 20
407 CCSG-9 Statement dtd 15 May 20
408 CCSG-9 Statement dtd 15 May 20
409 CCSG-9 Statement dtd 15 May 20
4,0 Transcript: DON Press Briefing with Acting Secretary of the Navy Thomas B. Modly and CNO Admiral Gilday dtd 2 Apr 20;
Crozier, B. CAPT Statement dtd 15 May 20; CCSG-9 Statement dtd 15 May 20
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334. CCSG-9 ordered that no CSG-9 personnel were permitted to make any digital
recordings of individuals in quarantine or isolation.411
335. After TR CO was relieved, TR XO notified the TR HODs of the time TR CO was
to depart the ship.412
336. TR Sailors recorded TR CO departing the ship and posted the recordings to
social media. Nearly 2,000 Sailors congregated in close proximity, with only a few
wearing face masks and without regard to social distancing, to send off the former TR
CO. Despite mandated use of face coverings, video of the former TR CO departing the
ship shows only a small number of Sailors complied.413
337. When C7F saw the video, he later stated to the crew that, “Our jobs just got a lot
harder,” referring to the crew’s complete disregard for social distancing.414
338. Forty-five Sailors who had been sent ashore were admitted to NFIG for treatment
of COVID-19. Of these Sailors, six required oxygen support and one was placed on a
ventilator for respiratory failure. The majority were admitted for close observation and
did not require additional intervention.415
339. On 5 April 5th, a 41 year-old Aviation Ordnanceman was evaluated at Naval
Hospital Guam Emergency Room and discharged the same day back to isolation at
Naval Base Guam. Member had tested positive for COVID-19 March 30th.416
340. On April 9th, a 41 year-old Aviation Ordnanceman was found unresponsive during
one of his twice daily medical checks while in isolation on Naval Base Guam and was
immediately transferred to Naval Hospital Guam Intensive Care Unit.417
341. On April 13th, a 41 year-old Aviation Ordnanceman died due to COVID-19 related
complications.418
342. NHG treated, at most, 10-1 1 TR Sailors simultaneously.419
4.1 CCSG-9 Memorandum to All Hands - Subject: MEDICAL QUARANTINE ORDER dtd 1 Apr 20
4.2 CCSG-9 Statement dtd 15 May 20
4.3 See FoF 165; Virus-stricken aircraft carrier erupts in applause and cheers as ousted Navy captain departs (3 Apr 20)
https://wwwwashingtonpost.com/national-security/crew-of-aircraft-carrier-with-coronavirus-outbreak-cheers-ousted-
captain/2020/04/03/7927e202-75af-1 1ea-ae50-7148009252e3_story.html
4.4 C7F Statement dtd 18 May 20
4.5 NHG CO Statement (Addendum)
4.6 Memo dtd 21 Apr 2020 Subj: LINE OF DUTY INVESTIGATION AOC
4.7 Memo dtd 21 Apr 2020 Subj: LINE OF DUTY INVESTIGATION AOC
4.8 Memo dtd 21 Apr 2020 Subj: LINE OF DUTY INVESTIGATION AOC
4,6 NHG CO Statement dtd 17 May 20
USN
USN
USN
b) (6)
b) (6)
b) (6)
FOR OFFICIAL USE ONLY
D-46
PQfi-^RGIAI=4JSg-QN4=¥
343. On April 6th, A-SN traveled to Guam, where he spoke with members of the TR
crew via the 1 MC and met with the former TR CO who was at the time in quarantine as
a result of his positive test for COVID-19.420
344. A-SN’s remarks over the 1 MC were recorded by members of the crew and
released to the press by means of a written transcript followed by the actual audio
recording.421
345. The transcript was released on the internet through various news sources and
appears to be a true and accurate representation of A-SN’s comments as heard on the
recording. These remarks were also widely reported.422
420 Transcript of Remarks by A-SN: Acting Navy Secretary Thomas Modly addresses USS Theodore Roosevelt crew about ‘stupid’
ousted captain CNN (6 Apr 20) https://www.cnn.com/2020/04/Q6/politics/thomas-modlv-transcript/index.html: How a Ship’s
Coronavirus Outbreak Became a Moral Crisis for the Military New York Times (6 Apr 20)
https://www.nvtimes.com/2020/04/06/us/politics/coronavirus-navv-secretarv-roosevelt-crozier.html (containing audio recording of A
SN remarks on TR); Crazier, B. CAPT Statement dtd 15 May 20
421 Transcript: Acting Navy Secretary Thomas Modly addresses USS Theodore Roosevelt crew about ‘stupid’ ousted captain CNN
(6 Apr 20) https://www.cnn.com/2020/04/Q6/politics/thomas-modlv-transcript/index.html: New York Times “How a Ship's
Coronavirus Outbreak Became a Moral Crisis for the Military, https://www.nvtimes.eom/2020/04/06/us/politics/coronavirus-navv-
secretarv-roosevelt-crozier.html (containing audio recording of A-SN remarks)
422 How a Ship’s Coronavirus Outbreak Became a Moral Crisis for the Military New York Times (6 Apr 20)
https://www.nvtimes.com/2020/04/06/us/politics/coronavirus-navv-secretarv-roosevelt-crozier.html (containing audio recording of A
SN remarks); SECNAV: Roosevelt skipper either ‘too naive or too stupid’ to command aircraft carrier Navy Times (6 Apr 20)
https://www.navvtimes.eom/news/coronavirus/2020/04/06/secnav-roosevelt-skipper-too-naive-or-too-stupid-to-command-or-sent-
letter-on-ourpose/: Transcript: Acting Navy Secretary Thomas Modly addresses USS Theodore Roosevelt crew about ‘stupid’
ousted captain CNN (6 Apr 20) https://www.cnn.com/2020/04/Q6/politics/thomas-modlv-transcript/index.html
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