Outline of Submissions by Counsel Assisting - Equine Influenza Inquiry

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                    Equine Influenza Inquiry
                          Outline of Submissions
                              Counsel Assisting

1     BACKGROUND TO THE INQUIRY

The equine influenza outbreak in Australia

1.1     Equine influenza is a virus which causes an acute respiratory disease in horses,
        donkeys, mules and zebras. Before August 2007 Australia was free of equine
        influenza, as was New Zealand. The importation of horses from New Zealand
        is of minor relevance here as that country prides itself upon its strict standards
        of biosecurity in the same way as Australia rightly could do so until August
        2007.

1.2     Equine influenza is endemic in Europe (except Iceland) and in North and South
        America. Although sporadic outbreaks occur in these areas they are usually
        minor because of the high level of vaccination. However epidemics do occur.
        In the past 20 years serious epidemics have occurred in South Africa (1986 and
        2003), India (1987), Hong Kong (1992), Dubai (1995) and the Philippines
        (1997). Most of these epidemics have been associated with the import of sub-
        clinically infected horses by air and inadequate post-arrival quarantine
        procedures. Each of these epidemics was widely discussed both publicly and in
        scientific circles.

1.3     Australia has a long history of importing horses. The first recorded imports
        were with the First Fleet in 1788. Horses were first imported by air in 1973.
        Since that time the number of horses imported by air has increased markedly.
        In the last 10 years the number imported from countries other than New
        Zealand has averaged in excess of 500 per year. In 2006 the number was 897.
        Those horses included thoroughbred and standard bred stallions imported for
        the Australian breeding season which commences on 1 September each year.
        At the end of that season most of those stallions are exported to northern
        hemisphere countries to participate in their breeding seasons. Those stallions
        are commonly referred to as “shuttle” stallions.

1.4     With the exception of horses from New Zealand, horses imported into Australia
        for release into the general horse population are required, by conditions
        imposed by their import permits, to satisfy a number of conditions before and
        after entry. They include vaccination against equine influenza, the undertaking
        of a period of Pre-Export Quarantine (PEQ) and of a further period of Post-
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           Arrival Quarantine (PAQ). In August 2007, PAQ for horses occurred exclusively
           either at the Eastern Creek Quarantine Station (ECQS) in New South Wales or
           the Spotswood Quarantine Station (SQS) in Victoria.

1.5        Eastern Creek receives up to 14 intakes of imported horses a year. As at
           August 2007, each intake was required to spend no fewer than 14 days in PAQ
           (to commence after the arrival of the last horse in each intake). Two of the
           annual intakes, scheduled for July and August, are usually “restricted” to
           exclude mares to facilitate the importation of the shuttle stallions. In 2007 the
           horses for the second of those intakes arrived at ECQS between 3 and 8
           August. Those 52 horses arrived in six consignments. Two consignments were
           from the United States, one from the United Kingdom, two from Ireland and one
           from Japan. The consignment from Japan, which arrived on 8 August, included
           9 horses which were offloaded in Melbourne and quarantined at Spotswood.
           The remaining four horses from Japan were transported by air from Melbourne
           to Sydney. Most of the 52 horses were “shuttle” stallions destined for the
           Coolmore or Darley stud farms in the Hunter Valley in New South Wales. One
           was destined for the Arrowfield Stud at Scone. A number of the horses were
           extremely valuable, attracting service fees which could exceed $40 million per
           year.

1.6        Each of the 52 horses was certified as having been vaccinated against equine
           influenza in May or June 2007. On 17 August, whilst in quarantine at ECQS,
           the Coolmore stallion Encosta De Lago was observed to have a slight cough,
           some nasal discharge and an increased temperature. At the time the stallion
           was suspected of suffering a possible low grade upper respiratory tract
           infection.1 On 20 August another Coolmore stallion, Danehill Dancer, stalled
           next to Encosta De Lago in row E of the stables, was observed to have a slight
           nasal discharge and elevated temperature. Two other Coolmore horses in the
           same row, Aussie Rules and Oratorio, were also observed to have slight nasal
           discharge.2 On the same day, one of the Darley stallions in row B, Elusive
           Quality, was also observed to have a high temperature but no nasal discharge
           or coughing.3

1.7        On 20 August nasal swabs and bloods were taken from all of the stallions in
           rows E and B of the stables at Eastern Creek. Those swabs and blood serum
           were sent for analysis to the CSIRO Australian Animal Health Laboratory
           (AAHL) at Geelong in Victoria. On 23 August, five of those horses returned
           positive results for equine influenza using a Real Time Polymerase Chain
           Reaction (RT-PCR) test. In addition, a serological analysis of bloods taken from
           the stallions on 24 and 25 July and 8, 13 and 20 August using an
           Haemagglutination Inhibition (HI) assay indicated that Encosta De Lago,
           Snitzel, Fox & Furkin and Antonius Pius had been infected with the equine
           influenza virus.4


1
    AQIS.1000.044.0019
2
    AQIS.1000.044.0022
3
    WIT.REX.001.0006 para 26.
4
    CI.0001.046.004 AHT.0001.001.0026; WIT.AAHL.001.0244. The sero-conversions of Wells High
    Class, Librettist, Country Reel and Jorrit Van Stal Redia between PEQ and the first PAQ sera
    samples were probably caused by their vaccination just prior to PEQ and not by any active infection.


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1.8        On 21 and 22 August, horses outside of ECQS also showed symptoms of
           equine influenza. On 21 August horses at Cooranbong on the Central Coast of
           New South Wales, and at Arcadia near Galston which is north of Sydney and
           Tamworth in north western New South Wales showed symptoms of equine
           influenza. On 22 August, two horses in the Centennial Parklands Equestrian
           Centre (CPEC) in the eastern suburbs of Sydney showed signs of the virus. On
           24 August, nasal swabs and blood samples were collected from 11 horses at
           CPEC. The nasal swabs were sent to the Elizabeth Macarthur Agriculture
           Institute (EMAI) in New South Wales for testing. The bloods were sent to
           AAHL. On the evening of 25 August the results of the RT-PCR testing of the
           nasal swabs from those 11 horses proved positive to equine influenza.

1.9        The horses in CPEC were the first horses in the general Australian horse
           population ever to test positive to equine influenza. On 25 August, pursuant to
           its obligations as a member of the World Organisation for Animal Health (OIE)5,
           Australia notified to the OIE the outbreak of equine influenza at CPEC. The
           naivety of the general horse population made it especially susceptible to
           contracting the virus, with result that the infection very quickly and broadly
           spread throughout those in contact with it.

1.10       The cases of equine influenza at Cooranbong, Arcadia, Tamworth and CPEC
           and about another 30 or so cases of equine influenza reported within days of
           them had a common link with one another: each of the horses had attended a
           horse competition near Maitland in New South Wales which was organised by
           the Ranch Riding Club and held over three days commencing on Friday
           17 August. More than 200 horses competed at that event which took place at
           two locations, Carroll’s Ranch and Rutherford Polocrosse Ground, both at
           Anambah Road, Rutherford. A number of the horses which attended the event
           developed symptoms of equine influenza within a week of doing so and were
           later diagnosed as affected by the virus. The extent of equine influenza spread
           among horses which attended that event is consistent with an infected horse
           having attended the event and infecting other horses there. Anecdotal evidence
           of the presence at the event of a coughing horse (the identity and owner of
           which have not been established) would seem to confirm that this is likely to
           have occurred.

1.11       Subsequent analyses have established that the virus which infected the horses
           in Eastern Creek and the general horse population is the same strain of an
           equine influenza virus A, sub-type H3N8. That virus isolated from a sample
           from CPEC is characterised as A/equine/Sydney/2888-8/2007 H3N8
           (abbreviated A/eq/Sydney/07 or Sydney/07). An isolate from within Eastern
           Creek is characterised as A/equine/Eastern Creek/2834/2007 H3N8
           (abbreviated as A/eq/Eastern Creek/07 or Eastern Creek/07). Those strains are
           identical.

An outbreak of equine influenza in Japan

1.12       On 15 August a racehorse at the Miho Training Centre, Ibaraki tested positive to
           equine influenza. Bans upon movement were made in respect of racecourses

5
    Formerly, the Office International des Epizooites (OIE).


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           and training centres where thoroughbred and pleasure horses were located.
           On 16 and 17 August further horses tested positive, and over the weekend of
           18 and 19 August a number of race meetings scheduled at Racecourses on the
           island of Hokkaido were cancelled.6

1.13       Japan notified the outbreak to the OIE on 28 August.

1.14       That notification records that the first outbreak occurred on 14 August in 21
           horses at a racehorse farm in Ritto City, Shiga. The following day the disease
           was identified in nine horses in Miho Training Centre. Both of these are on
           Honshu, the main island of Japan.7 Outbreaks also occurred on the island of
           Hokkaido, with the earliest reported as starting on 14 August at the town of
           Urakawa. Other outbreaks occurred among racehorses at the Sapporo and
           Hakodate Racecourses.8 The five PEQ premises where the 13 horses which
           arrived from Japan on 8 August underwent quarantine are on the island of
           Hokkaido.

1.15       The Japanese virus is also an H3N8 virus. Its shorthand description is
           Iberaki/07 (and sometimes Japan/07). Analysis of the HA1 genes of the
           Sydney/07 and Iberaki/07 viruses indicates that they are identical and have only
           a single nucleotide sequence difference to a virus strain isolate obtained on 29
           August in Pennsylvania in the United States of America.9 That virus is named
           Pennsylvania/07 (and sometimes Philadelphia/07).10

The social and economic effects of the outbreak

1.16       The social and economic effects of an outbreak of equine influenza virus in the
           Australian horse population were predictable and foreseen. In the third version
           of the Australian Veterinary Emergency Plan (AUSVETPLAN) for equine
           influenza which was published in draft form by the Department of Agriculture,
           Fisheries and Forestry (DAFF) and Animal Health Australia (AHA) before
           August 2007, it was stated:11

                   EI is likely to result in few adult horse deaths and will not lead to a
                   dramatic long-term export ban. The major impact of the disease will arise
                   from disruption to the use of horses for racing, breeding, recreation and
                   tourism. The overall impact will depend to a great extent upon the time of
                   the year when particular events normally take place, relative to the time
                   of the outbreak.

1.17       Such an outbreak was predicted to have a significant financial and social impact
           by disruption of employment in the racing industry. Other equestrian activities
           of economic significance were also likely to be postponed or cancelled with
           consequent economic loss.


6
     EII.0006.003.0272.
7
     DAFF.0001.051.3186.
8
     Email 18.08.07 DAFF.0001.052.0317; Dr Newton’s report at AHT.0001.001.0021 - 22.
9
     AHT.0001.001.0021 – 0022.
10
     University of Kentucky letter 13.12.07 CORR.0005.004.0062.
11
     AUSVETPLAN Disease Strategy, Equine influenza, version 3.7, 2007 proof for approval
     DAFF.0001.463.0197 pp37-38.


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1.18       Following the confirmation of equine influenza in the general horse population
           on 25 August, an immediate 72 hour nationwide horse standstill was imposed
           following a recommendation by the Consultative Committee on Emergency
           Animal Disease (CCEAD) as part of a coordinated response plan which was
           consistent with the AUSVETPLAN. Racing clubs and other equine associations
           were asked to cancel or postpone any meetings or events.12 Standstills were
           lifted in Western Australia, South Australia, Tasmania, the Northern Territory
           and Victoria by 31 August on the basis that no equine influenza cases had been
           detected there. By this time, 58 infected premises had already been identified
           in New South Wales and Queensland.13

1.19       The nationwide standstill caused considerable economic and financial hardship
           for horse owners and associated businesses. State wide horse movement bans
           were maintained in New South Wales, Queensland and the Australian Capital
           Territory. Some four weeks after equine influenza was first detected in New
           South Wales, a four-colour zoning system was introduced as a means to control
           the spread of equine influenza and to enable some movements within affected
           areas. The zones were drawn according to the level of infection found in each
           area, and movement restrictions applied both within and between the zones.14

1.20       By 30 September 2007, 3193 infected premises had been notified in New South
           Wales and Queensland. Approval was granted for the use of vaccination as a
           means of control in nominated buffer zones across New South Wales and
           Queensland,15 and was subsequently extended to use by industry groups and
           susceptible high socio-economic value horse populations in New South Wales,
           Queensland and Victoria. By 29 October 2007, the number of infected
           premises had more than doubled to 7058.16 By 31 January 2008, 50,000
           horses in NSW and 62,000 horses in Queensland had been vaccinated.17

1.21       The last reported detection of equine influenza was on 22 December 2007.18

1.22       The presence of equine influenza stalled Australia’s horse export markets. As
           at 6 September 2007, Hong Kong, New Zealand, The Philippines, Singapore,
           United Arab Emirates and Malaysia had suspended imports of horses from
           Australia.19 By 20 September 2007, Macau, France and Qatar had also notified




12
     AQIS.0002.004.0319.
13
     DAFF.1000.050.0224.
14
     DAFF.0001.214.0028.
15
     DAFF.0001.051.5980.
16
     DAFF.0001.540.5490.
17
     URL:
     http://www.outbreak.gov.au/pests_diseases/pests_diseases_animals/equine_influenza/docs/cvo-
     strategy-release-31jan08.pdf.
18
     URL:
     http://www.outbreak.gov.au/pests_diseases/pests_diseases_animals/equine_influenza/docs/cvo-
     international-release-jan08.pdf.
19
     DAFF.1000.050.0318.


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           Australia of their decision to suspend horse imports.20 Trade only resumed with
           Japan, Hong Kong and Macau in late January 2008.21

1.23       A report by the Australian Bureau of Agricultural and Resource Economics
           (ABARE)22 estimated that the costs resulting from the equine influenza outbreak
           during the initial response period, involving containment and eradication through
           restricted movement, had reached $500,000.00 per day for disease control and
           $4.6 million per day in forgone income in equine businesses, including those of
           racing, farming and recreational.23

1.24       Although racing had resumed in NSW and Queensland on 1 December 2007.
           Tabcorp chief executive Mr Elmer Funke Kupper estimated that by the time that
           normal racing was resumed in early 2008 the loss in turnover amounted to
           approximately $550 million24

1.25       In January 2008, the parties to the ‘Government and Livestock Industry Cost
           Sharing Deed in Respect of Emergency Animal Disease Responses’ (EAD
           Response Agreement)25 determined that the eligible expenditure on the
           response under that agreement, including vaccination, had reached the (already
           revised) limit of $64 million and, as a result, agreed to an upper limit of $108
           million.26 On 14 February 2008, the New South Wales Minister for Primary
           Industries, Mr Ian MacDonald, stated that the government had spent $46 million
           in containing the disease and that 100,000 horses had been vaccinated.

1.26       In addition, the Commonwealth Government had agreed to provide $95.5
           million in the 2007/2008 financial year to assist those suffering additional costs
           and financial hardship as a result of the EI outbreak.27

The establishment of this Inquiry and the Terms of Reference

1.27       In September 2007, the Parliament amended the Quarantine Act to enable the
           Minister for Agriculture, Fisheries and Forestry to appoint a person to conduct a
           commission of inquiry into the August 2007 outbreak of equine influenza in
           Australia.

1.28       On 25 September Commissioner Callinan was appointed under Section 66AY
           of that Act to conduct a commission of inquiry into that outbreak. Specifically,
           the Commissioner was asked to inquire into and report with respect to:

20
     DAFF.0001.214.0028.
21
     URL:
     http://www.outbreak.gov.au/pests_diseases/pests_diseases_animals/equine_influenza/docs/cvo-
     export-release-01feb08.pdf.
22
     Draft report dated 26 September 2007 – requested by Consultative Committee on Emergency Animal
     Disease (CCEAD) - DAFF.0001.637.2375.
23
     Following the first weekend of the national standstill, Tabcorp had recorded a loss in wagering
     turnover of $65 million - Media Release: Impact of Equine Influenza on Tabcorp Wagering Business,
     Published 24 August 2007. URL: http://www.tabcorp.com.au/news_mediarel_detail.aspx?view=329.
24
     NSW Legislative Council Hansard, 6 November 2007 – page 3520, The Hon. Amanda Fazio.
25
     AQIS.0001.059.0006.
26
     National Management Group Communiqué NMGI07/12 dated 7 January 2008. URL:
     http://www.outbreak.gov.au/pests_diseases/pests_diseases_animals/equine_influenza/docs/nmg-
     mrelease-07jan08.pdf.
27
     Mid-Year Economic and Fiscal Outlook 2007-2008.


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           (a)          The circumstances that have contributed to the outbreak of equine
                        influenza in Australia;

           (b)          The need for any strengthened biosecurity procedures for quarantine
                        management of imported horses.

1.29       Authorisation was given for the Commissioner, as he deemed necessary, to
           inquire into such other matters incidental to those stated above as might assist
           the Minister in considering the report.

1.30       The Inquiry progressed by the taking of evidence, both orally and in writing from
           approximately 265 witnesses. Thirteen parties were represented. Further,
           submissions have already been received from a number of persons and
           organisations who had either not sought or were not formally represented at the
           hearing.

1.31       It is important to recall that the Inquiry was not concerned with questions of how
           the virus spread once within the general horse population, nor associated with
           the losses that have been suffered. As the Terms of Reference make clear, the
           Inquiry was concerned only with identifying how the virus came to enter the
           general horse population initially and with making recommendations to ensure it
           does not happen again.

1.32       That is not to say events outside quarantine had no relevance. It was
           necessary, for example, to endeavour to identify the first horse in the general
           horse population to contract the virus. Obviously enough being able to do so
           would have dramatically increased the chances of identifying the means of the
           virus’ escape.

1.33       As we later set out, the evidence does not permit such a conclusion to be made.
           It has however lead to a range of conclusions concerning, principally,
           inadequacies and breakdowns in the practices and procedures regulating the
           importation of horses. Before dealing with those more specific issues it is
           necessary to take up the background to the virus and the importation of the six
           consignments.




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2         THE EQUINE INFLUENZA VIRUS

The different sub-types of the virus and lineage of the H3N8 sub-type

2.1         Equine influenza is caused by two sub-types of the influenza A virus. The
            H7N7 sub-type was first isolated in 1956 in a strain which was designated
            A/Eq/Prague/1/56.28 The H3N8 sub-type was first isolated in 1963 from horses
            in the United States in a strain known as A/Eq/Miami/1/63.29 The H7N7 sub-
            type has rarely been diagnosed as a cause of disease in the past 20 years and
            is believed to be extinct or only to persist at a very low level in some regions.30

2.2         Over time, mutations in the ribonucleic acid (RNA) sequence of the virus result
            in what is known as antigenic draft. The H3N8 sub-type has undergone
            periodic antigenic drift over the past 20 years resulting in the evolution of two
            distinct lineages which have been designated the “American-like” lineage and
            the “European-like” lineage based upon the initial geographical distribution of
            these viruses.31 This geographic distinction has recently become less apparent
            due to the isolation of the “American-like” viruses in Europe. However, the two
            distinct lineages of H3N8 viruses continue to co-circulate independently.

2.3         The Animal Health Trust Laboratory at Newmarket, which is an OIE reference
            laboratory for equine influenza32, has an extensive archive of strains of equine
            influenza which has enabled it to map globally the occurrence of circulating
            strains of the virus which have been submitted to it. That mapping shows that
            whilst the American-like and European-like lineages continue to be isolated, a
            variant American sub-lineage (also referred to as the Florida sub-lineage) has
            diverged, and that more recently this variant American sub-lineage has divided
            into two groups. One of these groups includes the Wisconsin/1/03 and South
            Africa/4/03 viruses. The other group includes Newmarket/5/03 and other strains
            which have been circulating in the United Kingdom and Ireland since 2003.

2.4         The principal consequence of antigenic drift for present concerns is that it
            results in antibodies produced by the horse in response to infection by any
            previous antigenic structure (or in the development of vaccines) becoming less
            effective in protecting the animal against disease caused by infection with the
            new mutant. We discuss this issue further, below.




28
     WIT.INQ.001.0015, footnote 41.
29
     WIT.INQ.001.0015, footnote 44.
30
     AUSVETPLAN para 1.1.
31
     WIT.INQ.001.0015, footnotes 7, 17; AUSVETPLAN para, 1.1.
32
     The role of a reference laboratory is to function as a centre of expertise and standardisation of
     diagnostic techniques for its designated disease – see www.oie.int/eng/OIE/organsation/
     en_LR.htm?e1d8.


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Animals and species infected by the virus

2.5        The equine influenza virus infects horses and other equids (such as donkeys,
           mules and zebras) can, but rarely affects other species.33 Transmission of the
           virus to human beings under natural conditions of exposure has not been
           reported as having occurred during any out breaks of the virus in horses.34

2.6        There was some suggestion during the Inquiry that the virus may also infect
           dogs, however, absent in the evidence was any significant indicator that the
           virus could be transmitted from an infected horse, to another animal, such as a
           dog or cat, and then subsequently to a horse in the general population.

2.7        Accordingly we think it unnecessary to explore any potential for the virus to
           have escaped quarantine by having been carried out of ECQS by a dog or cat
           in the nearby quarantine area set aside for those animals, or by the animals
           used by AQIS and Customs as detection dogs and which also are kept at
           ECQS. It is a matter we take up later.

The clinical signs of equine influenza

2.8        In fully susceptible horses the clinical signs of equine influenza are easily
           recognisable. The three most common signs are a deep, dry, hacking cough;
           the onset of pyrexia (ie raised temperature to between 390C and 41oC); and a
           watery nasal discharge which may later become mucopurulent. The period of
           pyrexia in infected horses is commonly between four to five days post infection,
           but the coughing may persist for up to one to three weeks. The mucopurulent
           nasal discharge occurs as a result of a secondary bacterial infection of the
           affected respiratory epithelium. Other signs of the disease in susceptible
           horses include depression, loss of appetite, laboured breathing and muscle pain
           and stiffness.35

2.9        Vaccination does not prevent infection, rather it reduces the incidence and
           severity of clinical signs. The extent to which it does so depends upon the
           efficacy of the vaccine. As we note above, this is in part a function of the extent
           of antigenic drift that has occurred between the virus strains which the vaccine
           contains and the challenge virus. One of the issues that we take up in these
           submissions is the fact most current vaccines have not been updated for some
           years. The clinical signs described above in vaccinated horses are variable and
           may be difficult to discern. In some cases there may be some, or little, or no
           coughing or pyrexia and sub-clinical infection can occur, that is, infection with
           no clinical signs at all.36

2.10       A number of other infectious and non-infectious diseases also affect the upper
           and lower respiratory tract of horses and cause coughing, with or without fever.
           Those disease include travel sickness (bacterial bronchopneumonia/
           leuropneumonia), equine viral arteritis and equine rhinovirus or adenovirus
           infection and strangles. The similarities in symptomology means a diagnosis of

33
     Refer to evidence regarding canines Randwick as well as United States.
34
     AUSVETPLAN, para 1.2.
35
     WIT.INQ.001.0015, para 33 AUSVETPLAN, para 1.4.1.
36
     AUSVETPLAN, para 1.4.1; WIT.INQ.001.0015, paras 68, 74, 77 and 81.


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           one or the other may not be immediately obvious. The main differentiating
           features between those diseases and equine influenza are its rapid spread in
           unvaccinated horses, the high morbidity rate and the prominence of the deep
           hacking cough.37 There is obviously room for uncertainty of diagnosis, initially
           at least in the case of shuttle stallions or indeed other horses that have travelled
           long distances and may only be suffering from travel sickness.

Long term effects on horses

2.11       Recovery from equine influenza is usually uncomplicated although coughing
           may persist for periods of up to three weeks. Mortality levels are low, although
           on occasions deaths have been recorded less infrequently in young foals or
           older horses debilitated by other disease. Death in adult horses is usually a
           consequence of secondary bacterial infection leading to pneumonia or pleuro-
           pneumonia.38 The severity of the disease among infected horses depends very
           much upon the vaccination or immune status of the infected horse, and the
           virulence of the virus strain.39

2.12       The virus does not persist in the recovered horse and there is no evidence of
           any long term carrier state after the infective period has ended.40

Incubation and virus excretion

2.13       It is important to detection of the illness to keep in mind that there are three
           relevant periods: the incubation period, the latent period and the infectious
           period. The incubation period is the time between infection and the appearance
           of abnormal clinical signs. The OIE Terrestrial Animal Health Code, 2007 gives
           a maximum incubation period for equine influenza of five days.41 In susceptible
           horse populations during severe epidemics, an incubation period of 2 -3 days
           has been observed. The incubation period is inversely proportional to the dose
           of the virus which explains why it tends to be shortest during the peak of an
           epidemic when many infected horses are shedding large amounts of the virus.
           Longer incubation periods are associated with the infective virus requiring
           several rounds of replication within the horse before causing sufficient
           pathology for clinical signs to become apparent. The latent period is the time
           between infection and the start of shedding of the virus. This period has been
           estimated from infection studies to be between 1 and 4 days with a most likely
           period of 2 days.42 It follows that an infected horse may start shedding during
           the incubation period and before it shows clinical signs of the disease.

2.14       The infectious period is the period during which infected horses shed virus and
           are infectious for other animals. The OIE Terrestrial Animal Code 2007
           suggests a maximum infectious period of 14 days. Studies suggest however

37
     AUSVETPLAN, para 1.4.4; Geering, Forman and Nunn (1995) Exotic Disease of Animals: A Field
     Guide for Australian Veterinarians.
38
     WIT.INQ.001.0015, para 37; AUSVETPLAN, para 1.4.1.
39
     WIT.INQ.001.0015, para 34.
40
     WIT.INQ.001.0015, para 37; AUSVETPLAN, para 1.6.2.
41
     HTTP://www.oie.int/eng/normes/mcode/A_summary.htm.
42
     Park, Wood, Daily, Newton & Ors (2004) The Effects of Strain Heterology on the Epidemiology of
     Equine Influenza in a Vaccinated Population.


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           that in susceptible unvaccinated horses shedding may persist for between 7 –
           10 days. Most shedding occurs in the early stages of the clinical disease when
           coughing is most pronounced. Shedding may occur in partially immune horses
           showing no clinical signs or only mild clinical signs.43

Pathogenesis of the virus

2.15       Equine influenza is spread via the respiratory tract. The virus is inhaled by the
           susceptible horse and infects the upper and lower respiratory tract. Shedding
           occurs in the form of nasal discharge or aerosolised droplets containing the
           virus. The characteristic harsh cough is an effective method of transmitting the
           virus for metres into the area around the affected horse. Infected horses may
           spread the virus up to 35 metres by coughing and there is evidence that the
           virus can travel for some considerable distance by wind borne spread. In the
           South African outbreak in 1986, the virus was claimed (anecdotally) to have
           spread over distances up to 8 kilometres.44 In fully susceptible groups of horses
           infection can spread rapidly within the group and between different groups. The
           latter can occur by the movement of recently infected horses to and from race
           meeting, studs, agricultural shows, events and sales. The rapid spread of the
           virus within the general Australian horse population following the three day
           event in Maitland best exemplifies this.

2.16       Contamination may also occur by means of horse transport vehicles,
           equipment, grooms, veterinary surgeons, trainers, farriers and other people who
           have close contact with the horses. That contamination depends upon the
           survival of the virus on skin, fabrics, contaminated equipment or in or on
           vehicles. Contaminated horse vehicles represent a major method of spread
           unless subjected to careful cleaning and disinfection. They were blamed as a
           source of the rapid spread of the virus in South Africa in 1986 and 2003. The
           vehicles often carry horses over long distances in an environment conducive to
           the persistence of the virus.45

Survival of the virus

2.17       The equine influenza virus has a lipid envelope and does not survive for long
           outside the horse. It is inactivated by exposure to ultraviolet light for 30
           minutes, by heating at 50oC for 30 minutes, and by exposure to sunlight for 15
           minutes at 15oC. It can however persist in water or soil under dark storage for
           periods of hours. The virus will not survive long in the environment in conditions
           of high humidity.46

2.18       The virus can however survive on skin, fabrics and the surfaces of
           contaminated equipment for some time. For example, in conditions of 35% -
           45% humidity and at a temperature of 28oC the virus has been shown to survive
           on hard, non-porous surfaces such as stainless steel and plastic for 28 to 48

43
     WIT.INQ.001.0015, para 35; AUSVETPLAN, para 1.6.1, although generally speaking windborne
     spread is controversial and requires favourable conditions: Gilkderson, T4244/L30 – L40;
     WIT.INQ.003.0014, 0016 – 0017.
44
     WIT.INQ.001.0015, para 31; AUSVETPLAN, para 1.6.3.
45
     AUSVETPLAN, para 1.6.3.
46
     WIT.INQ.001.0015, paras 30, 31, 32; AUSVETPLAN, para 1.6.2.


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                                                                                             SUBS.INQ.001.0012




           hours. It has also been shown to survive in the same conditions for less than 8
           to 12 hours on cloth and paper. The periods of survival are shorter in conditions
           of higher humidity. Studies have also shown that the virus may be transferred
           from stainless steel surfaces to hands and from paper tissues to hands.

2.19       The virus may be inactivated within a short period by a range of disinfectants
           and chemicals. Soaps and detergents are an effective decontaminant because
           of the lipidity of the envelope of the virus. The AUSVETPLAN decontamination
           manual lists a range of chemicals that can be used to inactivate equine
           influenza virus. They include soaps and detergents, oxidising agents (which
           include the product Virkon), alkalis, acids and aldehydes.47

Diagnosis of equine influenza

2.20       Diagnosis of infection by equine influenza is achieved by either detecting the
           virus in clinical samples, or by demonstrating an increase in the amount of
           antibodies to equine influenza in the horse’s blood.

2.21       The efficacy of these various methods of testing can be measured by the
           sensitivity and specificity of the test. The sensitivity of a test is the proportion of
           infected animals that test positive in the test. A test with the highest sensitivity
           is one which will produce the lowest number of false negatives. The specificity
           of a test is the proportion of non-infected animals that test negative in the test.
           A test with the highest specificity is one which will have the lowest number of
           false positives.48 If the objective is to rule out the presence of a particular
           infection in an animal, the surest test to use is the one with the highest
           sensitivity because that test has the lowest number of false negatives. That
           objective would appear to apply to the testing of imported horses for equine
           influenza both before they are imported to Australia and before they are
           released into the general population.49

2.22       There are three main methods used to detect the presence of antibodies to
           equine influenza in the horse’s blood. Each of those tests must be conducted in
           a laboratory. They are the Haemagglutination Inhibition (HI) test, the Single
           Radial Haemolysis (SRH) test and the Competitive Enzyme-Linked
           Immunosorbent Assay (C-ELISA) test. The HI and SRH tests involve OIE-
           approved methods. The HI test involves the comparison of two serum samples
           taken from the horse. The first should be taken as soon as possible after the
           onset of clinical signs. The second should be taken approximately two weeks
           later. The SRH test can take a single sample or compare two samples.50 The
           C-ELISA does not involve a comparison of two samples. It merely indicates
           whether the sample tested contains antibodies to any influenza A nucleo
           protein.51 These antibodies may be present by reason of the use of an
           inactivated vaccine or because of an active infection.52


47
     WIT.BIOS.004.0012, para 35; AUSVETPLAN, para 1.6.2.
48
     WIT.BIOS.004.0012, para 16.
49
     WIT.BIOS.004.0012, para 16; T3276-3277.
50
     T3266.
51
     WIT.INQ.001.0015, paras 46-52; WIT.BIOS.004.0012, paras 7 – 10.
52
     WIT.INQ.001.0015, T4219/L12 – L31.


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                                                                                                     SUBS.INQ.001.0013




2.23       The OIE Manual of Diagnostic Tests and Vaccines for Terrestrial Animals
           evaluates the HI and SRH tests as of equal efficacy. Few laboratories in the
           world use the SRH test which is more difficult and labour intensive than the HI
           test.53 The HI test is the serological test currently used in Australia to detect the
           presence of equine influenza antibodies in a blood sample. The test is sensitive
           and usually highly specific when the appropriate antigen is used.

2.24       There are a number of tests which can be used to detect either the virus (by
           isolating the virus) or a part of the virus. Some of these tests can be done in a
           laboratory. Others, often referred to as “rapid tests” or “stallside tests” can be
           done outside a laboratory. The virus can be isolated in embryonated hens eggs
           or cell cultures by a process which may take five to ten days to complete. Once
           the virus is isolated it can be sequenced to determine its genome type.54

2.25       The clinical samples are taken by nasal swabs, nasopharyngeal swabs or nasal
           or tracheal washings usually taken by endoscopy. In order to maximise the
           likelihood of diagnosis clinical samples should be taken as soon as possible
           after the onset of pyrexia and coughing as virus shedding may have
           commenced prior to the onset of clinical signs and may not last for more than 1
           to 2 days.55

2.26       The most common way of taking clinical samples is by nasal swab or
           nasopharyngeal swab. A nasal swab is a plastic handled cotton swab which is
           about 15cm (6 inches) in length. A nasopharyngeal swab is typically about
           50cm (20 inches) in length and involves using autoclavable tubing that contains
           a sterile swab on a soft stainless steel wire guide that is drawn back into the
           tubing. The procedure for taking a nasopharyngeal swab is a more invasive
           one and can be more stressful to a horse.56 Whether a standard nasal swab or
           long nasopharyngeal swab should be used depends upon the amounts of virus
           which the horse is shedding. In vaccinated horses the amount of nasal
           discharge and virus in it is likely to be much less than in an acutely infected,
           previously naïve horse, in which case, a nasopharyngeal swab may present as
           the method more likely to produce an accurate result.57

2.27       The tests used to detect parts of the viral antigen in clinical samples include the
           RT-PCR test, the antigen-capture ELISA test and various commercially
           available immunoassay tests which can give results in 15 to 45 minutes. These
           latter tests include the Espline influenza A&B-N, Directigen Flu A and Directigen
           Flu EZ, A+B tests.

2.28       The RT-PCR test is undertaken on clinical samples taken by nasal swab and is
           conducted in a laboratory. The test takes between two to four hours and the
           time taken from receipt of a sample until the availability of the test result is
           between four hours and one day. The test can detect a very small amount of


53
     WIT.BIOS.004.0012, paras 8 & 9.
54
     WIT.BIOS.004.0012; OIE (2004) Manual of Diagnostics Tests & Vaccines for Terrestrial Animals,
     Chapter 2.5.5; WIT.INQ.001.0015, para 41.
55
     WIT.INQ.001.0015, para 38; AUSVETPLAN, para 1.4.3.
56
     AUSVETPLAN, para 1.4.3; Nunn, 4.2.08, paras 20-24.
57
     WIT.BIOS.004.0012, para 21; WIT.INQ.001.0015, para 40.


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                                                                                          SUBS.INQ.001.0014




           antigen in a sample and is a highly sensitive test. It is also highly specific.58
           The test has been used extensively in the recent Australian outbreak. The
           methodology used was developed by Australian Animal Health Laboratory
           (AAHL) and then made available to a range of Australian laboratories. It does
           not require that the sample be taken at a time when the horse is infected and
           can be used after the horse has ceased shedding the virus.59

2.29       Currently there is no rapid PCR test available. New tests for avian influenza are
           however being developed. Recently a company in Singapore announced that it
           was developing a rapid PCR test kit which may produce a result within 20 to 30
           minutes.60

2.30       The antigen capture ELISA test was developed by the Animal Health Trust at
           Newmarket in the United Kingdom. It detects the nucelo-protein of the virus in
           clinical samples. The test must be conducted in a laboratory and the results are
           available 15 - 45 minutes from the time the laboratory analysis commences.
           There are no significant differences between the sensitivity of this test and the
           RT-PCR test61 although the test was not used for mass screening during the
           current outbreak because the RT-PCR was available and was considered to be
           more sensitive and specific.62

2.31       There is a number of commercially available immunoassay tests to detect
           influenza A virus. Most can be used outside a laboratory although some
           training and experience may be needed to ensure that they are performed
           properly and the storage and handling of the sampling test kits should be
           undertaken under favourable temperature and light conditions.63 Those tests
           include the Directigen and Espline tests referred to above. None of them is OIE
           approved and none appears to have been validated for use in horses which
           have been vaccinated for equine influenza. Some studies have been done on
           the sensitivity of the Directigen test. Those studies suggest sensitivities of
           between 33% and 100%. The highest sensitivity was achieved in samples
           obtained soon after infection of previously naïve horses. The sensitivity level
           decreases in relation to samples taken from previously infected or vaccinated
           animals that have antibody that reduces the amount and duration of viral
           multiplication and shedding.64 Generally speaking, these rapid tests are most
           likely to detect viral antigen when it is present in large amounts. That will be the
           case for an infected horse not previously infected or vaccinated against the
           virus. It is less likely to be the case for a horse which has previously been
           infected or vaccinated.

2.32       The Hong Kong Jockey Club (HKJC) is responsible for the import of horses into
           Hong Kong. For some time it has employed a regime of routinely testing all
           horses upon their arrival with an immuno-assay test. Until recently the test
           used was Directigen. The HKJC reports that it did not have a false negative in

58
     WIT.BIOS.004.0012, para 5.
59
     T3264.
60
     T3341-2.
61
     T3271.
62
     WIT.INQ.001.0015, para 44; WIT.BIOS.004.0012, para 10, Fn12.
63
     WIT.BIOS.004.0012, para 11.
64
     WIT.BIOS.004.0012, paras 14, 15, 17.


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                                                                                         SUBS.INQ.001.0015




           almost 6,00065 uses of it. It has now taken up the Espline test on the basis of its
           more simplified procedures.

2.33       The evidence suggested that were a similar testing regime to be taken upon
           Australia the well being of the horses and those handling them would be best
           served if nasal swabs or blood samples were taken after the animals arrived at
           the quarantine station and after some period of time had elapsed in order to
           allow the horse to settle. A number of restraints are available to assist in the
           taking of samples from the most difficult horses. These include hand held
           devices as well as the much larger padded crush – which, as the name
           suggests is used to restrain the horse to enable it to be examined. Such
           facilities are not currently available at either Tullamarine or Sydney Kingsford
           Smith Airport (SKSA).

Vaccination

2.34       Although the aim of vaccination is to prevent disease, very few vaccines
           assuredly do so. Most vaccines reduce the severity of disease by stimulating
           sufficient immunity to enable a horse to mount quickly an effective immune
           response after infection. The primary aim of vaccination against equine
           influenza is to reduce the severity of the clinical signs of the disease with
           consequential improvements in animal welfare by reason of shorter periods of
           convalescence, and a lower incidence of infection of other horses.

2.35       Equine influenza vaccines were first developed in the 1960’s in response to
           outbreaks in the United States in that decade. Historically, vaccination against
           H7N7 strains was quite successful in controlling equine influenza. Since the
           emergence of H3N8 strains the level of protection has varied due to the higher
           rate of antigenic drift. Immunity to equine influenza is short lived, either after
           vaccination or after natural infection.66

2.36       The effectiveness of a vaccine is a product of the level of detectable antibody
           produced in the exposed horse and the extent of antigenic drift that has
           occurred between the challenge virus and the strains of the virus in the vaccine.
           The level of detectable antibody produced is associated with the vaccine
           potency and the time which has elapsed since the last vaccination. Until
           recently equine influenza virus vaccines have consisted of killed or inactivated
           whole viruses or their sub-units, with or without an adjuvant (which is used to
           stimulate levels of antibody). More recently live attenuated influenza vaccines
           have become available in some countries. None of those vaccines has yet
           been approved for use in Australia.67

2.37       There have been several studies undertaken to examine the efficacy of various
           commercial vaccines against different virus strains, particularly after it was
           demonstrated that the H3N8 sub-type had diverged into two distinct lineages.
           The recent outbreak in South Africa, and the current Australian outbreak have
           been caused by viruses in the Florida sub-lineage of the American lineage.

65
     WIT.HKJC.001.0005.
66
     WIT.INQ.001.0015, para 67.
67
     T3265.


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                                                                                                       SUBS.INQ.001.0016




           Challenge trials have found that some currently available inactivated vaccines
           may offer short term protection against these viruses.68

2.38       The Animal Health Trust Laboratory is currently coordinating a surveillance
           program by OIE and WHO reference laboratories which is aimed at providing
           information on suitable vaccine strains. That expert surveillance panel has
           recommended that the H7N7 sub-type be omitted from current vaccines as no
           reports of infections with this sub-type have been substantiated during the past
           20 years. The panel has also recommended that vaccines should include
           representatives of both the American-like and the European-like lineages.
           However, despite these recommendations many commercially available
           vaccines still contain H7N7 virus strains and less than optimal representatives
           of the currently circulating H3N8 viruses.69




68
     WIT.INQ.001.0015, para 75.
69
     WIT.INQ.001.0015, para 75; OIE Manual of Diagnostic Tests and Vaccines for Terrestrial Animals,
     Chapter 2.5.5, Part C.


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                                                                                        SUBS.INQ.001.0017




3         RECENT OUTBREAKS OF EQUINE INFLUENZA AND CURRENTLY
          CIRCULATING STRAINS

Overview

3.1         Before the outbreak in August 2007 only Australia, New Zealand and Iceland
            had never experienced equine influenza. In the past 20 years six countries that
            had not previously been exposed to equine influenza have suffered major
            outbreaks. They are, South Africa (1986), India (1987), Hong Kong (1992),
            Dubai (1995), the Philippines (1997) and, most recently, Australia (2007). Of
            these countries, the disease has only recurred as a significant outbreak in
            South Africa (2003).70

3.2         Each of these other outbreaks has been associated with the importation of sub-
            clinically infected horses by air, and inadequate post-arrival quarantine
            procedures. The material which supports that observation other than in relation
            to the outbreaks in Dubai and the Philippines is summarised below. Various
            statements in published literature would suggest that the same matters
            contributed to the outbreaks in those latter two countries.71

South Africa (1986)

3.3         The outbreak in South Africa in 1986 originated from six horses imported from
            the United States which were infected at the time of their arrival at the post-
            arrival quarantine station at Johannesburg International Airport. A number of
            possible scenarios existed as explanations for the outbreak. Two recently
            vaccinated horses that had arrived from England were released from the
            quarantine station three days after the USA horses arrived. The two groups of
            horses mingled in quarantine, and the quarantine station did not have an “all in,
            all out” policy. The float that carried those horses from the quarantine station
            also loaded horses from Turffontein Racecourse as well as other
            thoroughbreds, and carried them to major studs and a training complex without
            any proper biosecurity measures. Furthermore, a private veterinarian treated
            the infected horses in quarantine and then subsequently treated horses at a
            local racetrack without undertaking sufficient biosecurity measures.72

South Africa (2003)

3.4         The outbreak in South Africa in 2003 was the subject of a report of a Board of
            Inquiry comprising Judge Edwin King, a retired judge and Dr Duncan McDonald,
            a senior veterinarian. That report identified the source of the outbreak as a
            group of horses imported into South Africa by air from the United States and
            other places, including the United Kingdom. The report concluded that the virus
            was most probably transmitted from the imported horses in quarantine to South
            African horses by indirect means on persons, vehicles or equipment.

3.5         Two possible means of transmission were identified. The first was by one of the
            vehicles used to transport the imported horses to the quarantine station. The
70
     DAFF.0001.051.3186.
71
     Mumford, 1998, Control of Influenza from an International Perspective, pp13-14.
72
     WIT.INQ.001.0015, para 25; DAFF.0001.067.0188; DAFF.0001.051.0318.


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                                                                                        SUBS.INQ.001.0018




           second was inadequate security surveillance at the quarantine station, the
           absence of any clear standard operating procedures, and the fact that private
           veterinarians had unlimited access to the horses without being briefed on
           biosecurity measures. In addition, it was noted that some of the imported
           horses may have been inadequately vaccinated because epidemiologically
           relevant strains were not included in the vaccines.73

India (1987)

3.6        Equine influenza was introduced into the northern states of India in January
           1987 by horses imported by air from France. The outbreak is reported to have
           occurred as a result of a failure to identify horses incubating the disease before
           shipping and inadequate quarantine at the port of entry.74

Hong Kong (1992)

3.7        The outbreak in Hong Kong in November 1992 was associated with the
           importation of infected horses by air in October from the United Kingdom and
           the Republic of Ireland. Those horses were not subject to government post-
           arrival quarantine but were kept by the Royal Hong Kong Jockey Club for 14
           days in stables immediately adjacent to the main stable complex. Grooms
           caring for the horses in “quarantine” also attended to other horses in the stables
           without any strict attention to decontamination procedures. At that time “all in,
           all out” quarantine procedures were not practised and one group of horses was
           released before the remaining horses had finished quarantine.75

Monitoring of currently circulating strains

3.8        Unlike the position in Australia and Japan, equine influenza is not a notifiable
           disease in the United Kingdom, Ireland or the United States of America.76 If
           outbreaks do however occur in any of those countries they are required, as
           members of the OIE, to give a notification of it.

3.9        Notwithstanding that equine influenza is not a notifiable disease within those
           countries there are laboratories which receive and record the results of
           analyses of samples of the virus. In Ireland the laboratory is at the Irish Equine
           Centre in County Kildare. In the United States, the laboratory is the Gluck
           Equine Research Center at the University of Kentucky. In the United Kingdom
           the relevant laboratory is at the Animal Health Trust.

3.10       Each year the animal Health Trust, in its role as an OIE reference laboratory,
           prepares a report of outbreaks of equine influenza in the United Kingdom and
           the rest of the world and provides that report to the OIE’s Expert Surveillance
           Panel. The summaries below are taken from the report for 2007.




73
     DAFF.1000.011.0047; WIT.INQ.001.0015, para 26.
74
     DAFF.0001.067.0188.
75
     DAFF.0001.067.0190; WIT.INQ.001.0015, para 27.
76
     T2920.


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Equine influenza in the United Kingdom (2007)

3.11       There were a number of minor outbreaks reported in the United Kingdom in
           2007.    They included outbreaks at Horsham, Stoke-on-Trent, Solihull,
           Maidstone, Southampton, Strathaven, Lincolnshire, Cheshire, Berkshire and
           Lambourn. With one exception, all viruses detected were members of the
           H3N8 variant – American lineage and similar to the Newmarket/5/03 strain. The
           exception was a strain isolated in Lincolnshire, in a horse with clinical signs,
           imported from Spain.       That strain (Lincolnshire/07) is similar to the
           Wisconsin/1/03 and South Africa/4/03 strains.

3.12       Two of the six consignments into Eastern Creek between 3 and 8 August
           included horses from the United Kingdom. Those horses were in consignments
           arriving on 4 and 7 August. The 22 horses concerned underwent Post-Export
           Quarantine (PEQ) at three premises. They were the National and Dalharn
           Studs in Suffolk and the Nunnery Stud in Norfolk. There was no evidence to
           suggest outbreaks among horses in these premises in 2007.

Equine influenza in Ireland (2007)

3.13       Inquiries of the Irish Equine Centre indicate that the virus strains circulating in
           Ireland in 2007 were of the variant American lineage but not from the
           Wisconsin/1/03 sub-group.        The strains identified included Laois/07,
           Donnegal/07, Meath/07, Carlow/1/07, Carlow/2/07 and Kildare/07. The Animal
           Health Trust Influenza Surveillance Report for 2007 reports that there were four
           outbreaks in the United Kingdom which could be traced to horses recently
           imported from County Killkenny in the Republic of Ireland. Analysis of those
           virus strains showed that they were of the variant American sub-lineage similar
           to the Newmarket/5/03 strain.

3.14       Two of the consignments into Eastern Creek included horses from Ireland.
           There were six horses in the first of the three consignments which arrived on 7
           August and 12 horses in the third of those consignments. The horses in those
           consignments undertook PEQ in five different facilities. They were the
           Kildangang and National Studs in County Kildare and Fairy King Farm,
           Prospect Farm and Greentree Stud in County Tipperary. Inquiries of the Irish
           Department of Agriculture indicate that there have been no reported incidents of
           equine influenza in any of those studs.

Equine influenza in the United States (2007)

3.15       Inquiries of the Gluck Equine Research Center, which is also an OIE reference
           laboratory, have indicated that in 2007, equine influenza viruses were reported
           as circulating in Florida, Kentucky, Pennsylvania and California. This is likely,
           however, to represent only a small fraction of the cases of equine influenza in
           the United States because, whilst the disease is endemic there it is not a
           reportable disease in any State. All of the strains which were reported as
           circulating were of the variant American lineage descended from the
           Wisconsin/03 strain. One of those strains is Pennsylvania/07 which is almost
           identical to Sydney/07 and Iberaki/07 in its HA1 amino acid sequence
           alignment.


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                                                                                       SUBS.INQ.001.0020




3.16       Two of the six consignments included eight horses from the United States.
           Three of the horses undertook PEQ at premises of EquiAir at Canyon County in
           California and five of the horses undertook PEQ at Jonabell Farm at Lexington
           in Kentucky. In response to inquiries made by the Australian Embassy in
           Washington, the United States Department of Agriculture advised that no cases
           of equine influenza were identified at the Canyon County premises or nearby
           locations during, or after PEQ, and that on the Jonabell Farm there had not
           been any cases of equine influenza for several years. Inquiries of the Kentucky
           State Veterinarian’s Office also similarly indicated that there had been no
           reports of influenza in the area surrounding that farm.

Equine influenza in Japan (2007)

3.17       The first outbreak of equine influenza in Japan was detected at a racehorse at
           the Miho Training Centre on Honshu, the main island of Japan. Other
           outbreaks occurred on the island of Hokkaido with the earliest reported case
           occurring on 14 August at the town of Urakawa. Analysis of the HA1 amino
           acid sequence alignment in the Sydney/07 and Iberaki/07 viruses indicate that
           they are almost identical. These results are consistent with a close relationship
           between Sydney/07 and Iberaki/07 isolated within a very short timespan so that
           accumulated sequence changes did not have time to develop.77

3.18       The 13 horses in the consignment from Japan which arrived in Melbourne, and
           then travelled to Sydney on 8 August undertook quarantine at five different PEQ
           stations. Each of those was on the island of Hokkaido. They were at the East
           Stud, Urakawa, the Shaddai Stallion Station between the towns of Abira and
           Atsuma, the Breeders’ Stallion Station at Hidaka, the Japan Bloodhorse
           Breeders’ Association at Shinhidaka and the Northern Farm at Chitose. In
           August or early September outbreaks were reported in a number of those
           places.




77
     AHT.0001.001.0020 – 0023.


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4        AUSTRALIA’S INTERNATIONAL OBLIGATIONS AND QUARANTINE
         POLICY

Australia’s quarantine policy

4.1        Australia’s quarantine policy is intended to give effect to obligations assumed
           under World Trade Organisation agreements78 and by virtue of association with
           the OIE.79      Successive Australian Governments have maintained a
           conservative, but not a zero-risk approach to the management of biosecurity
           risks. That approach is described in the Department of Agriculture, Forestry
           and Fisheries (DAFF) Import Risk Analysis Handbook 200780 as follows:

                   The objective of Australia’s biosecurity policy and risk management
                   measures is the prevention or control of the entry, establishment or
                   spread of pest or diseases that could cause significant harm to people,
                   animals, plants and other aspects of the environment. Australia has
                   diverse native flora and fauna and a large agricultural sector, and is
                   relatively free from the more significant pests and diseases present in
                   other countries. Therefore, successive Australian governments have
                   maintained a conservative, but not a zero-risk, approach to the
                   management of biosecurity risks. This approach is consistent with the
                   World Trade Organisations (WTO’s) Agreement on the Application of
                   Sanitary and Phytosanitary Measures (SPS Agreement). Annex A of the
                   SPS Agreement defines the concept of a ‘appropriate level of protection’
                   (ALOP) as the level of protection deemed appropriate by a WTO member
                   establishing a sanitary or phytosanitary measure to protect human,
                   animal or plant life or health within its territory. Among a number of
                   obligations, a WTO member should take into account the object of
                   minimising negative trade effects in setting is ALOP. Like many other
                   countries, Australia expresses it ALOP in qualitative terms. Our ALOP,
                   which reflects community expectations through Australian government
                   policy is currently expressed as providing a high level of sanitary and
                   phytosanitary protection, aimed at reducing risk to a very low level, but
                   not to zero.

4.2        The fact that Australia maintains a conservative but not zero-risk approach to
           biosecurity risks was emphasised in the Australian Quarantine Review (the
           Nairn Review) recommendation that “the continued perception in some quarters
           that there ever has been or ever can be a ‘no risk’ quarantine policy for any
           country – let alone a major agricultural trading nation such as Australia, reflects
           a fundamental misconception that needs to be corrected in an ongoing
           awareness campaign”.81

4.3        The Australian Government’s response to the Nairn Review noted that ‘no
           quarantine service can totally eliminate the risk that pests and diseases will




78
   Including the Agreement on the Application of Sanitary and Phytosanitary Measures.
79
   Particularly the recommendations of the Terrestrial Animal Health Code.
80
    DAFF (2007) Import Risk Analysis Handbook 2007. AQIS.2001.002.0580.
81
    Nairn, ME, Allen PG, Inglis AR and Tanner C (1996) Australian Quarantine: A Shared Responsibility.
    Department of Primary Industries and Energy, Canberra at p83.


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                                                                                                   SUBS.INQ.001.0022




           enter the country’82 and that ‘there will always be an element of risk’ with
           imports.83

4.4        That response also emphasised that established Government policy was that
           quarantine is a “shared responsibility” between governments (Commonwealth,
           States and Territories), importers, relevant industries and the wider
           community.84




82
     DPIE (1997) Australian Quarantine – a Shared Responsibility: the Government Response, p4
     Department of Primary Industries and Energy, Canberra.
83
     DPIE (1997) Australian Quarantine – a Shared Responsibility: the Government Response, p10
     Department of Primary Industries and Energy, Canberra.
84
     DPIE (1997) Australian Quarantine – a Shared Responsibility: the Government Response, pp 8,9,12
     Department of Primary Industries and Energy, Canberra.


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                                                                                           SUBS.INQ.001.0023




5        THE STRUCTURE OF AND SENIOR PERSONNEL OF THE
         DEPARTMENT OF AGRICULTURE, FISHERIES AND FORESTRY

5.1        The Department of Agriculture, Fisheries and Forestry (DAFF) is responsible at
           the Commonwealth level for the animal and plant biosecurity policy
           development and the establishment and implementation of biosecurity risk
           management.       AQIS and Biosecurity Australia (BA) are the two main
           organisations within DAFF responsible for those areas. Until the mid-1990s
           operational functions relevant to quarantine were vested with the State
           governments under an arrangement which drew upon Commonwealth funding
           for that purpose.

5.2        AQIS is responsible for the development and implementation of operational
           procedures to manage identified quarantine risks and to administer the
           Quarantine Act.

5.3        BA was established within DAFF in October 2000 for the purpose of making
           recommendations about the import and export of goods and the conditions
           under which that should desirably happen. Prior to October 2000 those
           functions had been performed by the Animal Quarantine Policy Branch within
           AQIS. In December 2004, BA was re-established as a prescribed agency and
           became thereby, somewhat independent from DAFF although its Chief
           Executive remains responsible to the Secretary.

5.4        BA’s responsibilities include:

           (a)          undertaking import risk analyses;

           (b)          providing biosecurity policy advice and recommendations as a result of
                        import risk analyses;

           (c)          provide day to day advice to AQIS on biosecurity issues including on the
                        implementation of biosecurity policy and the consideration of more
                        specific applications for import permits;

           (d)          participating in the development of international standards relevant to
                        biosecurity policy and implementation through the World Organisation
                        for Animal Health (OIE) and the International Plant Protection
                        Convention.

5.5        BA’s staff responsible for these tasks are mostly animal and plant scientists,
           plant pathologists, veterinarians, epidemiologists, virologists and aquatic
           specialists. It is therefore well placed as a technical expert on each of the areas
           of concern to it.

5.6        BA operates through two branches – an animal biosecurity branch responsible
           for the functions described above in relation to animals and aquatic animals and
           a plant security branch. Specifically, it develops quarantine policies and
           assesses the risks associated with the importation of exotic pests and diseases
           of live animals, their genetic material and products. In August 2004 the General
           Manager of BA was Dr Robyn Martin. The Senior Scientist within the animal


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                                                                                       SUBS.INQ.001.0024




           biosecurity branch and therefore the Principal Scientist (Animal Biosecurity) was
           Dr Mike Nunn. Both Ms Martin and Dr Nunn reported to Mr John Cahill, Chief
           Executive Officer of BA.

5.7        AQIS operates through two divisions – a quarantine division and an exports
           division. Each of the quarantine and export divisions is headed by an Executive
           Manager reporting to the Executive Director of AQIS. In August 2007, Ms Jenni
           Gordon was the Executive Manager of Quarantine and Mr Stephen Hunter the
           Executive Director of AQIS. Mr Hunter reported directly to the Secretary of the
           Department, Mr Conal O’Connor.

5.8        The functions undertaken by AQIS in its quarantine and export divisions are
           divided into a number of national programs. Each of those programs has a
           Program Manager. There is further division by reference to the existence also
           of regional (State) programs.     In essence the national programs carry
           responsibility for policy development and the regions responsibility for their
           implementation.

5.9        The national programs are administered by three branches within the
           quarantine division. Those branches are Border, Cargo Management and
           Shipping and Animal and Plant Quarantine. Each of those branches has a
           National Manager to whom the relevant Program Manager reports and the three
           National Managers in return report to the Executive Manager, Quarantine. Only
           the Animal and Plant Quarantine Branch and the Post-Entry Animal Quarantine
           (PEAQ) and Live Animal Imports Programs (LAI) are of relevance here. In
           August 2007 the most senior positions in them were held by Mr David Ironside
           who was the National Program Manger for both the PEAQ and LAI programs
           and Mr Peter Liehne who was the National Manager for Animal and Plant
           Quarantine. They each reported to Ms Gordon.

5.10       The national programs are responsible for the development of operational
           policies and procedure, for developing national program budgets, for allocating
           funding within the national program budget to each region and for monitoring
           and reviewing performance of and service delivery by the program at a national
           level.

5.11       Regional offices exist in Western Australia, South Australia, Victoria, Tasmania,
           New South Wales, South-East Queensland and Far North Queensland. Those
           regional offices are responsible for delivery of the services of the national
           programs.

5.12       Each regional office is headed by a regional manager. In New South Wales
           there are three Assistant Regional Managers reporting to that Regional Manger.
           Each Assistant Regional Manager is responsible for a number of the national
           programs as they apply in their particular region. Underneath those Assistant
           Regional Managers, a Manager is appointed to take responsibility for each of
           the national programs. In New South Wales Dr Phillip Widders was in August
           2007, the Chief Quarantine Officer (Animals) and had responsibility for the live
           animal imports and post-entry animal quarantine programs. He reported to one
           of the Assistant Regional Managers, Ms Julie Sims.



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                                                                                            SUBS.INQ.001.0025




5.13       The Manager of ECQS, who in August 2007 was Mr Greg Hankins, also reports
           to Dr Widders in his (Dr Widders) capacity as Program Manager of Post-Entry
           Animal Quarantine. Within the quarantine station some officers are responsible
           for animal quarantine and others for plant quarantine. There is an animal
           quarantine supervisor who reports to the quarantine station manager and two
           senior quarantine officers reporting to that person. In August 2007, the relevant
           persons responsible for horse related issues in the grooms quarters was Ms
           Rhonda Christesen (a senior quarantine officer) and Mr Holloway the animal
           quarantine supervisor.

5.14       A number of these officers and employees had not held their positions for any
           significant period of time before August 2007. Mr Hunter had been appointed
           Executive Director on 10 April 2007. Ms Gordon’s appointment as AQIS
           Executive Manager took effect at the end of February 2007 although she had
           held other positions within AQIS previously. Mr Ironside commenced as
           Manager of the two national programs in March 2006. Mr Hankins commenced
           as Manger of ECQS on 2 March 2007. Mr Holloway had commenced in his
           position only marginally earlier in February 2007.

5.15       AQIS claims to operate under a matrix management organisational structure.
           Such division of responsibility as experienced here and which results in
           employees being responsible to two divisions is typical of such. It was also
           evidenced in the departmental structure splitting the policy and operational arms
           between national and regional programs. It is a division of responsibility that Mr
           Ironside admitted can be a challenge to manage.85

5.16       The level of cross-involvement of programs is most apparent in the analysis of
           operations at Sydney Kingsford Smith Airport (SKSA) and ECQS. In the arrival
           of the typical consignment, four programs each managed by different program
           managers (with the exception of the LAI and PEAQ regional programs both of
           which are managed by Dr Widders) and reporting to five regional or national
           managers bear responsibility for activities:

           (a)          the LAI program is responsible for the horses and their equipment and
                        grooms and their luggage but only where both groom and luggage are
                        travelling to ECQS;

           (b)          the airports program has responsibility for any luggage not travelling to
                        ECQS;

           (c)          the air cargo program is responsible for the airstalls; and

           (d)          the PEAQ program is responsible for operations at ECQS.




85
     T325/L32.


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                                                                                         SUBS.INQ.001.0026




6        HORSE IMPORT POLICIES

Overview

6.1        Australia’s quarantine policies for horses are specific to each country or region
           of export and are based on the equine health status of that country or region.
           There is a number of diseases of quarantine concern associated with the
           importation of horses. Those diseases include equine influenza. Other
           diseases of concern include:

           (a)          African Horse Sickness

           (b)          Contagious Equine Metritis

           (c)          Equine Encephalitides

           (d)          Equine Infectious Anaemia

           (e)          Equine Piroplasmosis

           (f)          Equine Viral Arteritis

           (g)          Japanese Encephalitis

           (h)          Surra

           (i)          West Nile Virus

6.2        Those quarantine policies have been developed by the Biosecurity Australia
           and its predecessors. Before October 2000 that function was performed by the
           Animal Quarantine Policy Branch of AQIS. Between October 2000 and
           December 2004, it was performed by the Market Access and Biosecurity
           Division of DAFF. Since December 2004 it has been performed by Biosecurity
           Australia in its capacity as a prescribed agency.

6.3        The documents containing and constituting the quarantine policies for the
           importation of horses from specific countries or regions are variously described
           as “conditions”86 for importation or “quarantine requirements”87 for importation or
           “amended quarantine requirements”.88, 89 From about 1995 these “conditions”
           or “quarantine requirements” or “amended quarantine requirements” where
           published have been accompanied by a “policy memorandum” summarising the
           new or revised requirements and briefly explaining the reasons for them.




86
     DAFF.0001.564.0005.
87
     DAFF.0001.564.0017.
88
     DAFF.0001.564.0058.
89
     T2896.


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                                                                                                        SUBS.INQ.001.0027




6.4         Those requirements are then imposed by AQIS as conditions applicable to the
            importation of horses. The requirements and import conditions draw a
            distinction between the “temporary” and “permanent” importation of horses.
            “(P)ermanent importation” is importation for a period of more than two months
            or for breeding purposes in which the case the period that the horse is to remain
            in Australia is irrelevant. “(T)emporary importation” is importation for a period of
            less than two months where the horse is not imported for breeding purposes.
            Horses are usually imported temporarily for competition such as racing or
            participating in equestrian events.90

Import conditions relevant to equine influenza as at August 2007

6.5         As at August 2007 and before the outbreak of equine influenza, the countries or
            regions that could export horses to Australia were the first 15 member states of
            the European Union,91 Canada, Fiji, Hong Kong, Japan, Macau, New
            Caledonia, New Zealand, Norfolk Island, Norway, the United Arab Emirates, the
            United States, Singapore and Switzerland.

6.6         Before the outbreak the “policies” for temporary and permanent importation of
            horses from the United Kingdom, Ireland, the United States and Japan were
            contained in and constituted by the following documents:

            (a)         United Kingdom and Ireland – Animal Quarantine Policy Memorandum
                        2000/10 dated 28 January 2000 to which was attached separate
                        requirements for the permanent and temporary importation of horses
                        from member states of the European Union.92,93

            (b)         United States – Animal Biosecurity Policy Memorandum 2003/04 dated
                        27 February 2003 to which was attached separate quarantine
                        requirements for the permanent and temporary importation of horses
                        from the United States (which were effective from 1 May 2003).94

            (c)         Japan – Animal Quarantine Policy Memorandum 2000/15 dated 2 March
                        2000 to which was attached separate quarantine requirements for the
                        permanent and temporary importation of horses from Japan.95

6.7         In each case the attached requirements were imposed by AQIS as conditions
            applicable to the importation of horses from the United Kingdom, Ireland, the
            United States and Japan. They included the following specific conditions which
            addressed the risk of equine influenza:


90
     WIT.BIOS.003.0001, para 24.
91
     Austria, Belgium, Denmark, Finland, France, Germany, Greece, Republic of Ireland, Italy,
     Luxembourg, Netherlands, Portugal, Spain, Sweden, United Kingdom.
92
     DAFF.0001.564.0080 – 0106.
93
     There were after January 2000, temporary suspensions of imports of horses from the United
     Kingdom and other member countries of the European Union and interim conditions which later
     permitted importation, in each case to take into account outbreaks of foot and mouth disease in 2001
     and 2007. DAFF.0001.564.0117. None of those conditions needs to be considered in the present
     context.
94
     DAFF.0001.564.0407 – 0428.
95
     DAFF.0001.564.0244 – 0268.


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                                                                                            SUBS.INQ.001.0028




           (a)          In the two months immediately prior to export the horse must have been
                        continuously resident in the country of origin an establishment or
                        establishments in which no case of equine influenza had occurred during
                        the previous three months. (In the case of the permanent but not
                        temporary importation of horses from Japan, certification was also
                        required that there had been no case of equine influenza reported in
                        Japan in the three months prior to the date of certification).

           (b)          The horse has undergone a minimum period of PEQ in the country of
                        origin in premises which meet specified AQIS standards. That period
                        was 21 days for permanent importation and 14 days for temporary
                        importation.

           (c)          During the four months before PEQ (in the case of Japan this period was
                        six months) the horse was vaccinated against equine influenza using “an
                        approved inactivated vaccine” either once as a booster to a certified
                        primary course or twice at an interval of four to six weeks.

           (d)          The horse was required to undergo PAQ in a government animal
                        quarantine station or other approved premises for a minimum period of
                        14 days. In the case of the temporary importation of horses, AQIS
                        standards for the “approved PAQ premises” were expressly specified.
                        No standards were specified for approval PAQ premises to be used for
                        the permanent importation of horses.

6.8        The conditions of import require that each horse be accompanied by an Animal
           Health Certificate which conforms to one of the OIE certificates and which is
           signed by an Official Veterinarian. That is a reference to a veterinarian
           authorised by the relevant Veterinary Administration of the exporting country to
           perform animal health and/or public health inspection of commodities and to
           perform certification in conformity with the provisions of the Terrestrial Code.
           The Animal Health Certificate is required to attest to each of the matters
           described above. It is also required to attest to the following matters:

           (a)          That the horse was examined by an Official Veterinarian within 24 hours
                        prior to leaving PEQ premises and found to be free from evidence of
                        infectious or contagious disease and fit to travel.

           (b)          That the vehicle for the transport of the horse to the port of export was
                        cleaned and disinfected prior to loading the horse and other animals of
                        the same consignment.

           (c)          That during transport to the port of export the horse had no contact with
                        horses not of the same certified health status.

           (d)          That the compartment of the aircraft or vessel to be occupied by the
                        horse and all removable, equipment, penning and containers including
                        loading ramps had been satisfactorily cleaned and disinfected prior to
                        loading.




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                                                                                            SUBS.INQ.001.0029




           (e)          That at the time of loading onto the aircraft or vessel the horse was
                        healthy and fit to travel.

6.9        The AQIS specified standards for the PEQ premises were contained in an
           appendix to the requirements and conditions for permanent and temporary
           importation. They deal with the location of the premises, the facilities at the
           premises and their operation. Specifically they required the following:

           (a)          That there be no other horses held or exercised within 100 metres of
                        horses on the premises (unless specifically authorised by AQIS).

           (b)          The premises have facilities for veterinary examination and collection of
                        samples and for the segregation and isolation of sick or suspect horses.

           (c)          The premises have stables so constructed so that they can be readily
                        cleaned and disinfected.

           (d)          The premises have an area for the cleaning and disinfection of vehicles
                        well separated from stables, holding pens and the loading area and
                        facilities for the safe loading and unloading of horses.

           (e)          The stables, yards, fences and feeding and watering arrangements be
                        constructed so that the horses are protected from injury and that their
                        other welfare needs are met.

           (f)          The stables be cleaned and disinfected and various yards and paddocks
                        cleaned to the satisfaction of an Official Veterinarian before the
                        commencement of PEQ.

           (g)          The PEQ be supervised by an Official Veterinarian. During PEQ the
                        premises must only be occupied by horses of the export consignment
                        unless otherwise agreed by the supervising Official Veterinarian and
                        AQIS.

           (h)          All equipment used in the feeding, handling and treatment of the horses
                        in PEQ must be new or cleaned and must be disinfected before use and
                        must be used only in the premises for the duration of the PEQ.

           (i)          Personnel attending the horse must don outer clothing and footwear
                        used exclusively in the premises during PEQ and wash hands before
                        handling the horses.

           (j)          Entry to the premises should be prevented unless specifically authorised
                        by the supervising Official Veterinarian. All visitor entries should be
                        recorded.

           (k)          Vehicles for transport of horses from the PEQ premises to the port of
                        embarkation must be cleaned and disinfected to the satisfaction of the
                        Official Veterinarian prior to loading.




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                                                                                         SUBS.INQ.001.0030




            (l)         The owner of person in charge of the PEQ premises must not be the
                        owner or vendor of any of the horses except as specifically authorised
                        by AQIS.96

6.10        As noted above, the AQIS standards for “approved PAQ premises” were
            expressly specified in relation to conditions for the temporary importation of
            horses but not otherwise. In that case they were contained in an appendix to
            the requirements or conditions.97 The specified conditions are intended to apply
            to both government animal quarantine stations and any other approved PAQ
            premises.98 Although the conditions relating to permanent importation did not
            specify any AQIS standards for approved PAQ premises, it has apparently been
            AQIS’ and Biosecurity Australia’s understanding that the same requirements
            applied to both temporary and permanent importation. In view of the fact that
            import permits were issued subject to different conditions depending upon
            whether the importation was permanent or temporary, this was an
            unsatisfactory state of affairs if it was intended that the AQIS standards for PAQ
            premises applied in both circumstances. It has been remedied in the revised
            requirements issued subsequent to the outbreak.99

6.11        The various reference to vaccination against equine influenza using an
            “approved inactivated vaccine” or an “inactivated vaccine” are to vaccines
            approved for use in the exporting country (registered or licensed by the
            government or appropriate authority in that country for the use intended).
            Neither Biosecurity Australia nor AQIS in any sense approves vaccines for use
            in another country. The reference to an “inactivated” vaccine is to a “killed” as
            distinct from a “live” vaccine which contains live attenuated equine influenza
            virus.100 As is apparent from the discussion above, the import requirements
            introduced after the outbreak now refer to vaccination “not using a vaccine
            containing live equine influenza virus”. That description allows the use of
            inactivated vaccines or vaccines which contain a different live virus that
            contains antigens derived from equine influenza: for example, the canary pox-
            vectored vaccine.101

Revised import conditions implemented after the outbreak

6.12        After the outbreak in August 2007 a working group was formed within the
            CCEAMD to examine the existing policy for the importation of horses with
            respect to equine influenza. The members of that working group were
            Dr Robyn Martin, Dr Patricia Ellis and Andrew Cameron. Dr Ellis was eminently
            qualified and experienced in relation to the disease risks posed by the
            importation of horses into Australia and specifically the risk that equine
            influenza posed.102 Andrew Cameron is the Deputy Chief Veterinary Officer of
            Victoria.103 That working group recommended that changes be made to the

96
      DAFF.0001.564.0081 at 0089 – 0090.
97
      DAFF.0001.564.0094 at 0102 – 0103.
98
      T2931.
99
      T2932 – T2933.
100
      CORR.0005.002.0058.
101
      CORR.0005.002.0058.
102
      WIT.PME.001.0001, paras 1 – 10, 43, 45.
103
      T2937.


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                                                                                           SUBS.INQ.001.0031




            existing policy. Those recommendations were endorsed by the CCEAD and
            subsequently adopted by Biosecurity Australia and issued as recommendations
            to AQIS as “interim quarantine measures for the importation of horses” under
            Biosecurity Australia Advice 2007/21 dated 28 September 2007.104

6.13        The following amendments to existing policy were made:

            (a)         Equine influenza vaccination – that the horse have been vaccinated
                        regularly according to vaccine manufacturers recommendation since
                        receiving a primary vaccination course and that in addition to current
                        equine influenza vaccination, the horse receive a booster vaccination
                        between 14 and 21 days of entering PEQ.

            (b)         Diagnostic testing for equine influenza in PEQ and PAQ – the horse be
                        tested by a RT-PCR test (also known as a qPCR test twice105) in PEQ
                        seven to ten days apart with the last test within four days of departure
                        and also be tested by PCR testing on swabs taken five days after the
                        last horse arrives in PAQ (an antigen ELISA test alternative in PEQ).

            (c)         Duration of PAQ period – the quarantine period be extended to 21 days
                        (from 14 days) for horses imported permanently where they have
                        undergone PEQ in different premises and become intermingled as one
                        consignment on an aircraft or in the PAQ premises.

            (d)         Operation of quarantine premises – recommendations were made for
                        strengthening of various operational guidelines during PEQ and PAQ.
                        For example operations and procedures in PEQ are required to be
                        documented and capable of being audited and during PEQ each horse
                        must have rectal temperatures measured and recorded and the records
                        are to be made available to AQIS upon request. For PAQ, the AQIS
                        standards were specified for both permanent and temporary importation
                        and included additional requirements. They were that all procedures
                        regarding the operation of the premises are to be documented and
                        subject to audit including operating procedures for veterinarians,
                        handlers and visitors and that any personnel attending the horses must
                        shower when arriving at the PAQ premises and shower and change out
                        of clothing and footwear before leaving. On completion of PAQ any
                        equipment used in feeding, handling and treating the horses must be
                        disinfected before removal from the premises.106

            (e)         Each horse must have rectal temperature measured and recorded upon
                        arrival and again within four hours and then twice daily thereafter and
                        must be tested by a PCR test if the rectal temperature is over 38.50C.

            (f)         A blood sample for reference serum must be collected from each horse
                        within 24 hours of each arrival and despatched for storage.



104
      DAFF.1000.008.0084.
105
      T4189 – T4190.
106
      DAFF.0001.564.0123.


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                                                                                            SUBS.INQ.001.0032




6.14        (The first interim quarantine measures for temporary and permanent importation
            of horses were issued for member states of the European Union on 28
            September 2007. Similar interim measures were issued for the permanent and
            temporary importation of horses from the United States dated 9 November
            2007.)107

6.15        In its advice 2007/21, Biosecurity Australia advised that AQIS would make
            arrangements for PEQ premises to be inspected with the competent authority of
            the exporting country prior to the first consignments being exported from any
            country.

6.16        On 6 December 2007, Biosecurity Australia released further amendments to the
            interim measures for the importation of horses from member states of the
            European Union under Biosecurity Australia Advice 2007/23.108        Those
            amendments addressed to the following two matters:

            (a)         Pre-export equine influenza vaccination – to clarify the timing of the
                        vaccinations. During the six months before the commencement of PEQ
                        the horse must be vaccinated on at least two occasions. The first which
                        must be between six and two months prior to commencement of PEQ
                        must have been either as a booster to a primary course or as a second
                        vaccination to a primary course and the second must be given between
                        21 and 14 days prior to commencement of PEQ.

            (b)         Diagnostic testing – an additional PCR test is to be undertaken within 24
                        hours of arrival in addition to the PCR test to be undertaken five days
                        after the last horse arrives in PAQ.

6.17        (The interim quarantine measures announced on 28 September 2007 were also
            introduced for temporary and permanent imports of horses from the United Arab
            Emirates, Macau, Hong Kong and Singapore. The interim measures for those
            countries and regions were also amended in accordance with the amendments
            announced on 6 December 2007.)109

The absence of any formal risk analysis relating to the importation of live horses

6.18        The quarantine policies described above have developed over time and the
            conditions or requirements have been varied to take account of outbreaks of
            particular diseases or revised assessments of the risks attaching to those
            diseases. Most significantly, there has not been any formal risk analysis
            undertaken by Biosecurity Australia or any of its predecessors in relation to the
            importation of live horses which in one document identifies the diseases and
            risks associated with importation and describes the way in which they are to be
            addressed by the imposition of import conditions so as to achieve the outcome
            that the “level of quarantine risk”110 is sufficiently low to enable the importation



107
      DAFF.INQ.006.0001, DAFF.INQ.007.0001.
108
      DAFF.INQ.003.0001, DAFF.INQ.004.0001, DAFF.INQ.005.0001.
109
      DAFF.INQ.003.0001.
110
      Section 5D of the Quarantine Act.


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                                                                                           SUBS.INQ.001.0033




            to proceed consistently with Australia’s conservative but not zero-risk approach
            to animal and plant biosecurity risks.111

6.19        Biosecurity Australia’s risk assessments can be undertaken as formal import
            risks analyses in relation to particular goods or animals imported from specific
            countries or regions or more generally. These formal risk analyses may be
            either regulated or non-regulated. The regulated risk analyses are conducted in
            accordance with administrative processes which have been formulated and
            published by DAFF and Biosecurity Australia. The first such process was
            published in 1998 and the second in 2003 in a Handbook described as the
            Import Risk Analysis Handbook 2003. In September 2007, DAFF published a
            revised handbook, the Import Risk Analysis Handbook 2007.112 That Handbook
            draws a distinction between regulated and non-regulated import risk
            analyses.113

6.20        One consequence of the absence of any formal import risk analysis, either
            regulated or non-regulated, in relation to horses is that there is not available to
            the officers of AQIS exercising delegated authority to grant import permits, any
            document which explains why particular conditions have been adopted and why
            their adoption sufficiently addresses the risks presented by any particular
            disease or diseases.114

6.21        A further consequence of the absence of any such formal import risk analysis is
            that there has never been any rigorous review of the policy which has
            developed since the early 1990s to identify those conditions which are no longer
            applicable, those which require amendment and those which should be
            included.115

6.22        Ms Martin, who has been managing the sections of Biosecurity Australia and its
            predecessors which deal with policies for the importation of live horses since
            about 2000,116 agreed that there should be a non-regulated but formal import
            risk analysis in relation to horses which identifies the disease risks (including
            equine influenza) and their consequences and explain how those risks and their
            consequences are sufficiently managed by the imposition of conditions.117

6.23        Dr Nunn, whose role as Principal Scientist requires him to provide scientific
            policy advice on animal quarantine and disease control,118 also agreed that the
            undertaking of such an exercise would be “useful” for at least three reasons.
            First, it would require a rigorous review of the current import conditions and their
            adequacies in the light of current scientific and other information; secondly, it
            would result in there being available in one place an analysis of the disease
            risks associated with importation and how they are addressed by the import


111
      T2898 – T2899.
112
      AQIS.2001.002.0582.
113
      Clause 4.1 of Import Risk Analysis Handbook 2007; AQIS.2001.002.0591.
114
      T2899.
115
      T2934.
116
      T2893.
117
      T2934.
118
      T3257 – T3258.


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                                                                                          SUBS.INQ.001.0034




            conditions; and thirdly, it would provide a reference point recording current
            policy which could then be the subject of regular review.119

The relationship between AQIS and Biosecurity Australia in relation to the
formulation of policy for importation of horses

6.24        The work of Biosecurity Australia was described by its Chief Executive, John
            Cahill as having five key elements. They include undertaking import risk
            analyses, providing biosecurity policy advice and recommendations as a result
            of such analyses and providing day to day advice to AQIS on biosecurity issues
            including on the implementation of policy and the consideration of more specific
            applications for import permits.120 However, there is not currently in place any
            protocol or procedure which regulates the way in which AQIS may have contact
            with Biosecurity Australia for the purpose of seeking advice or which regulates
            whether and in what circumstances Biosecurity Australia can initiate the giving
            of advice to AQIS without any request for it to do so.121 The current position
            would appear to be that if Biosecurity Australia becomes aware of import
            conditions that require reconsideration or which may be inadequate it will initiate
            the giving of further advice either to AQIS or to the Director of Animal and Plant
            Quarantine.122

6.25        The fact that there was a need to establish mechanisms to underpin regular and
            systematic reviews of quarantine policies and procedures as between
            Biosecurity Australia and AQIS was recognised in late 2005 when a project was
            commenced to track electronically requests for advice from AQIS to Biosecurity
            Australia and the responses to those requests. In addition, regular meetings
            were initiated between senior executives of AQIS and Biosecurity Australia as
            well as others in areas of DAFF involved in biosecurity issues. However, the
            evidence indicates that those meetings only involved senior executives and
            addressed matters at a very general level.123 Dr Nunn agreed that the current
            position is that quarantine policy is reviewed whenever there is a change in the
            science or a change in the disease situation overseas or some other changes
            occurs that merits a review of policy.124 Dr Martin summarised the position in
            the same way. She agreed that there was no procedure or requirement as
            between AQIS and Biosecurity Australia that required the latter to take a
            proactive position in relation to the imposition of conditions as distinct from
            reacting to requests for information or to new emerging information about a
            disease or risk which comes to Biosecurity Australia’s attention.125




119
      T3307 – T3308.
120
      WIT.BIOS.001.0001, para 6.
121
      T3993.
122
      T3993.
123
      T3996 – T3997.
124
      T3305.
125
      T2917.


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                                                                                           SUBS.INQ.001.0035




6.26        As between AQIS and Biosecurity Australia there is also uncertainty as to the
            role which Biosecurity Australia has in relation to operational or procedural
            matters.126 The absence of clarity as to Biosecurity Australia’s role in relation to
            operational and procedural matters is illustrated by reference to the import
            conditions current as at August 2007 and the subsequently amended measures
            introduced in September 2007. Those conditions deal with what is to happen in
            PEQ and PAQ however, they do not do so exhaustively in the sense that
            Biosecurity Australia has never in any structured way undertaken an
            investigation or inquiry to understand the sequence of activities and events from
            the point in time when the horses enter PEQ in the country of export until the
            time when they are released into the general Australian horse population at the
            end of PAQ, so as to identify the various risks which arise and to formulate
            biosecurity measures designed to address them.127

6.27        The current position in relation to PEQ premises is that they are approved by
            the Veterinary Administration of the country of export. AQIS does not maintain
            a list of those premises.128 Although some of those premises have been visited
            in the context of the outbreak of foot and mouth disease in 2001129 there is not
            in place any procedure which requires premises to be inspected and approved
            by Biosecurity Australia or AQIS and subsequently reviewed and audited from
            time to time.130

Deficiencies in the policies and import conditions as currently formulated

Vaccination

6.28        Many of the vaccines which are currently available still contain H7N7 virus
            strain and less than optimal representatives of the H3N8 viruses. As at
            February 2008 there were no commercially available vaccines which contained
            strains of the variant American sub-lineage virus (also referred to as the Florida
            sub-lineage) which includes the Wisconsin/1/03 and South Africa/4/03 strains of
            the virus and which sub-lineage now includes the Sydney/07, Iberaki/07 and
            Pennsylvania/07 strains.131

6.29        In his evidence to the Inquiry, Dr Newton of the Animal Health Trust (AHT)
            stated that Merial, the manufacturer of ProteqFlu is currently completing the
            licensing process for a vaccine which includes the Ohio/03 strain of the H3N8
            virus which is a strain in the Florida sub-lineage. His recommendation and that
            of the OIE experts surveillance panel is that vaccines should be used which
            contain a strain from Clade 1 of the variant American or Florida sub-lineage
            virus.132 Dr Gilkerson gave evidence that enquiries he has made indicate that
            the Merial ProteqFlu containing the Ohio/03 strain should be commercially
            available by the middle of 2008.


126
      T2929, T2939.
127
      T2930, T2939 – T2940.
128
      T2616.
129
      T2600 – T2601, T2627.
130
      T2627.
131
      T4187.
132
      T4187 – T4188.


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                                                                                          SUBS.INQ.001.0036




6.30        With one exception in 1995 (which required that the inactivated vaccine
            incorporate the Suffolk/89 antigen)133 neither Biosecurity Australia nor any of its
            predecessors has specified that the vaccine contain any particular strain or
            representative strain.134 During that same period Biosecurity Australia has been
            aware that some vaccines may not provide adequate protection or are less
            effective than others. For example, in 2005 in response to comments from Mr
            Barry Smyth who was then President of the Australian Horse Industry Council
            Inc that currently available vaccines did not contain “epidemiologically relevant
            strains”, Biosecurity Australia noted that it was “aware that many currently
            available vaccines, including Duvaxyn IE Plus, may not provide adequate
            protection”.135 Notwithstanding that this was apparently the view within
            Biosecurity Australia, it did not recommend or require by any import conditions
            or otherwise that vaccines containing out of date strains not be used136 or that
            vaccines which were regarded as less efficacious than others which were
            available not be used.137

6.31        Two reasons were proffered by Dr Martin as to why neither of these courses
            were taken. The first was that if the currently available vaccines did contain the
            most up to date strains Biosecurity Australia may have looked at specifying a
            particular vaccine or vaccines.138 The second was that vaccination was only
            one of a number of measures taken to minimise the risk of horses with equine
            influenza being introduced into the general Australian horse population.139

PAQ

6.32        The primary course of a vaccination comprises at least two doses. Once a
            primary course has been administered a horse may receive annual vaccinations
            or boosters to that primary course. The conditions current as at August 2007
            permitted either vaccination once as a booster to a certified primary course or
            twice at an interval of four to six weeks. They did not specify that the
            vaccinations have to be in accordance with manufacturers recommendations
            which would, presumably, require that the same vaccine be used either as the
            booster to the certified primary course or where there are to be two vaccinations
            at an interval of four to six weeks.140 Whilst it is generally accepted that
            sequential vaccinations with different vaccines is “sub-optimal” some
            investigations conducted by the Animal Health Trust have suggested that the
            mixing of vaccines does not appear to have a significant affect on levels of
            immunity.141 However, the benefits of using the same vaccines depend upon
            the product chosen and whether it contains more recently circulating strains. If
            it does the use of that product as a booster, as distinct from requiring it to be




133
      DAFF.0001.564.0017.
134
      T2903.
135
      DAFF.0001.091.0347.
136
      T2903.
137
      T2904 – T2910.
138
      T2902.
139
      T2904.
140
      T4221 – T4222.
141
      T4185 – T4186.


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                                                                                    SUBS.INQ.001.0037




               used as a primary course may lead to sub-optimal immune responses against
               the recent viruses.142




142
      T4186.


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                                                                                            SUBS.INQ.001.0038




7          THE QUARANTINE ACT

Overview

7.1          The Commonwealth laws governing the importation of live animals into
             Australia and their treatment before they are released into the general animal
             population are the Quarantine Act), and subordinate legislation including the
             Quarantine Regulations 2000 and the Quarantine Proclamation 1998.

7.2          Before 1 July 1909 when the Act first came into effect, the States had enacted
             uniform quarantine legislation. On the passing of the Commonwealth legislation
             the States continued to deliver operational services for quarantine under formal
             agency arrangements with the Commonwealth. Since 1995, the performance
             and delivery of quarantine functions have been transferred from the States and
             Territories to the Commonwealth.143

7.3          The Quarantine Act, to the extent that it deals with animal, plant and general
             quarantine, is administered by the Minister for Agriculture, Fisheries and
             Forestry. The relevant department is the Department of Agriculture, Fisheries
             and Forestry (DAFF) which deals with matters which include agricultural and
             pastoral industries and quarantine.

7.4          Under the Act, the secretary of DAFF is the Director of Animal and Plant
             Quarantine.144 That Director, under the Minister, is charged with the execution
             of the Quarantine Act and any regulations and proclamations in force under it in
             relation to animal and plant quarantine. The Minister may appoint Chief
             Quarantine Officers (animals) and Chief Quarantine Officers (plants).145 The
             Director of Animal and Plant Quarantine may appoint quarantine officers
             (animals) and quarantine officers (plants).146 Those officers are given various
             powers. The persons who may be appointed quarantine officers include
             employees of a State or Territory.

7.5          The Act provides for the delegation of powers. The Minister may delegate
             powers to the Secretary of the Department or to a Director of Quarantine (which
             expression includes the Director of Human Quarantine) or to a quarantine
             officer. The Secretary may delegate his or her powers to a Director of
             Quarantine and a Director may delegate powers to a quarantine officer.147

Importation of live animals

7.6          The importation of a live animal into Australia is prohibited unless a Director of
             Quarantine has granted a permit to import the animal.148 A permit may be
             granted subject to compliance with conditions or requirements either before or
             after the importation of the animal.149 Permits may be granted to cover a single

143
      The Nairn Report, Australian Quarantine A Shared Responsibility (1996 para 1.6).
144
      Quarantine Act, Section 9AA(1).
145
      Quarantine Act, Section 9AA(2).
146
      Quarantine Act, Section 9AA(3).
147
      Section 10B.
148
      Quarantine Proclamation 1998, s37(1); Section 5(1), Section 13(1)(f), Section (2A).
149
      Section 13(2B) of the Act.


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             importation, or multiple importations and multiple goods.150 An application for a
             permit must be in writing in a form approved by a Director of Quarantine.151 A
             Director of Quarantine, or his or her duly authorised delegate152 may grant a
             permit.

7.7          In deciding whether to grant a permit a Director or his or her delegate must
             consider the “level of quarantine risk” if the permit were granted, and whether, if
             the permit be granted, the imposition of conditions would be necessary to limit
             the level of quarantine risk to one that is “acceptably low”.153 The “level of
             quarantine risk” is a reference to the probability of a disease or pest being
             introduced, established or spread in Australia, and the disease or pest causing
             harm to human beings, animals, plants or other aspects of the environment or
             economic activities, and the probable extent of such harm.154 If a permit is
             granted a Director of Quarantine must allocate and mark an identifying number
             on the permit, and give the number to the applicant.155

Airports where horses may be landed

7.8          Except in circumstances which are the subject of a written permission from a
             Director of Quarantine, imported animals must be landed at a generally, or
             specifically designated airport.156

7.9          The airports where imported animals generally may be landed include Kingsford
             Smith Airport (KSA), Sydney in New South Wales and Tullamarine Airport in
             Victoria as well as the airports at Brisbane, Adelaide, Perth and Hobart. There
             are currently no specifically designated airports where imported live horses may
             be landed.157

Appointed quarantine stations

7.10         The places appointed under the Act as quarantine stations for the performance
             of quarantine by animals include Eastern Creek Quarantine Station (ECQS) in
             New South Wales, Spotswood Quarantine Station (SQS) in Victoria and
             Sandown Racecourse in Victoria.158 There are other places appointed to be
             stations for the quarantining of animals or plants. None of those places
             currently accept horses.

Quarantine measures and powers

7.11         The Act defines “quarantine” in relation to animals to include measures for
             examination, exclusion, detention, observation, segregation, isolation,
             protection, treatment or seizure and destruction, which have as their object the
             prevention or control of the introduction, establishment or spread of diseases or

150
      Section 13(2AA).
151
      Regulation 70, Quarantine Regulations 2000.
152
      Section 13(2AA), Section 10B.
153
      Section 70, Quarantine Proclamation 1998.
154
      Section 5D of the Quarantine Act.
155
      Regulation 71, Quarantine Regulations 2000.
156
      Section 20D.
157
      Proclamation, Sections10, 11; Quarantine Act Section 13(1)(b).
158
      Proclamation, Section 14 and Schedule 1, part 1, and Section 13(1)(c) of the Act.


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                                                                                          SUBS.INQ.001.0040




             pests that will or could cause significant damage including to animals or
             economic activities.159

7.12         The Act describes the circumstances in which vessels (which include aircraft),
             installations, persons, goods (which include animals) and plants are “subject to
             quarantine”. Those circumstances include when they are “ordered into
             quarantine” and continue until they are “released from quarantine”.

7.13         The goods which are “subject to quarantine” include animals on board an
             aircraft which has arrived from a place outside Australia160, animals infected
             with a quaratineable disease161, animals which have been in contact with or
             exposed to infection from a quarantineable disease162, and animals that have
             been “ordered into quarantine” by a quarantine officer.163 Vessels, installations
             goods (including animals) that become “subject to quarantine” continue to be so
             subject until they are “released from quarantine”.164

7.14         Animals may be “ordered into quarantine” if, in the opinion of a quarantine
             officer, they are, or are likely to be infected with a quarantineable disease.165
             On their arrival in Australia imported animals which have not been released
             from quarantine must be ordered into quarantine unless an authorised
             quarantine officer following an inspection, permits the imported animal to be
             delivered to the importer because there is no reason to suspect that the animal
             is suffering from any disease, or is a source of infection.166 Animals which have
             been imported into Australia and not released from quarantine may, by an
             electronic notice, be “ordered into quarantine” if there are reasonable grounds
             to believe that there is an unacceptably high level of quarantine risk in respect
             of them.167

7.15         Once an animal has been ordered into quarantine, a quarantine officer may
             direct that it be detained or taken to and detained at a quarantine station or
             other place for such period as the quarantine officer determines.168 The officer
             may also give directions as to the extent to which the animal may be moved,
             dealt with or interfered with, and may give directions to the importer or owner of
             the animal or the person who is in control of it. At the same time, a quarantine
             officer may give directions as to any treament which should be undertaken in
             respect of any airstalls, equipment or vehicle which may have been exposed to
             the animal at a time when it was subject to quarantine.169 Similar directions
             may be made with respect to the treatment, or destruction, or disposal of




159
      Section 4(1).
160
      Section 18(2)(a)(i).
161
      Section 18(2)(b).
162
      Section 18(2)(c).
163
      Section 18(2)(f).
164
      Section 19A(1).
165
      Section 35(1AAA).
166
      Section 52(1),(2),(4).
167
      Section 56.
168
      Section 48(1).
169
      Section 48(1),(2),(3),(4).


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                                                                                        SUBS.INQ.001.0041




           packaging material and waste material associated with the carriage of the
           animals.170

7.16       Quarantine officers are given various substantial powers in relation to animals
           which are, or have been, or are believed, on reasonable grounds to be, or to
           have been, subject to quarantine. Those powers include, to require questions
           to be answered or documents to be produced or samples to be provided.171
           The quarantine officer in charge of a quarantine station may give directions to a
           person in the quarantine station to leave or to subject him or herself to such
           treatment as is required by the direction.172 A person who enters or leaves a
           quarantine station or quarantine area or takes an animal, plant or other goods
           into or out of a quarantine station or area without the written permission of a
           quarantine officer commits an offence.173 A quarantine officer may give
           specified persons or classes of persons written permission to do relevant acts,
           and those permissions may or may not be subject to conditions. If a person
           enter or leave a quarantine station or take an animal or plant or other goods into
           or out of the quarantine station, or interfere with any animals, plants or other
           goods that are subject to quarantine in contravention of any such condition and
           that person is reckless as to whether or not the condition is contravened, the
           person also commits an offence.174

Compliance agreements

7.17       A Director of Quarantine may enter into a compliance agreement with a person
           in connection with the application of particular procedures in respect of goods
           and the supervision, monitoring and testing of that persons compliance with
           those procedures.175 A compliance agreement must describe the records to be
           created and kept of the procedures which are the subject of the agreement, and
           the means by which those procedures are to be supervised, monitored and
           tested.176

Recovery of quarantine expenses

7.18       The importer and owner of any animal subject to quarantine are liable to the
           Commonwealth for expenses connected with the examination of the animal, its
           transportation, detention, maintenance, treatment and movement and its
           removal, disposal or destruction under a power conferred or an order or
           direction given under the Act.177 Those expenses may be recovered as a debt
           due to the Commonwealth.178 The Act provides that the Minister may by notice
           published in the Gazette, make determinations of fees to be paid in connection
           with the management and maintenance of animals at a quarantine station.179
           The current determination in relation to fees to be charged for services provided

170
    Section 48(AD).
171
    Section 70(B).
172
    Section 70(E).
173
    Section 76(2).
174
    Section 76(3),(4).
175
    Section 66B.
176
    Regulations, reg.72.
177
    Section 64(1).
178
    Section 66.
179
    Section 86E(1B).


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                                                                                    SUBS.INQ.001.0042




           in connection with quarantine stations is in item 30 of the Quarantine Service
           Fees Determinations 2001.




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                                                                                                        SUBS.INQ.001.0043




8          AQIS WORK INSTRUCTIONS AND PROCEDURES

Prior to 2003

8.1         The earliest document setting in any structured way procedures for AQIS
            officers in relation to imported horses, is the Quarantine Station Operations
            Manual180 developed in about 1998.181 That manual was not limited to
            operations with respect to horses, but did include operating procedures for
            horses182 and a section on equine influenza.183 The manual also contained
            disinfection procedures,184 and procedures in respect of site security185 and
            record keeping for internal review and auditing;186 procedures relevant to the
            importation of horses. It is not clear, on the evidence before the Inquiry, the
            extent to which the quarantine stations were having regard to, and complying
            with, this manual. In any event, as noted elsewhere, the manual was not
            subsequently regarded by officers in the PEAQ program in Canberra to
            sufficiently document procedures for horses.

Development of the Live Horse Work Instruction and the Operations Manual

8.2         In 2003, officers in the LAI program in Canberra undertook a project to
            formulate work instructions for the clearance of the various species of animals
            imported into Australia, including horses. The project evolved out of a number
            of other projects that were being undertaken by the program:

            (a)         the Order into Quarantine project, which arose out of the identification of
                        inconsistencies in the processes by which officers in the regions were
                        ordering imported live animals into quarantine187

            (b)         a staffing review of the LAI program, which arose out of the identification
                        of inconsistencies between regional offices as to the tasks being
                        undertaken by veterinary officers (as opposed to general quarantine
                        officers) within the LAI program188

            (c)         a project to develop a standardised examination and record of
                        examination for the inspection of cats, dogs and horses in post arrival
                        quarantine




180
      DAFF.0001.812.0007–0085. There were also two documents relating to access by persons to the
      quarantine stations which, on their face, appear to have been prepared at one of the quarantine
      stations in November 1998 and June 1999 respectively. The documents are headed “Horse Visitor
      Rules during quarantine” (EII.0001.001.0218) and “Horse Grooms - please note”
      DAFF.0001.100.0259.
181
      See WIT.AQIS.015.0001 at 66 and WIT.AQIS.016.0001 at 44.
182
      DAFF.0001.812.0047 - 0048.
183
      DAFF.0001.812.0065.
184
      DAFF.0001.812.0071 - 0072.
185
      DAFF.0001.812.0079.
186
      DAFF.0001.812.0081.
187
      The final report on the Order into project is DAFF.0001.815.0033.
188
      The final report on the LAI staffing review is DAFF.0001.069.2306.


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                                                                                        SUBS.INQ.001.0044




            (d)         an understanding that there was no centralised place where AQIS
                        procedures relating to the importation of an commodity could be
                        located.189

8.3         Mr Michael Hibbert was the acting national manager of the LAI and PEAQ
            programs from March 2003 to June 2004, and was responsible for the
            development of the work instruction for horses during that period.190 Dr
            Hibbert’s evidence was that the work instruction “was to be a collation of the
            current work practices of the various regions … at that particular time”.191 Dr
            Hibbert gave responsibility for preparing the work instruction to Mr George
            Hughes, an officer in the LAI program in Canberra.

8.4         At about the same time as the work instruction project, a project was on foot for
            the development of an operations manual for each species of animal housed at
            government quarantine stations. That project was part of the PEAQ business
            plan for 2003–04.192 Dr Hibbert was involved in the decision to develop
            operations manuals,193 as was Narelle Clegg, the acting Manager, Animal
            Programs.194 Dr Hibbert was of the view that the quarantine stations operated
            by AQIS did not have matching, or auditable, documented procedures. He
            considered that the operations manual which was developed in about 1998 was
            “a generic document lacking in detail in relation to specific procedures and
            records”.195

8.5         Dr Hibbert expressed the view that the operations manual would provide
            consistency in procedures, allow internal auditing and provide a resource from
            training. The operations manual for horses was to be separate from the Live
            Horse Work Instruction “so that the Operations Manual could be used as a tool
            for training staff at the Quarantine Stations, and given that AUSVETPLAN
            referred to an Operations Manual for Quarantine Stations”.196 In late 2003 or
            early 2004, Bernadette Oakes, an officer in the LAI and PEAQ programs in
            Canberra, was requested by Dr Hibbert to prepare the operations manual for
            horses.     He prioritised the operations manual for horses, because he
            considered horses were a higher quarantine risk than cats and dogs.197

8.6         Mr Hughes drafted the Live Horse Work Instruction, having regard to, among
            other things, information obtained from the regions regarding the documented
            processes and procedures for managing horse importation, the Order into
            Quarantine project and the standardised examination project referred to above,
            and observations of the clearance processes around the country.198 No advice,
            in respect of the adequacy from a biosecurity perspective of the arrangements
            contained in the Live Horse Work Instruction, was sought, or obtained, from
            Biosecurity Australia.

189
      WIT.AQIS.015.0001 at 22 - 56.
190
      WIT.AQIS.015.0001 at 55 - 57.
191
      WIT.AQIS.015.0001 at 58.
192
      WIT.AQIS.016.0001 at 45.
193
      WIT.AQIS.015.0001 at 66 - 69.
194
      WIT.AQIS.016.0001 at 3, 45.
195
      WIT.AQIS.015.0001 at 66.
196
      WIT.AQIS.015.0001 at 68.
197
      WIT.AQIS.015.0001 at 68 - 69.
198
      WIT.AQIS.015.0001 at 58.


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                                                                                                   SUBS.INQ.001.0045




8.7         A draft of the Live Horse Work Instruction was posted on the AQIS intranet in
            September 2003, and officers in the regions were invited to comment upon it by
            7 November 2003.199

8.8         Notwithstanding the project to develop the Operations Manual, the Live Horse
            Work Instruction included a section on the procedures for horses at the
            quarantine station. Dr Hibbert’s explanation for this was as follows:

                   As the Work Instructions were intended to be a collation of the available
                   information at the time and were completed prior to the Operations
                   Manual … all the available information was included in the relevant Work
                   Instructions. The intention was to remove activities specific to the
                   Quarantine Station staff from the relevant Work Instructions after that
                   material had been included in the Operations Manual … and that
                   Operations Manual had been finalised.200

8.9         In his oral evidence, Dr Hibbert explained that the quarantine station procedures
            were to be reviewed and recorded in short form in the Live Horse Work
            Instruction, as a minor aspect of that work instruction. It was a collection of
            what was available at the time, which would be developed into an expanded
            form in the Operations Manual.201 Dr Clegg also acknowledged that the work
            instruction was an attempt to document what was already being done in the
            regions, and was not exhaustive in respect of the procedures at the quarantine
            stations.202

8.10        Dr Widders provided comments on the draft Live Horse Work Instruction to Mr
            Hughes on 31 October 2003.203 His comments included that the section on
            personnel at the airport required upgrading:

                   These work instructions require that farriers and vets attending the
                   horses during PAQ change clothes and shower out, this should apply
                   equally to people handling horses at arrival. Currently truck drivers may
                   assist in unloading and loading, we require that they wear overalls if they
                   do, but this is less than a full shower out, and truck drivers could be off
                   doing another job straight after the quarantine job. I believe it should be
                   put to the importer to provide sufficient personnel to handle the horses on
                   arrival (doesn’t happen currently, that’s why drivers often required) and
                   have handlers sign to confirm that they will shower/change clothes etc or
                                                                          204
                   have them accredited so they undertake to do same.

8.11        No amendment to this section of the draft work instruction was ever made.205

8.12        Dr Widders also made comments in respect of the horse health examination
            required to be undertaken within 48 hours of the horse’s arrival at the


199
      WIT.AQIS.006.0001 at 33.
200
      WIT.AQIS.015.0001 at 59.
201
      T3763.
202
      T3362.
203
      DAFF.1001.004.0258–0275.
204
      DAFF.1001.004.0265.
205
      Compare the version of the work instruction commented on by Dr Widders (at DAFF.1001.004.0265)
      with the finalised work instruction (at AQIS.0001.001.0016).


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                                                                                                         SUBS.INQ.001.0046




             quarantine station.206 His comments were to the effect, among other things, that
             the level of examination required was over and above any inspection required to
             assess the quarantine health status of the horse and would, consequently,
             impose a significant cost on the importer in circumstances where the benefit
             accruing to AQIS and the importer was negligible.207 It is not clear on the
             evidence whether any amendments were made to the work instruction, in
             respect of the horse health examination, as a result of Dr Widders’ comments.

8.13         In responding to the draft work instruction, Dr Widders restricted his comments
             to matters affecting the LAI program because, as at the time, he did not have a
             role in the PEAQ program. He assumed responsibility for the PEAQ program
             (in addition to his other responsibilities) in January 2004.208

8.14         Mr Hughes did amend the work instruction to take into consideration some of
             the feedback received from Dr Widders. In respect of Dr Widders’ comments
             about personnel at the airport, Dr Hibbert’s evidence was that his intention was
             to include in the Operations Manual a procedure which required the truck
             drivers who had contact with horses to shower before departure from a
             quarantine station.209 This was because there were no shower facilities at the
             airport and the drivers had to go to the quarantine stations. In oral evidence, Dr
             Hibbert agreed that there was not really any reason why this requirement could
             not have been incorporated into the Live Horse Work Instruction.210 The Live
             Horse Work Instruction was subsequently finalised and circulated as set out
             further below.

8.15         Ms Oakes prepared the Operations Manual having regard to:211

             (a)        her knowledge of the quarantine stations operated by AQIS gained from
                        visiting ECQS in 1998 and from telephone conversations she had with
                        the AQIS quarantine station managers from time to time in the course of
                        her normal duties

             (b)        the Quarantine Station Operations Manual from 1998212

             (c)        the biosecurity arrangements for the Sydney 2000 Olympics

             (d)        the operations manuals for the privately operated facilities at Sandown
                        and Canterbury



206
      DAFF.1001.004.0273 - 0274. Although these comments were placed under document H in
      attachment 1 to the work instruction - “AQIS horse health record sheet” - it appears by their content
      that they were intended to be in respect of document G - “Examination of the horse in post arrival
      quarantine”. The Examination document is not included in the copy of the work instruction containing
      Dr Widders’ comments, but a version of it appears to be in the finalised work instruction at
      AQIS.0001.001.0034.
207
      DAFF.1001.004.0273 - 0274.
208
      WIT.AQIS.006.0001 at 3.
209
      WIT.AQIS.015.0001 at 61.
210
      T3735.
211
      WIT.AQIS.032.0001 at 17.
212
      DAFF.0001.812.0007.


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                                                                                                          SUBS.INQ.001.0047




             (e)        telephone conversations with Wayne Gundry, the Manager of
                        Spotswood Quarantine Station, in relation to the development of the
                        Operations Manual during which the specific procedures and process
                        used at Spotswood Quarantine Station and ECQS were discussed.

8.16         As with the Live Horse Work Instruction; no advice, in respect of the adequacy
             from a biosecurity perspective of the arrangements contained in the Operations
             Manual, was sought, or obtained, from Biosecurity Australia.

8.17         Ms Oakes sent an email, attaching the Operations Manual and requesting
             comments, to persons including Mr Gundry, Dr Widders and Joanne Eddy (the
             Animal Quarantine Supervisor at ECQS) on 31 March 2004.213 After not
             receiving any response, Ms Oakes sent a follow–up request for comments on 3
             May 2004.214

8.18         Shortly after, on 5 May 2004, Mr Hibbert sent at email to the Regional
             Managers including the Regional Manager of NSW, Graham Turner.215 The
             email attached the report on the LAI staffing review referred to above216 and
             stated, among other things:

                    The review…includes some national recommendations such as
                    formulation of work instructions…The work instructions have been
                    formulated for each imported species are currently available on the
                    intranet…

                    The work instructions were formulated to ensure a nationally consistent
                    process and are now the reference information related to clearance of
                    animals for officers of the live animal import section. They include the
                    most appropriate process for meeting the Quarantine Act’s requirements
                    (including approved forms) for live animal imports and will be updated as
                    required. The work instructions can be implemented immediately.217

8.19         On 11 May 2004, Mr Hughes advised some officers in the regions, including Dr
             Widders and Claire McKee, who was the Manager of ECQS at that time, that
             the Live Horse Work Instruction had been updated to include more detailed
             directions in relation to the release into quarantine surveillance of mares in foal.
             Mr Hughes’ email stated, among other things:

                    The updated document is available on AQISnet…under Quarantine and
                    import operations/Live animal/Work instructions. If you have not already
                    done so please save this link to your favourites as this will be the main
                    area for accessing internal LAI/PEAQ related documents. I will let you




213
      DAFF.0001.217.4859.
214
      DAFF.0001.217.4784.
215
      DAFF.0001.069.2305–2334.
216
      The final report on the staffing review was finalised, and approved for circulation to AQIS regional
      managers, at an earlier time but the circulation of it was delayed due to resources in the LAI program
      being directed elsewhere in subsequent months. (WIT.AQIS.015.0001 at 52 -53; WIT.AQIS.016.0001
      at 33).
217
      DAFF.0001.069.2305.


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                                                                                               SUBS.INQ.001.0048




                   know when documents are updated or new documents included on this
                        218
                   site.

8.20        The content of the Live Horse Work Instruction is discussed separately.

8.21        Dr Widders was not aware of any further direction or training in respect of the
            Live Horse Work Instruction, or any review of the implementation or efficacy of
            the Live Horse Work Instruction, after that time.219 Up to the time of the equine
            influenza outbreak, the Live Horse Work Instruction remained on the AQIS
            intranet in the form posted on 11 May 2004.220

8.22        On 13 May 2004, a Quarantine Station Managers meeting was held at which
            the attendees included Dr Hibbert, Dr Widders, Ms McKee, and Ms Eddy.221
            The minutes of the meeting include the following reference to the Operations
            Manual (here referred to by Dr Hibbert as the “Draft Horse SOP”):

                   6.         Development of standard operating procedures (cats, dogs and
                              horses)

                   …

                   Michael [Hibbert] advised that a draft horse sop was distributed to the
                   regions but that he would like to re draft this document and redistribute
                   prior to seeking feedback.

                   The [quarantine station managers] advised that the development of such
                                                                     222
                   documents should have substantial regional input.

8.23        Following consideration of the LAI staffing review and the final version of the
            work instructions including that for horses, on 19 May 2004 Dr Widders
            expressed the view to Mr Turner and Julie Sims (the NSW Assistant Regional
            Manager with responsibility for the LAI and PEAQ programs) that the work
            instructions had:

                   been developed by staff with no or limited experience of clearance
                   procedures, and require significant input to ensure that they are
                   practical.223

8.24        Shortly thereafter, Dr Widders provided comments on the LAI staffing review to
            Mr Turner,224 who forwarded the comments (with minor alterations225) to Ms
            Gordon.226 Dr Widders comments included the following:

            (a)         Of all live animal imports, the import of horses from countries other than
                        New Zealand represented the greatest risk for the introduction of serious

218
      DAFF.0001.217.4783.
219
      WIT.AQIS.006.0001 at 34.
220
      WIT.AQIS.016.0001at 41 – 42.
221
      DAFF.0001.210.0238 - 0243.
222
      DAFF.0001.210.0239 - 0240.
223
      DAFF.0001.088.0096.
224
      DAFF.0001.069.2449 - 2459.
225
      DAFF.0001.597.0135.
226
      DAFF.0001.069.2295 - 2304 .


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                                                                                             SUBS.INQ.001.0049




                        exotic disease, namely equine influenza. He did not support any
                        reduction in direct AQIS oversight of these imports.

            (b)         He had qualified support for the recommendation in the review that
                        airport clearance of horses be performed by a quarantine officer rather
                        than a veterinary officer. The qualifications included that the quarantine
                        officer was supported by practical work instructions, and that procedures
                        were developed to ensure horse importers provided for sufficient and
                        appropriately trained staff at the airport during the unloading and that
                        any risks for dissemination of exotic diseases via airport personnel were
                        addressed. (Following this time, Dr Widders maintained the view that
                        the documented procedure for clearance of horses at the airport did not
                        adequately address the quarantine risks, and so continued to require, up
                        until the equine influenza outbreak, that clearance of all horses from
                        countries other than New Zealand be undertaken by a veterinary
                        officer).227

            (c)         He had no support for the recommendation in the review that
                        examination of horses at the beginning of post arrival quarantine be
                        performed by a private vet. He considered that removal of that task from
                        an AQIS veterinary officer would remove a critical oversight of the
                        performance of quarantine because it was through that inspection that
                        the veterinary officer could assess the health of horses in the critical
                        period immediately post-arrival when respiratory disease was most
                        common.

            (d)         The work instructions drafted by AQIS Canberra for a range of animal
                        commodities required significant input from experienced regional officers
                        to ensure that they were operationally practical.

            (e)         A procedure must be developed and implemented for monitoring the
                        effectiveness of functions performed in the regional LAI program. The
                        response from officers in Canberra to Dr Widders’ comments on the
                        work instructions was in the nature of surprise and disappointment,
                        because the view was that there had been significant regional input into
                        the work instructions.

8.25        The response from officers in Canberra to Dr Widders’ comments on the work
            instructions was in the nature of surprise and disappointment, because the view
            was that there had been significant regional input into the work instructions.

8.26        In about mid June 2004, Ms Gordon and Mr Turner agreed for a meeting to take
            place between officers in the LAI and PEAQ programs in NSW and Canberra.
            The intention of the meeting, according to Mr Turner, was for the officers to
            discuss issues with a view to establishing a clear and common understanding
            and direction for program service delivery in NSW.228 Mr Turner proposed an
            agenda that included the LAI staffing review, but did not expressly refer to the
            Live Horse Work Instructions.229 Ms Gordon’s view was that the intention of the
227
      WIT.AQIS.006.0001 at 46, T998.
228
      DAFF.0001.069.2522.
229
      DAFF.0002.052.6455.


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                                                                                            SUBS.INQ.001.0050




            meeting was “to resolve issues of management at Eastern Creek—specifically
            who is responsible for what.” She had concerns about:

                   the understanding of staff of where they fit into a complex management
                   structure which requires them to exercise professional judgement while
                   noting the need for national consistency, efficiency and effectiveness
                                                230
                   against Corporate outcomes.

8.27        Ms Gordon was of the view that the LAI staffing review was not relevant to the
            meeting because the decision had already been taken—it had been signed off
            by senior management in Canberra after taking account of the view of all
            regional offices and officers and was not being revisited at that point—and the
            issue was one of “responsiveness” by the region.231 Dr Clegg, who was to
            participate in the meeting, suggested to Ms Gordon that the meeting could
            discuss Dr Widders’ comments on the LAI staffing review,232 but it is no clear on
            the evidence before the Inquiry whether that was agreed to by Ms Gordon and
            communicated to Mr Turner. Dr Widders listed the matters he wanted
            discussed at the meeting233 (although he did not circulate it) as including:

                   Implementation of LAI review recommendations

                         Level 4 dedicated (cf Level 3 ACU in Vic)

                         Private vets and costs/oversight of quarantine

                         Extent of vet check mandated for imported animals (companion
                         ans plus horses)

                   Work procedures and input from regions (what response has been
                   received from regions?)

8.28        The final item was intended to prompt discussion of the development of work
            procedures and the consideration of input from the regions and whether other
            regions had also had input.234

8.29        After a number of postponements due to participant unavailability, the meeting
            took place in October 2004 and was attended by Dr Widders, Ms Sims, Dr
            Clegg, Kylie Lance (who was then the National Manager of the LAI and PEAQ
            programs) and possibly Ms McKee.235 Mr Turner introduced the meeting but
            was then called away. Dr Widders’ evidence was that there was discussion of
            the Live Horse Work Instruction at the meeting—that he expressed his view that
            the existing work instructions still required some work and input from regional
            officers, and that they did not address significant risks, particularly at the
            airport.236


230
      DAFF.0002.052.6454.
231
      DAFF.0002.052.6454.
232
      DAFF.0002.052.9430.
233
      DAFF.0001.737.0003.
234
      T1249.
235
      WIT.AQIS.016.0001, para 43.
236
      T979, T1001 - 1005.


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                                                                                            SUBS.INQ.001.0051




8.30        Dr Widders’ evidence was that at no time in the period from that meeting to
            August 2007 was he requested by the national program to have further input
            into the Live Horse Work Instruction. The NSW regional office left it up to Dr
            Widders to discuss the technical issues with the work instruction with the
            national program.237 Dr Widders also gave evidence that he forwarded his
            comments on the Live Horse Work Instruction to the national program again in
            2006,238 although it is not clear what prompted that or what consideration was
            given to his comments at the time. In any event, it is clear that no amendments
            were made to the Live Horse Work Instruction as a result.

8.31        The Operations Manual was discussed at at least two Quarantine Station
            Managers meetings in 2005 at which Dr Widders, Ms Eddy and Mr Hamid,
            among others, were present. The minutes of the meeting held on 10 February
            2005239 recorded the following:

                   2.    Dog, cat, horse SOP’s

                   George [Hughes] advised that the dog, cat and horse SOP’s were now up
                   on the intranet and encouraged the group to participate in providing
                   comments. The group had no comment to make at the moment as they
                   had not had a chance to go through the documents. Kylie [Lance]
                   requested that all comments be into the program by the end of
                             240
                   February.

8.32        The minutes of the meeting held on 9 November 2005241 recorded the following:

                   Horse work instructions

                   Jo [Eddy] and Mohamad [Hamid] mentioned that there were draft work
                   instructions on the intranet that were there for comment and George
                   Hughes had reviewed and updated the first draft in January and had not
                   been reviewed since.
                                                                                242
                   Action: Tran to review and update the Horse work instructions.

8.33        (“Tran” appears to have been a reference to Tran Tang, an officer in the PEAQ
            program in Canberra who was present at the meeting).243 On the basis of the
            description of events that had occurred in respect of the documents referred to
            in the minutes of these two meetings, it appears that the documents referred to
            were the Operations Manual.

8.34        It appears that no significant steps towards finalising the Operations Manual
            were taken between February 2005 and the equine influenza outbreak, at which
            time the Operations Manual remained in draft form on the AQIS intranet. The
            content of the Operations Manual is discussed separately.

237
      T1004 - 1005.
238
      WIT.AQIS.006.0001 at 34.
239
      DAFF.0001.555.1489 - 1491.
240
      DAFF.0001.555.1489.
241
      DAFF.0001.555.1556 - 1560.
242
      DAFF.0001.555.1559.
243
      DAFF.0001.555.1556 - 1560.


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                                                                                                SUBS.INQ.001.0052




8.35        The lack of action in respect of the Operations Manual was despite the subject
            of its finalisation being included as an item in a number of business plans for the
            PEAQ program, as follows. The following strategy and milestones were
            included in the PEAQ program business plan for 2005–06,244 as a means by
            which “PEAQ is planning to accomplish its objectives and/or mitigate risk”:245

                   Outline

                   To achieve border security and animal welfare by implementing national
                   work procedures for the daily care of cats, dogs and horses undertaking
                   post-arrival quarantine.

                   Rationale

                   The formulation of standard work procedures contributes to maintenance
                   of an acceptable and consistent client service delivery standard providing
                   a basis for training staff and performance through people appraisals.

                   Current procedures to be reviewed and inconsistencies identified.

                   Milestones

                   Standard work procedures documented and implemented nationally.
                   Expected completion date: August 2005

                   Audit of standard work procedures at each quarantine station. Expected
                   completion date: March 2006

                   Review of standard work procedures. Expected completion date: June
                   2006

8.36        Dr Clegg’s evidence was that item in the business plan was intended to include
            having the Operations Manual finished and ‘signed off’ by August 2005, and
            then there would be an audit to look at whether the Operations Manual was
            being implemented and at how effective it was.246 The first business plan
            review, dated 8 December 2005, in respect of the PEAQ program business plan
            for 2005–06,247 commented against the milestone of “standard work procedures
            documented and implemented nationally” that “standard work procedures are
            being reviewed for effectiveness”.248 The second business plan review,249 dated
            9 May 2006, included under the heading of “Non-Achievements and Corrective
            Action”:250

                   Non-Achievement

                   Audit of standard work procedures at each quarantine station.



244
      DAFF.0001.669.0001 - 0015.
245
      DAFF.0001.669.0007.
246
      T3377 - 3378.
247
      Business Plan Review to the Finance and Audit Committee: AQIS.2003.045.0085–0089.
248
      AQIS.2003.045.0088.
249
      Business Plan Review to the Business Plan Review Committee: AQIS.2003.045.0090 - 0095.
250
      AQIS.2003.045.0094.


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                                                                                                SUBS.INQ.001.0053




                   Corrective action

                   Due to lack of resources Live Animal Imports has deferred the audit of
                   work procedures at quarantine stations and will be incorporated into the
                   06/07 PEAQ business plan.

8.37        Dr Clegg conceded that the entries in the business plan review documentation
            could be misleading to the extent that it suggested that the standard work
            procedures in respect of horses had been finalised and that the only non-
            achievement was in respect of auditing, whereas the Operations Manual had
            not been finalised.251

8.38        The PEAQ program business plan for 2006–07252 did not include any specific
            annual strategies in respect of procedures for horses at the quarantine stations.
            It included as an ongoing strategy:

                   Revise and review work instructions to ensure consistency and
                                                253
                   appropriateness of practice.

            but that item was not intended to catch the finalisation and audit of standard
            work procedures that had not been achieved under the previous business plan.
            Instead, the subject of finalising, implementing and auditing procedures with
            respect to horses at the quarantine stations was not included in the business
            plan because there was insufficient resources to enable it to be addressed in
            light of the other projects that had a higher priority.254 Dr Clegg, who signed off
            on this business plan, considered the absence of documented procedures for
            looking after horses in quarantine stations was unsatisfactory but:

                   [i]t hadn’t been addressed for a number of years, and, therefore, another
                   delay while other activities were taken up didn’t seem to me to be a major
                   issue. There was a draft on the intranet. The managers were aware of it
                   and it was raised, in fact, by two of the managers at Eastern Creek in
                          255
                   2006.

8.39        Dr Clegg also noted in this context that the Live Horse Work Instruction was a
            finalised document that was available to staff in the quarantine stations.256

8.40        Mr Ironside, as the officer responsible for drafting the PEAQ program business
            plan for 2007–08,257 included in that plan as an ‘Annual Strategy’:

                   Development and provision of nationally consistent standard operating
                   procedures and work instructions on the intranet for dogs, cats and
                          258
                   horses.



251
      T3380 - 3383.
252
      DAFF.0001.669.0260 - 0273.
253
      DAFF.0001.669.0265.
254
      T3385 - 3386.
255
      T3386.
256
      T3387.
257
      AQIS.2002.017.0023 - 0037.
258
      AQIS.2002.017.0033.


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                                                                                                 SUBS.INQ.001.0054




8.41        Mr Ironside included this item, which was directed at getting the Operations
            Manual finalised and on the AQIS intranet, in part as a result of Mr Hankins’
            inquiry to him in March or April 2007, which is discussed below, and subsequent
            discussions between them.259

8.42        Mr Ironside conceded in evidence that nothing had happened, in the time since
            the PEAQ program business plan for 2005–06 was formulated, in relation to the
            documentation and implementation of the procedures for horses at the
            quarantine stations.260 His explanation for that state of affairs was:

                   in terms of the work procedures and operations manuals that relate to the
                   whole range of activities that fall under the live animal imports and post–
                   entry animal quarantine programs, there is a need to prioritise the project
                   work that gets done, and not every project that is listed in the business
                   plan gets done each year, because invariably every year something
                   happens and there are other issues which arise which assume greater
                   priority than the things that you had listed in the business plan.

                   And prior to August [2007], the auditing of work procedures and the
                   finalisation of the operations manual, while it was something that had
                   been ongoing and had been seen to be something that needed to be
                                                                                     261
                   done, hadn’t assumed that level of priority that saw it get done.

8.43        Dr Clegg’s evidence was also that the Operations Manual was not finalised
            because other activities had taken priority.262

Live Horse Work Instruction

8.44        The Live Horse Work Instruction reflected the AQIS approach to documented
            procedures current at the time it was drafted.263 It was in the form of an
            overarching–type document that, under the AQIS policy on SOPs discussed
            elsewhere, would fall into the classification of a SOP rather than a work
            instruction.264

8.45        The Live Horse Work Instruction identified the responsibilities of key personnel
            as including the following:265

            (a)         The AQIS Regional Manager was to ensure that all quarantine officers
                        involved with the imports of live horses were aware of the work
                        instruction and had access to it, and that the “nominated officer” was
                        trained in the process of horse clearance.

            (b)         The AQIS Quarantine Officer (also referred to as the “nominated officer”)
                        was to ensure they were familiar with the work instruction, and was


259
      T273 - 274.
260
      T278.
261
      T278 - 279.
262
      T3371 - 3372.
263
      WIT.DAFF.002.0001 at 68.
264
      T293.
265
      AQIS.0001.001.0014.


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                                                                                            SUBS.INQ.001.0055




                        responsible for overseeing the live horse clearance and post-arrival
                        inspection procedures.

8.46        Attachment 1 to the Live Horse Work Instruction was headed ‘useful
            documents’ and contained 13 documents.266 There was no express statement
            in the work instruction to the effect that each of those documents had to be
            used, although there were some references in the body of the work instruction
            to individual documents in Attachment 1.

Import Clearance

8.47        Section 1 of the Live Horse Work Instruction, headed ‘Import Clearance’ set out
            procedures in respect of the clearance of horses at the airport and their
            associated documentation. The procedures specified included the following:267

            (a)         ensure that only personnel relevant to the unloading and transport of the
                        horses are present at the transfer area

            (b)         ensure that any personnel (other than those that travelled on the flight
                        with the horses) that are required to handle horses during the unload are
                        wearing appropriate clothing. (No guidance is included in respect of
                        what would constitute “appropriate clothing”)

            (c)         check the general health of the horse and confirm the identity of the
                        horse against the paperwork

            (d)         consult with the vet or grooms travelling with the horses regarding the
                        health of the horse during the transport

            (e)         ensure all relevant documentation (health certificates, AIMS entry,
                        airway bill, copy of import permit) is received

            (f)         order the horses into quarantine pursuant to section 52 of the Act, and
                        give directions for the transport of the horses to the quarantine station
                        pursuant to section 48 of the Act

            (g)         ensure that any lead ropes and head collars used with the horses
                        accompany the horses to the quarantine station, and direct that any lead
                        ropes and head collars belonging to the trucks that were used with the
                        horses are disinfected at the quarantine station

            (h)         seal the truck for travel to the quarantine station and inform the
                        quarantine station of the time of departure from the airport and number
                        of trucks and horses

            (i)         upon return to the office, check the documentation received in respect of
                        the consignment, having regard to specified matters for the import
                        permit, health certificates and any certificates of equivalence; and
                        complete the coversheet for each health certificate. (The reference to
266
      AQIS.0001.001.0022 - 0048.
267
      AQIS.0001.001.0016 - 0018.


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                                                                                                           SUBS.INQ.001.0056




                        the coversheet is perhaps intended to be a reference to document A in
                        attachment 1 to the work instruction—“Coversheet for document
                        clearance of live horses”268— although that coversheet is designed to be
                        completed in respect of each consignment rather than each health
                        certificate)

             (j)        forward all documents to the quarantine station.

Procedures at all quarantine stations

8.48         Section 2 of the Live Horse Work Instruction set out the procedures for the
             quarantine stations.

8.49         At the outset, it is noted that the structure of this section of the work instruction
             was less than ideal.269 The procedures set out in the body of the Live Horse
             Work Instruction were not very comprehensive or detailed. In some instances,
             the procedures themselves or at least the detail of the procedures was provided
             in the documents included in Attachment 1 to the work instruction. As noted
             above, Attachment 1 was headed ‘useful documents’ and there was no express
             requirement that each of the documents contained in the attachment must be
             used. Nevertheless, it is assumed that where procedures or the detail of
             procedures was provided in a document contained in the attachment, that the
             work instruction required those procedures to be followed. On that basis, the
             procedures for the quarantine stations set out in the Live Horse Work Instruction
             for quarantine officers, grooms and private vets and farriers were as follows.

8.50         Quarantine officers were to do the following things:270

             (a)        confirm that the seals on the trucks were intact on arrival at the
                        quarantine station, and then break the seals

             (b)        ensure the transport vehicles were cleaned and disinfected, using a
                        specified treatment, prior to leaving the quarantine station

             (c)        ensure the grooms accompanying the horses read and signed the “AQIS
                        instructions for grooms form”. (Presumably this was a reference to
                        either document D - “Groom authorisation to enter the AQIS Quarantine
                        Facility”271 or document E - “Post Arrival Quarantine Instructions for
                        Grooms”272 - in Attachment 1 to the work instruction, although only the
                        former of those documents expressly provided a place for a groom’s
                        signature).

             (d)        check, daily, the health record sheet on which the grooms were to record
                        the horses’ rectal temperatures, taken twice daily at 12 hour intervals,
                        and any health abnormalities - document H in attachment 1 to the work

268
      AQIS.0001.001.0025.
269
      Deficiencies with the Live Horse Work Instruction are discussed more comprehensively later in this
      chapter.
270
      AQIS.0001.001.0019 - 0021.
271
      AQIS.0001.001.0026 - 0027.
272
      AQIS.0001.001.0032 .


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                                                                                             SUBS.INQ.001.0057




                        instruction.273 (The “Information Sheet for the Post Arrival Quarantine of
                        Horses” - document B in Attachment 1274 - stated that quarantine staff
                        would also liaise with grooms daily regarding the horses’ health)275

            (e)         inform the manager of the quarantine station of any abnormality in
                        relation to the health of the any of the horses, and notify an AQIS
                        veterinary officer of any health issues

            (f)         make approved vets and farriers aware of the post arrival quarantine
                        requirements for vets and farriers, prior to them entering the quarantine
                        station. (Those ‘requirements’ were not specified in the body of the work
                        instruction, but presumably were the requirements set out in document F
                        in Attachment 1 to the work instruction - “Post Arrival Quarantine
                        Instructions for Veterinarians and Farriers”).276

            (g)         ensure any equipment used on the horses was correctly disinfected prior
                        to leaving the quarantine station.

8.51        AQIS veterinary officers were required to perform two veterinary inspections of
            the horses prior to their release from quarantine.277 The first inspection, to be
            carried out within 48 hours of the horse’s arrival, involved confirming the horse’s
            identity, conducting a tick inspection, drawing bloods for the national serum
            bank and conducting a clinical health examination. The second inspection, to
            be carried out within 48 hours prior to release, was to enable the veterinary
            officer to assess the horse’s fitness for release from quarantine.

8.52        Grooms were required to have the authorisation of the manager of the
            quarantine station and the importing agent to enter the quarantine station.
            Grooms were responsible for monitoring the horses’ health, including through
            taking the horses’ temperature twice daily and observing whether there were
            any signs of ill health. The temperatures and any health abnormalities were
            required to be recorded on the AQIS horse health record sheet. Grooms were
            required to notify a quarantine officer if a private vet or farrier was required to
            attend to a horse, and to inform the manager of the quarantine station of any
            health abnormalities. (They were not expressly or otherwise required to inform
            AQIS of raised temperatures). The grooms were required to wear dedicated
            clothing and footwear, which clothing and footwear had to remain in the
            quarantine station, whilst contacting horses. They were also required to have a
            complete head–to–toe three–minute shower, and to change into fresh clothing
            and footwear, immediately before leaving the quarantine station. Grooms were
            required to acknowledge and agree to comply with these requirements by
            signing the “Groom Authorisation to enter the AQIS quarantine facility”—
            document D in Attachment 1 to the work instruction.278



273
      AQIS.0001.001.0036.
274
      AQIS.0001.001.0030 - 0031.
275
      AQIS.0001.001.0030.
276
      AQIS.0001.001.0033.
277
      AQIS.0001.001.0020 - 0021, 0034 - 0035.
278
      AQIS.0001.001.0026.


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                                                                                                  SUBS.INQ.001.0058




8.53        The importing agent was also required to sign the “Groom Authorisation” form to
            indicate that they had fully explained AQIS requirements to the groom and had
            instructed the groom to fully comply. The importing agent also acknowledged
            the following:

                   I understand that AQIS will audit compliance with the conditions listed
                   above. Detection of non-compliance with the above conditions will result
                   in increased auditing or eviction of the groom from the AQIS quarantine
                   facility. I will be responsible for any costs incurred relating to increased
                                         279
                   auditing of grooms.

8.54        (The work instruction does not otherwise expressly refer to the auditing by AQIS
            of the grooms’ compliance with AQIS requirements, other than perhaps in
            respect of the recording of temperatures).

8.55        As with grooms, private vets and farriers were required to have the
            authorisation of the manager of the quarantine station and the importing agent
            to enter the quarantine station; were required to wear dedicated clothing and
            footwear whilst contacting the horses and were required to “shower out”. Any
            horse equipment had to remain in the quarantine station for the duration of the
            quarantine, or be disinfected by AQIS staff before removal. Private vets and
            farriers were required to obtain permission from AQIS before implementing any
            treatment and to detail, on the AQIS horse health record, any abnormalities in
            the horse’s health, and any diagnosis or treatments implemented.280

8.56        The Live Horse Work Instruction did not expressly require AQIS staff (or anyone
            else) to take steps to ensure that private vets and farriers were complying with
            those procedures. Mr Ironside’s evidence was that, where there was a
            requirement for a person other than a quarantine officer to do something, then it
            was implicit that AQIS staff were to enforce those requirements.281

Operations manual

8.57        The requirements of the Operations Manual provided for a stronger biosecurity
            regime than that provided by the Live Horse Work Instruction in a number of
            respects. For example, the Operations Manual expressly provided that:

            (a)         A system review (to determine whether the procedures designed to
                        assure quality are appropriate or in need of improvement) and an
                        internal audit (to seek to verify that approved procedures and work
                        instructions are being followed) were to be conducted by AQIS
                        management at least once during, and then after, each period of post-
                        arrival quarantine; with all findings and any corrective actions
                        documented.282

            (b)         The owner/transport agent was responsible for ensuring that all persons
                        who work in the quarantine facility were familiar with the principles of

279
      AQIS.0001.001.0027.
280
      AQIS.0001.001.0033.
281
      T350 - T351.
282
      AQIS.0001.001.0084 and 0128.


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                                                                                            SUBS.INQ.001.0059




                        quarantine and the procedures of the facility which ensure quarantine
                        security and containment.283

            (c)         Entry of all persons into the quarantine station had to be recorded and
                        24–hour security was to be maintained around the perimeter of, and
                        within, the station.284

            (d)         All persons entering and exiting the quarantine station had to use a
                        footbath containing an approved disinfectant, such as Virkon.285

            (e)         The premises were to include suitable amenities to allow personnel to
                        practice personal hygiene and decontamination.286

            (f)         Standard operating procedures were to be handed to authorised
                        persons. Those standard operating procedures provided detail of
                        procedures required for cleaning and disinfection of trucks287 and
                        equipment;288 personal decontamination;289 security;290 entry and exit of
                        private vets,291 farriers and grooms,292 and emergency maintenance staff
                        and contractors;293 and cleaning and disinfection of premises after
                        release of the horses.294

            (g)         Cleaning and disinfecting of trucks and equipment was to be in
                        accordance with specified procedures, including the disinfection of any
                        area inside the vehicle’s cabin that was potentially disinfected.295 (The
                        Live Horse Work Instruction required the cleaning and disinfecting of
                        transport vehicles but did not descend to the level of detail provided in
                        the Operations Manual).

            (h)         Private vets and farriers were required to sign a form agreeing to comply
                        with specified AQIS requirements prior to entry to the quarantine
                        station.296  The requirements were largely those included in the
                        Instructions documents for private vets and farriers contained in
                        Attachment 1 to the Live Horse Work Instruction.

            (i)         The drivers of the vehicles transporting the horses to the quarantine
                        station had to sign a declaration that the horses had been brought to the
                        station by the most direct route and on trip without stops on the way.297


283
      AQIS.0001.001.0088.
284
      AQIS.0001.001.0092, 0101 and 0104.
285
      AQIS.0001.001.0092.
286
      AQIS.0001.001.0092.
287
      AQIS.0001.001.0098.
288
      AQIS.0001.001.0099.
289
      AQIS.0001.001.0100.
290
      AQIS.0001.001.0101.
291
      AQIS.0001.001.0104.
292
      AQIS.0001.001.0106.
293
      AQIS.0001.001.0108.
294
      AQIS.0001.001.0111.
295
      AQIS.0001.001.0098.
296
      AQIS.0001.001.0116 and 0127.
297
      AQIS.0001.001.0119.


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                                                                                                SUBS.INQ.001.0060




            (j)         AQIS officers were required to sign a declaration regarding the arrival,
                        unloading, cleaning and disinfection of the transport vehicle that brought
                        horses to the quarantine station.298

Groom induction checklist and induction record

8.58        The Groom Induction Checklist & Induction Record,299 updated in March
            2007,300 included a statement that the document was for ‘grooms who work at
            Eastern Creek without continuous supervision’. It contained a checklist of items
            relating generally to occupational health and safety and AQIS requirements of
            persons at ECQS. It did not specifically include requirements directed to
            biosecurity beyond requiring the signing of the visitors’ book when entering and
            leaving the quarantine station. (The Visitors’ book is discussed below.) The
            document contained spaces for the “new employee” (that is, the groom) and the
            “person who provides training” (the AQIS officer) to initial against each item
            included in the checklist.

Authorisation for groom to enter Eastern Creek Post Entry Quarantine Station

8.59        The Groom Authorisation document301 differed to the authorisation document
            contained in Attachment 1 to the Live Horse Work Instruction by including the
            following conditions:

            (a)         The groom was to sign in/sign out on each occasion they enter/leave the
                        station.

            (b)         The groom had to comply with all instructions/directions issued by
                        station management.

            (c)         The horse’s temperature had to be recorded on the stable door (as
                        opposed to in the AQIS horse health record sheet, as required in the
                        Live Horse Work Instruction).

            (d)         Any abnormalities in the health of a horse, diagnoses or treatments
                        implemented had to be reported to management and detailed on the
                        horse’s health record by the senior groom.

            (e)         The groom had to adhere to the conditions of Post Arrival Quarantine
                        Procedures and Code of Conduct as implemented by AQIS and the
                        Importing Agent. (What is meant by the ‘conditions of Post Arrival
                        Quarantine Procedures and Code of Conduct’ is discussed elsewhere).

            (f)         The groom had to report any security incident or concern to Station staff.

8.60        The Groom Authorisation document also included, as additional requirements
            for senior grooms, that they ensure that:

298
      AQIS.0001.001.0120.
299
      AQIS.1000.003.0045.
300
      For an earlier version, see AQIS.2001.013.0008. The substantive amendment appears to be
      substituting Mr Holloway’s contact details for those of Ms Eddy.
301
      AQIS.1000.003.0050 - 0051.


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                                                                                               SUBS.INQ.001.0061




            (a)         grooms in their charge signed in/signed out on each occasion they
                        entered/exited the station

            (b)         no unauthorised visitors were allowed in the horse facility

            (c)         requests for all visitors were to be made to station management in
                        advance

            (d)         vets and farriers that were required to attend horses were the
                        responsibility of the senior grooms whilst they were on the station. They
                        had to sign the visitors’ book in the administration office if they attended
                        during office hours or the grooms’ register if out of hours.

8.61        This Groom Authorisation document did not include the “authorisation by
            importing agent” section which is in the authorisation document contained in the
            Live Horse Work instruction.

Operating procedure for horses

8.62        The Operating Procedures document302 was styled as an information sheet for
            grooms, vets, farriers and drivers. It commenced with a warning about equine
            influenza. Its content was largely in accordance with the Live Horse Work
            Instruction, although it also included the following additional matters:

            (a)         Grooms were prohibited from contact with horses outside of the
                        quarantine station during the PAQ period303

            (b)         The importing agent or groom was to notify AQIS of arrangements for
                        attendance from private vets—prior notice is required for visits during
                        office hours; out–of–hours attendance is to be notified on the following
                        business day304

            (c)         Grooms, farriers and private vets performing non-elective services were
                        required to complete documentation prior to entering ECQS.305 (No
                        further description of the “documentation” is included)

            (d)         Persons issued with keys and access cards for ECQS were not to give
                        those keys or access cards to anyone.306

8.63        This document was in use at ECQS from a time before June 2006.307 In his
            evidence, Mr Ironside described this “more of an information document” rather
            than a document that was required to be provided.308




302
      AQIS.0001.001.0056–0059.
303
      AQIS.0001.001.0058.
304
      AQIS.0001.001.0058.
305
      AQIS.0001.001.0058.
306
      AQIS.0001.001.0059.
307
      T1468.
308
      T338.


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                                                                                       SUBS.INQ.001.0062




AQIS expectations of horse grooms at ECQS

8.64        The Expectation of Grooms document309 was prepared by Mr Hankins in late
            July or early August 2007. It was directed to behavioural matters, rather than
            biosecurity. In addition to being provided to each groom during the induction
            process, copies of the document were laminated and placed in each of the
            rooms and the common area in the grooms’ quarters, prior to the August 2007
            stallion intake.310

Visitors book

8.65        There was a visitors’ book in the grooms’ quarters,311 and another in the Animal
            Quarantine Office.312 The book in the office was only available during office
            hours.313

8.66        The visitors’ books have spaces for details to be completed of the visitor’s
            name, address, animal’s name or reason for visit, and the date and time of entry
            and exit.

Horse procedures document

8.67        This document314 was prepared, in June 2007, by Rhonda Christesen, a level 4
            Senior Quarantine Officer who was principally responsible for looking after
            horse intakes at ECQS. Ms Christesen had been requested to prepare a list of
            the procedures involved in ‘landing’ horses at ECQS,315 so that other AQIS
            officers would have some information about how to carry out her job whilst she
            was on leave from early July 2007.316 The document does not deal with the
            induction of grooms. Ms Christesen’s explanation for that omission was that the
            persons who would fill her role knew about the groom induction part of the
            process and she was trying to include things in the process that might get
            overlooked.317

Checklist of cleanliness - horses

8.68        This document318 was prepared by Ms Christesen as a checklist of matters she
            was concerned about in respect of the equine enclosure, to ensure the
            enclosure was left clean and otherwise in order at the end of a quarantine
            period.




309
      AQIS.0002.014.0044.
310
      WIT.AQIS.012.0001 at 49.
311
      AQIS.1000.037.0001 - 0027.
312
      AQIS.1000.036.0001 - 0026.
313
      WIT.AQIS.010.0001 at 76.
314
      AQIS.0001.001.0049 - 52.
315
      WIT.AQIS.012.0001 at 47.
316
      WIT.AQIS.010.0001 at 107.
317
      T1435 - 1436.
318
      DAFF.0001.611.0726; T1447–1448.


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                                                                                                SUBS.INQ.001.0063




Importers’ horse health records

8.69        These documents319 were produced and maintained by the grooms at the
            quarantine station rather than AQIS. Mr Hankins’ evidence was, however, that
            they are provided to AQIS to go on file at the end of the post-arrival quarantine
            period.

Development of other procedures

8.70        In addition to the nationally documented procedures—the Live Horse Work
            Instruction and the Operations Manual—a number of documents relevant to the
            procedures for horses were at produced at ECQS from time to time. Those
            documents included the following:

Groom Induction Checklist & Induction Record

8.71        The Groom Induction Checklist & Induction Record,320 updated in March
            2007,321 included a statement that the document was for ‘grooms who work at
            Eastern Creek without continuous supervision’. It contained a checklist of items
            relating generally to occupational health and safety and AQIS requirements of
            persons at ECQS. It did not specifically include requirements directed to
            biosecurity beyond requiring the signing of the visitors’ book when entering and
            leaving the quarantine station. (The Visitors’ book is discussed below.) The
            document contained spaces for the “new employee” (that is, the groom) and the
            “person who provides training” (the AQIS officer) to initial against each item
            included in the checklist.

Authorisation for groom to enter Eastern Creek Post Entry Quarantine Station

8.72        The Groom Authorisation document322 differed to the authorisation document
            contained in Attachment 1 to the Live Horse Work Instruction by including the
            following conditions:

            (a)         The groom was to sign in/sign out on each occasion they enter/leave the
                        station.

            (b)         The groom had to comply with all instructions/directions issued by
                        station management.

            (c)         The horse’s temperature had to be recorded on the stable door (as
                        opposed to in the AQIS horse health record sheet, as required in the
                        Live Horse Work Instruction).

            (d)         Any abnormalities in the health of a horse, diagnoses or treatments
                        implemented had to be reported to management and detailed on the
                        horse’s health record by the senior groom.

319
      For example, see AQIS.1000.012.0001, DAFF.0001.100.0608, IRT.0001.004.0050.
320
      AQIS.1000.003.0045.
321
      For an earlier version, see AQIS.2001.013.0008. The substantive amendment appears to be
      substituting Mr Holloway’s contact details for those of Ms Eddy.
322
      AQIS.1000.003.0050 - 0051.


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                                                                                               SUBS.INQ.001.0064




            (e)         The groom had to adhere to the conditions of Post Arrival Quarantine
                        Procedures and Code of Conduct as implemented by AQIS and the
                        Importing Agent. (What is meant by the ‘conditions of Post Arrival
                        Quarantine Procedures and Code of Conduct’ is discussed elsewhere).

            (f)         The groom had to report any security incident or concern to Station staff.

8.73        The Groom Authorisation document also included, as additional requirements
            for senior grooms, that they ensure that:

            (a)         grooms in their charge signed in/signed out on each occasion they
                        entered/exited the station

            (b)         no unauthorised visitors were allowed in the horse facility

            (c)         requests for all visitors were to be made to station management in
                        advance

            (d)         vets and farriers that were required to attend horses were the
                        responsibility of the senior grooms whilst they were on the station. They
                        had to sign the visitors’ book in the administration office if they attended
                        during office hours or the grooms’ register if out of hours.

8.74        This Groom Authorisation document did not include the “authorisation by
            importing agent” section which is in the authorisation document contained in the
            Live Horse Work instruction.

Operating procedure for horses

8.75        The Operating Procedures document323 was styled as an information sheet for
            grooms, vets, farriers and drivers. It commenced with a warning about equine
            influenza. Its content was largely in accordance with the Live Horse Work
            Instruction, although it also included the following additional matters:

            (a)         Grooms were prohibited from contact with horses outside of the
                        quarantine station during the PAQ period324

            (b)         The importing agent or groom was to notify AQIS of arrangements for
                        attendance from private vets—prior notice is required for visits during
                        office hours; out–of–hours attendance is to be notified on the following
                        business day325

            (c)         Grooms, farriers and private vets performing non-elective services were
                        required to complete documentation prior to entering ECQS.326 (No
                        further description of the “documentation” is included)



323
      AQIS.0001.001.0056–0059.
324
      AQIS.0001.001.0058.
325
      AQIS.0001.001.0058.
326
      AQIS.0001.001.0058.


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                                                                                                SUBS.INQ.001.0065




            (d)         Persons issued with keys and access cards for ECQS were not to give
                        those keys or access cards to anyone.327

8.76        This document was in use at ECQS from a time before June 2006.328 In his
            evidence, Mr Ironside described this “more of an information document” rather
            than a document that was required to be provided.329

AQIS expectations of horse grooms at ECQS

8.77        The Expectation of Grooms document330 was prepared by Mr Hankins in late
            July or early August 2007. It was directed to behavioural matters, rather than
            biosecurity. In addition to being provided to each groom during the induction
            process, copies of the document were laminated and placed in each of the
            rooms and the common area in the grooms’ quarters, prior to the August 2007
            stallion intake.331

Sandown HACCP Manual

8.78        Two privately operated facilities have been approved by AQIS, under section
            46A of the Act, as post–arrival quarantine stations for horses. The Sydney Turf
            Club has a facility at Canterbury in New South Wales which, although approved
            in 2003, has not actually received horses.332 Racing Victoria Limited (“RVL”)
            (and previously its predecessor, the Victorian Racing Club) operates a
            quarantine station for horses at Sandown in Victoria.

8.79        Horses were first quarantined at Sandown in 1993. A purpose built facility
            became operational in 1997, and there have been two such stations in
            operation since approximately 2000. The facilities allow race horses to remain
            in training, using the Sandown race track, while in post arrival quarantine.333

8.80        RVL has developed a Hazard Analysis Critical Control Point (HACCP)–based
            quarantine program for the Sandown facility, set out in a manual (“the HACCP
            Manual”).334 The manual has been approved by AQIS.335

8.81        The purpose of the program is expressed in the HACCP Manual to be:

                   to conduct a hazard analysis of risks at each step of the quarantine
                   management program for international horses attending the Victorian
                   Spring Carnival, identify critical control points where hazards may occur
                   and develop control, monitoring, corrective action, documentation and
                   verification procedures to minimise any possible risk from exotic diseases
                                                                               336
                   of horses on a site where dual quarantine stations operate.


327
      AQIS.0001.001.0059.
328
      T1468.
329
      T338.
330
      AQIS.0002.014.0044.
331
      WIT.AQIS.012.0001 at 49.
332
      WIT.DAFF.002.0001 at 14 and 19.
333
      WIT.SAND.001.0001 at 4 – 6, 19 and 20.
334
      SAND.0001.001.0012 - 0124.
335
      WIT.SAND.001.0001 at 21 and WIT.DAFF.002.0001 at 17.
336
      SAND.0001.001.0014.


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                                                                                               SUBS.INQ.001.0066




8.82        Equine influenza is identified as a disease of quarantine concern in the
            description of hazards contained in the manual,337 and the hazard analysis table
            in the manual identifies points at which the transmission of equine influenza
            could occur and the control measures applicable.338

8.83        The HACCP Manual also contains standard operating procedures designed for
            different categories of persons accessing the site or for different operational
            issues which may be encountered.339 The standard operating procedures are
            generally more detailed than those in AQIS’s Live Horse Work Instruction.
            Further, in a number of respects the standard operating procedures in the
            HACCP Manual give rise to more stringent biosecurity measures than the
            procedures required by the Live Horse Work Instruction. Some examples are
            as follows:

            (a)         Upon horses arriving at the facility, RVL quarantine officers are required
                        to stress the need for all visitors to the quarantine station to follow
                        disinfection procedures and adherence to all standard operating
                        procedures; and, the first morning after arrival, are to check that all
                        persons have understood and are complying with those procedures.340

            (b)         A guard is stationed at the facility—24 hours per day, 7 days per
                        week.341 The standard operating procedure requires the guard to ensure
                        that entry to the facility is restricted to authorised persons (persons
                        authorised by AQIS to enter, upon submission to AQIS of the person’s
                        name by RVL),342 with a list of such persons being kept at the entry area.
                        The entry/exit log must be completed and signed by all persons entering
                        the facility.343

            (c)         Guards are also required to familiarise themselves with the standard
                        operating procedures for grooms, private vets and farriers and, where
                        possible, to ensure all procedures are followed; and, particularly, to
                        ensure that private vets and farriers shower prior to leaving the facility.
                        Guards are also required to ensure that horse gear and other equipment
                        is not removed from the facility.344

            (d)         As with the Live Horse Work Instruction, the HACCP Manual standard
                        operating procedure requires grooms to take, and record, the rectal
                        temperature of the horses twice daily. In addition, quarantine officers
                        are required, for the first four days of the post–arrival quarantine period,
                        to take steps to ensure the temperatures recorded by the grooms are
                        correct - for example, by recording the temperatures and comparing
                        those temperatures with those recorded by the groom. For subsequent


337
      SAND.0001.001.0022.
338
      SAND.0001.001.0029 - 0033.
339
      WIT.SAND.001.0001 at 23.
340
      SAND.0001.001.0046.
341
      WIT.SAND.001.0001 at 24.
342
      WIT.SAND.001.0001 at 31.
343
      SAND.0001.001.0047.
344
      SAND.0001.001.0047 - 0048.


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                                                                                             SUBS.INQ.001.0067




                        days, the quarantine officer must check the temperatures recorded by
                        the grooms and make random checks of horse temperatures.345

            (e)         Grooms are prohibited from having contact with horses other than those
                        in the quarantine station during the period of post-arrival quarantine.346

            (f)         A RVL quarantine officer is required to conduct an internal audit against
                        the HACCP Manual once during each period of post–arrival
                        quarantine.347

            (g)         Documentation is required to be completed at various stages - for
                        example, by a RVL quarantine officer following inspection of horse
                        transport vehicles, following quarantine management steps upon horses
                        arriving at the quarantine station and following the internal audit; by
                        private vets following each attendance on a horse and by the security
                        guard each time a person enters or exits the station. Any incidents or
                        non-conformities are to be recorded, and corrective action taken.348
                        After corrective action is taken, monitoring may be increased to ensure
                        that the corrective action is effective.349

IRT Guidelines

8.84        IRT has created its own documents for provision to its grooms serving at ECQS.
            It is relevant that mention be made of them here. The documents do not carry
            the formal approval of AQIS although Ms Dressing, an IRT employee, gave
            evidence that copies of them have been provided to successive managers at
            ECQS since she first drafted them in 1998.

8.85        The only document provided by IRT to all onsite grooms at ECQS during the
            July and August 2007 intakes was headed “Welcome to Eastern Creek
            Quarantine Station”.350 This document primarily deals with housekeeping
            arrangements for the grooms’ quarters. Ms Dressing recalled leaving a copy of
            this document on every bed in the accommodation wing of the grooms’ quarters
            and the three porta cabins.351 Some years earlier,352 IRT had developed a
            different document headed “Guidelines for IRT Representatives and Contract
            Labour Caring for Horses Whilst at the Eastern Creek Quarantine Facility”.353 It
            too dealt largely with housekeeping issues but did also seek to set out some
            procedures of biosecurity concern by including some passages said to have
            been taken from “’the Quarantine Station Operations Manual’”.           Those
            instructions include requirements to ensure:

            (a)         the cleanliness (but notably not disinfection) of equipment used on
                        horses before permitting it to leave ECQS;
345
      SAND.0001.001.0052.
346
      SAND.0001.001.0058.
347
      SAND.0001.001.0040, 0085, 0097 and 0098.
348
      SAND.0001.001.0040 and 0085.
349
      SAND.0001.001.0042.
350
      IRT.0001.001.0021.
351
      WIT.IRT.009.0008.
352
      T505/L33
353
      AQIS.1001.003.0012


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                                                                                             SUBS.INQ.001.0068




           (b)          the twice daily taking of the rectal temperature of each horse;

           (c)          the disinfection of large vehicles before their departure from ECQS; and

           (d)          unauthorised visitors not be permitted entry to the horse quarantine
                        facility.

8.86       Noticeably, there is no reference to showering in or out although there is a
           reference to “all work clothes, shoes and horse gear” remaining in quarantine
           for the duration of PAQ.




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9         THE IMPORTATION OF HORSES INTO AUSTRALIA

9.1         We deal in this part in a broad way with the sequence of events from PEQ to
            PAQ. We deal by way of example with areas which have arisen as being of
            concern and which demonstrate failings either in the policies and procedures
            relevant to the import of horses into Australia or in their implementation.
            Specific details of the importation of the six consignments, of the activities of
            individuals and of the development and adherence to relevant policies and
            procedures is dealt with elsewhere in these submissions.

Importers and the issue of import permits

9.2         The process concerning the importation of any horse into Australia commences
            with the application for an Import Permit. Applications are lodged with AQIS
            usually by the import agent on behalf of the owner. Necessary details on the
            application concern the identity of the horse, its place of PEQ, name of the
            official veterinary service that will supervise the PEQ, and details of the mode of
            travel and route to be followed in bringing the horse to Australia. A fee is also
            payable.354

9.3         Three import agents came to the attention of the Inquiry: International
            Racehorse Transport (“IRT”); Crispin Bennett International Horse Transport
            (“CBIHT”); and New Zealand Bloodstock (“NZB”). The Inquiry received
            evidence from a number of witnesses from IRT and CBIHT, and IRT was
            represented at the hearings. These importers each offer a service dealing with
            most if not all aspects of the transportation of horses across international
            borders including the formalities of obtaining an import permit, road and air
            transport, the provision of airstalls, flying grooms and veterinarians and customs
            clearance, health certification and blood testing.355

9.4         The application is assessed by an AQIS technical officer within the Animal and
            Plant Quarantine Branch. One such officer who gave evidence to the Inquiry
            was Ms Ainslee Brown.356 Prior to the outbreak of equine influenza five officers
            were employed in this or similar capacity. Following the outbreak the number of
            officers with responsibility for this function was increased to nine. That is not to
            say those officers are required to deal exclusively with horses as the bulk of the
            import permits issued by the program (some 8,000 in 2007) are for cats and
            dogs. As Ms Brown explained, less than 2% of applications for import permits
            issued each year relate to horses.

9.5         The application process results in the issue of an Import Permit and
            accompanying conditions. In the case of the import of horses from countries
            other than New Zealand, those conditions include periods of both PEQ and
            PAQ. In the usual example the relevant conditions are drawn from the policies
            developed by Biosecurity Australia we have referred to elsewhere and relevant
            to the country of origin for the horse. To a large extent the conditions reveal
            little difference in the conditions imposed on horses entering Australia from one

354
      WIT.AQIS.014.0005.
355
      WIT.IRT.001.0001; T1368/L18.
356
      WIT.AQIS.014.0001.


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                                                                                        SUBS.INQ.001.0070




           country or another. With only some exceptions which are not presently
           significant, the import conditions for horses in force prior to the outbreak were
           developed during the 1990s and have received only minor amendments since
           then.

9.6        Ms Brown’s evidence was that whilst she considered herself to have the
           relevant power to add to, subtract from or vary the conditions of import
           established by BA, she rarely did so and even then to a minor degree only.
           Thus, the airport conditions ordinarily imposed tend to mirror the matters set out
           in the import policy developed by BA for that country.

9.7        The usual form of conditions for the permanent import of horses (as the import
           of the shuttle stallions is classified) require vaccination against diseases of
           concern to Australia; isolation in an approved PEQ facility and upon arrival at a
           government PAQ station; testing for a range of equine diseases; treatment for
           internal and external parasites; and certification that the conditions of import
           have been met by the home authority in the country of export.

PEQ

9.8        Before entering into Australia each horse is to spend a specified period of time,
           ordinarily 21 days, at an approved PEQ facility in the country of origin.

9.9        These facilities are, by and large, privately operated, including by some of the
           larger studs. This was the case for example with the Coolmore stallions that
           travelled to Australia from Ireland in August 2007 which had spent their PEQ at
           the Fairy King and Prospect farms owned by Coolmore in County Fethard,
           Ireland.

9.10       Evidence was received from a number of witnesses with direct experience of
           PEQ facilities in Ireland, the United Kingdom, Japan and the United States.
           That evidence demonstrates only minor variance in the approach to quarantine
           around the world. What they do tend to highlight however – perhaps a product
           of the endemic nature of equine influenza in countries other than New Zealand
           and Australia – is that by and large the precautions taken are insufficient to
           adequately ensure the risk that equine influenza is transmitted between horses
           in PEQ is minimised.

9.11       No effort is taken, for example, to ensure farriers, veterinarians or other people
           attending horses in quarantine shower before entering, or, just as importantly,
           leaving the PEQ station. Hand washing and stepping through foot baths is a
           regular practice but as became apparent during the course of this Inquiry,
           entirely inadequate to prevent the spread of a virulent disease such as equine
           influenza. Similarly, no regular procedure is employed to ensure any equipment
           used on or by horses is disinfected so as to minimise any risk it poses to the
           containment of the disease. There was no evidence that overseas veterinarians
           took particular care for example to decontaminate themselves or their
           equipment between horses nor any evidence to suggest that was a procedure
           enforceable at any PEQ station. A similar observation may be made of the
           evidence concerning the farriers. Attendance by farriers on horses whilst in



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           PEQ appears common enough. Ms Cushing for example357 gave evidence she
           would arrange for a farrier to attend, occasionally in the days approaching
           departure, to clean and tidy the horses hooves, even if only for presentation
           purposes. No criticism can be directed towards Ms Cushing for doing so, but it
           does highlight the potential difficulties associated with non-essential visits to
           horses within PEQ where those visitors are not also subject to an appropriate
           decontamination process. Farriers in particular demonstrate that risk, working
           as they do so near to the horse’s mouth and nostrils. There seems little doubt
           that any horse, even a vaccinated one, shedding equine influenza, will deposit
           droplets of the virus around the head and shoulders of its farrier. If that farrier
           does not shower between horses within the same station – as it seems is
           always the case – there is a very high likelihood that the next horse will inhale
           the virus during the course of any work done on it.

9.12       Equally, the close contact had by grooms with horses and the fact they will
           ordinarily work on at least on occasion during the course of the PEQ with more
           than one horse at the station, means they too are a likely source of cross-
           contamination whilst there. Absent a regime of isolation of grooms and horses
           and of showering as a means of preventing cross-contamination, the quarantine
           methods employed both overseas and in Australia do not appear to adequately
           address these particular risks.

9.13       That is not to say that conduct of the PEQ neglects basic health and quarantine
           protocols. Horses are regularly examined by local and in some cases
           Government veterinarians in an effort to monitor their health. This is particularly
           relevant it seems in the case of temperature monitoring which is undertaken on
           a daily basis and which is regularly cited as an important health oversight.

9.14       Equally, care appears also to be taken during the PEQ period to ensure the
           sterilisation of all transport vehicles, feed, shavings, equipment and luggage,
           including during the transport of the horses to the airport. Most of the witnesses
           relevant to the carriage of the Coolmore horses from Ireland and Japan for
           example, spoke of the cleanliness of the vehicles used to transport the horses
           to the airport for their departure to Australia and the presence of Government
           officials during that process.

9.15       These steps notwithstanding, inadequate precaution it seems is taken against
           the possible spread of the equine influenza virus overseas. As we have noted
           elsewhere equine influenza is endemic in most other nations importing horses
           into Australia and is a particularly virulent disease. It may be spread easily and
           a quarantine protocol involving washing hands and stepping through foot baths
           only is ineffective to ensure the high risk of spread is minimised. That is not to
           say that that risk cannot be minimised. Soap and water alone can be sufficient
           to destroy the virus. The point is that the most prevalent means of spreading it,
           by aerosol, is regularly overlooked or underestimated. This is particularly the
           case in those PEQ stations that are either part of a farm holding non-
           quarantined horses (in which the risk of windborne spread theoretically exists)
           or which permit the unrestricted access of grooms, visitors and other handlers
           to the quarantine area without a “shower in, shower out” regime in place. Such

357
      WIT.COOL.003.0001.


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           scenarios make it quite possible for horses to become infected as late as the
           proposed day of departure from PEQ, bringing the consequence that it will
           arrive in Australia, shedding the virus, but perhaps without also being
           symptomatic.

9.16       At the completion of the PEQ period the horses are transported to the airport
           where they are loaded into airstalls and onto the aircraft. It is not unusual for an
           aircraft to be carrying horses that have served their PEQ at different stations.
           This further highlights the potential for cross-contamination, which, if it occurs,
           serves only to complicate the identification of any horse carrying the virus upon
           its arrival into Australia.

9.17       Each horse is required to travel with its passport and the various health and
           vaccination certificates required by the import conditions. These are given to an
           AQIS officer following arrival for their subsequent assessment for compliance.

9.18       The prospect that a horse might become infected between the PEQ station and
           its arrival into Australia does exist although it appears unlikely except by cross-
           contamination from an infected horse sharing the aircraft space. It is
           theoretically possible for example, that ground staff at the airport responsible for
           loading the airstalls could if they had recently contacted an infected horse
           shedding the virus outside the airport, come so near to the opening to the
           airstall near to the horses mouth and nostrils, that the virus be deposited there
           by them only to later be inhaled by the horse causing it to become infected.
           Similarly, the evidence suggests that the air crew (if themselves contaminated
           with the virus) may present a risk should they walk into the cargo space during
           the course of the flight and come near enough to the airstalls and the horses
           inside them. There is no real suggestion such a source of contamination was
           relevant to the August 2007 outbreak, however it does serve to reinforce the
           message that all horses should be treated on arrival as if they were infected and
           shedding the virus.

9.19       Once on the aircraft the risk of cross-contamination is obvious. The airstalls are
           packed closely together and, whilst ordinarily holding only one horse, an airstall
           is capable of holding up to two horses. They are only partially enclosed and, as
           might be expected, a flow of air through them is encouraged. On occasion
           grooms will enter an airstall to be with a horse, often doing so during take off
           and landing.

9.20       During the course of the flight grooms will share the task of monitoring the
           horses. Thus, apart from the obvious airborne route of transmission of the virus
           inside the cabin, the prospect also exists that the virus might be transferred by a
           groom as he or she moves about the cargo hold coming into contact with
           several horses, their airstalls and their feed and equipment.

9.21       The journey to Australia usually involves a stop over at one or more locations.
           The evidence did not indicate that on any of those occasions other horses were
           taken on board although that is not to say that has never occurred. Further
           details of this and other more particular aspects relevant to the transportation of
           each consignment here is set out below.



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9.22        During a stopover the horses remain on the aircraft. Grooms and others
            attending the horses, such as the vets, may come and go and the occasion is
            normally used to collect fresh water and for the passengers to stretch their legs.

9.23        In the case of consignment six bringing horses from Japan to Sydney via Hong
            Kong and Melbourne, further cargo was taken on board in Hong Kong
            necessitating the movement of the horse stalls within the cargo space.358 As
            with the example of the loading of the horses at the point of embarkation, it is
            theoretically possible that this represents a point of contamination.
            Circumstances suggest that it is unlikely that any horse was infected during this
            process in August 2007 (it relies entirely upon the virus being carried onto the
            aircraft by a person or on cargo that comes close to a horses nose or near
            enough to a groom for subsequent transfer, or by being carried on by air), but
            the fact that transportation occurs in this way reinforces the notion that there
            can be no certainty that the journey poses no risk to the integrity of the
            quarantine program.

9.24        Following arrival in Australia several procedures are expected to occur within a
            relatively narrow space of time.

9.25        Immediately upon arrival the aircraft is boarded by AQIS and Australian
            Customs officers whose task it is to ensure the “clearance”359 of passengers
            and crew. There is some uncertainty however, about the task required of the
            AQIS officers. This was particularly evident in relation to consignment six. The
            evidence suggests360 that it is usual for aircraft to be cleared for both quarantine
            and customs purposes at its first place of landing in Australia. In the event of
            consignment six that place was Melbourne, however the flight was not cleared
            either there or in Sydney by AQIS airside officers. The evidence of Ms
            Bucciarelli, a customs officer who had boarded that aircraft was that she
            advised a female AQIS officer on the tarmac that the plane had arrived and that
            there were grooms on board. The female AQIS officer (whose identity was
            never confirmed), apparently told Ms Bucciarelli that she did not need to enter
            the aircraft as it had already been cleared in Melbourne and was being treated
            as a domestic flight.361 The consequence of that failure to attend the aircraft
            was that the aircraft was not examined to ensure it had been disinsected before
            arrival, none of the passengers or crew had their person, clothing or luggage
            inspected or cleaned, nor were the declarations on the incoming passenger
            card read and considered for their quarantine implications.

9.26        Once the aircraft has been cleared the process of unloading each airstall
            commences. This again involves the cooperation of airport or airline ground
            handling staff who otherwise have no relevance to the importation of the horses
            and, none of whom it seems are themselves subject to any formal
            decontamination process. It is possible that one of them could come near
            enough to an infected horse or perhaps contact part of the airstall upon which
            the virus had been deposited and then carry the virus into the general horse

358
      WIT.COOL.003.0001.
359
      “Clearance” in this sense may be taken to mean the questioning, inspection and where necessary
      disinfection of a person and their luggage to ensure compliance with quarantine protocols.
360
      T695/L33.
361
      T696/L14.


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            population. There is however no evidence to support any suggestion that such
            a hypothesis would be more than the expression of mere possibility here. Apart
            from anything else the timing of the arrival of the horses does not for reasons
            we have expressed elsewhere, speak of any contamination of horses in the
            general horse population as early as 9 or 10 August 2007. What is relevant
            about the issue however is that it seems not to have been appreciated by most
            involved in the transport of horses in Australia just how potentially easily spread
            of equine influenza can be particularly in a fully susceptible population. Several
            surfaces including skin and clothing can act as an effective fomite for the
            carriage of the virus and continue to be so in appropriate conditions for up to 48
            hours.    Vigilance in observing proper precautions and decontamination
            techniques is therefore a significant part of the process of ensuring this virus
            does not again enter Australia or escape into the general horse population.

9.27        The airstalls are unloaded by moving them through the cargo hold onto scissor
            lifts and ultimately onto trolleys which are pulled by a small tug to a livestock
            transfer facility (LTF) for unloading. At SKSA this is a journey of some several
            hundred metres. At Melbourne airport it ordinarily occurs reasonably near to
            the aircraft given there is no dedicated transfer facility there.

9.28        Once inside the LTF one of the attendants lowers the side of the airstall
            enabling the horse to be lead by a groom – usually a “flying groom” who has
            travelled with the horse, in the airstall, from the aircraft to the LTF – more or
            less directly into one of the waiting horse transporters. The stalls, once cleared
            of any luggage are then driven to a nearby storage area before they are
            wrapped in plastic and removed to a disinfection facility. The Inquiry received
            evidence about this process. There is no evidence to suggest the virus
            escaped by any failure of it.

9.29        The horses are inspected briefly by the AQIS veterinary officer (Dr Widders or
            Dr Hee Song) at the LTF. Generally speaking, however, a proper examination
            of the horse and its health certificates is only carried out after arrival at ECQS
            and even then not all that regularly: Dr Widders for example, gave evidence that
            he has not undertaken a full clinical examination of horses at ECQS for a
            number of years.362 He said that he had neither the time nor the resources to to
            so.363 The examination of the paperwork may occur some days later and the
            checking undertaken at the airport may not even include assessing whether the
            horse had a valid import permit.364

9.30        The tasks that ought be performed by AQIS airside officers at the airport are
            important ones. Whilst it is not expected that they have any role in relation to
            the horses (that being a role for the AQIS veterinarians Dr Widders and Dr Hee
            Song), they are the only persons responsible for the screening of people,
            luggage and equipment that has arrived with the horses and not travelling to
            ECQS. The evidence revealed a number of inadequacies in the preparation of
            AQIS officers to carry out this task and the manner in which it was carried out in
            any event.

362
      T1209/L10.
363
      T1209/L46.
364
      T678/L33.


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9.31        First, the system by which AQIS is made aware of the arrival of aircraft carrying
            horses is insufficient it seems to ensure each flight is correctly cleared. At least
            two examples of this failure appear from the evidence, the first being the
            occasion cited above on which the passengers and crew from consignment six
            were not cleared by AQIS airside officers at all. The second is an example
            given by Mr Gallagher, an AQIS airside officer, who recalls attending the arrival
            of a cargo freighter on 3 August 2007 that was found unexpectedly to him at
            least, to be carrying live horses.365

9.32        Secondly, the training and education of AQIS airside officers appears
            insufficient to ensure they are aware of even the most basic precautions to be
            taken against the spread of equine influenza. Few if any of the AQIS airside
            officers who gave evidence knew anything about the risks presented by equine
            influenza and few had received any formal induction to their task; an informal
            system of education by “buddying” appearing to be the most common form of
            training offered.

9.33        Thirdly, there is some confusion about where the AQIS airside officers are to
            perform their function of checking clothing, luggage and equipment. Mr
            Gallagher for example366, does not consider it necessary for a quarantine officer
            in the airport program to attend the LTF rather than clearing passengers, crew
            and their luggage on the plane itself. The primary difficulty that became
            apparent with this approach was that some of the luggage and equipment, far
            from being readily accessible to AQIS officers on the aircraft, was kept with the
            horses in their airstalls or packed in a spare airstall or container and revealed
            only once the aircraft has been unloaded and the equipment and luggage made
            available to its owner at the LTF. Furthermore, there appears little utility in
            cleaning any luggage or equipment that is only going to be collected in the LTF
            with other, potentially unchecked equipment handled by grooms after they have
            had contact with the horses during their unloading.

9.34        Fourthly, it is clear that on occasions no proper attempt was made to clear
            passengers, their luggage or equipment at all, either because no AQIS airside
            officers attended at the LTF or because if they did so they did not undertake a
            thorough inspection or undertake any task that would have properly
            decontaminated an infected person or object. Mr Cornter, a senior IRT
            employee who has attended at SKSA several times considered procedures at
            the LTF to be inconsistently followed by AQIS officers.367 Much of the
            procedure it seems was concerned with scrubbing boots, washing hands and
            spraying horse equipment. As is set out elsewhere the equine influenza virus
            can survive for long periods on clothes, hair, skin and a variety of other
            surfaces, none of which received any real attention in the disinfection regime
            that was described by the AQIS airside officers who gave evidence to the
            Inquiry. This is particularly significant in the example of grooms who had
            travelled with the horses on the aircraft but do not then travel to ECQS. The
            possibility exists that unless decontaminated at the airport, anyone of them
            could carry the virus into the general horse population. Fortunately, some of the

365
      WIT.AQIS.003.0001.
366
      WIT.AQIS.003.0005.
367
      T525/L28.


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                                                                                               SUBS.INQ.001.0076




            grooms who regularly travel away from quarantine at the airport are conscious
            of the risk themselves: Mr Bruce “Snow” McDonald for example goes to some
            particular effort to change out of his clothes at the airport, keep them separate
            from the rest of his luggage, wash and disinfect with a disinfectant solution on
            arrival at his home and take care to avoid other horses during this time.

9.35        There is no evidence to suggest that the August 2007 outbreak was caused by
            the virus having escaped from the LTF on a person or equipment, however the
            point to be made is that the procedures in place and the ordinary activities of
            AQIS airside officers would not adequately prevent against this occurring in the
            future.

9.36        There are some other aspects of SKSA and activities there that require
            mention:

            (a)         There are a large number of entrants to the airport areas who are not
                        essential to the transport of the horses. It appears commonplace for
                        some of these people to enter the aircraft before it is unloaded and to
                        come, later, into contact with horses, their airstalls, grooms and their
                        luggage and equipment. Video footage shown to the Inquiry of the
                        arrival of consignment three includes for example at one point quite
                        revealing images of a person’s hands passing directly in front of a
                        horses’ mouth and nostrils before unhooking and lowering the airstall
                        door. That person is apparently a visitor to the airport, perhaps an
                        owner or a person associated with the import agent. If that horse were
                        infected and shedding the virus there would be a good likelihood it
                        seems, that the virus would have passed to that person’s skin or clothing
                        for possible carriage out of the airport, and potentially into the general
                        horse population. Unlike the drivers of the horse transporters these non-
                        essential entrants are not given any dedicated clothing to wear and
                        notably are only rarely subject to scrutiny by the AQIS airside officers. It
                        is common for them also to offer lifts to grooms and veterinarians who
                        have travelled with the horses, out of the airport and to destinations
                        other than ECQS. As we have noted elsewhere this is a technically
                        possible route for the escape of the virus, although it appears not to
                        have been a likely cause in relation to the outbreak with which this
                        Inquiry is concerned.

            (b)         The AQIS veterinary officers who are ostensibly responsible for what
                        occurs in the LTF are unaware of their powers in relation to control over
                        that facility. Dr Hee Song noted that the growing numbers of additional
                        persons inside the LTF was a problem and one that he had taken up
                        with one of the major importers, Mr Wallace.368 Dr Widders gave
                        evidence that there had been some but unresolved debate about the
                        powers to exclude non-essential entrants to that facility.369 He operated
                        on the basis that he did not have that power.370 Furthermore, the
                        consequence of permitting entry to the LTF to persons who have no role

368
      T608/43.
369
      T609/3; T637/46; AQIS.2005.085.0005.
370
      T1012/25; T1017/38.


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                        to play in the unloading of the horses is a material non-compliance until
                        the work instruction – Clearance of Live Horses.371 Dr Hee Song
                        considered compliance was impossible.372 That probably overstates it.
                        The more accurate account is probably that a practice of permitting too
                        many entrants into the LTF had become so entrenched that it had
                        become easier to allow it to continue than to bring it to an end.

           (c)          The drivers of the horse transporters appear careful to ensure the
                        interior of the horse box is cleaned and disinfected before arrival at the
                        airport. They are also required by the AQIS veterinary officer in
                        attendance, to wear overalls and to keep them on until their departure
                        from ECQS. The same video footage referred to above shows drivers
                        getting quite close to the horses during the process of them being
                        loaded into the transporter, including by placing their hands upon the
                        horse’s hindquarters in order to guide it into its stall. What is perhaps
                        more significant about the involvement of the drivers is that, including by
                        their own admission, they invariably get close enough to the horses
                        during their loading and unloading to be breathed upon by them and to
                        come to touch enough of the interior of the horse compartment that
                        undoubtedly has been breathed upon by the horse, that they most
                        certainly present as a real risk of acting as a carrier of the virus. By
                        chance, the drivers also undergo a decontamination process of sorts by
                        the time they are ready to exit ECQS when they undertake the task of
                        spraying the interior of the horse compartment with a disinfectant
                        solution, a task one driver described as resulting in him receiving a
                        noticeable covering of the solution from head to toe.373 However there
                        are two reasons this should not be considered of itself a reason to
                        believe the drivers or their vehicles present a lesser risk: first, on
                        occasions, drivers assist each other in disinfecting their vehicles and it is
                        not necessarily the case that a driver leaves ECQS having doused his
                        vehicle and therefore himself, in disinfectant solution. Secondly and
                        perhaps more importantly, drivers do not as a matter of course disinfect
                        the front cabin or the strappers cabins in the rear of the horse
                        compartment, areas that, because they are used by grooms and to
                        transport luggage from the airport to ECQS could well become areas
                        where the virus is deposited.

                        That having been said it appears unlikely that an improperly disinfected
                        horse transporter or a driver was the source of the outbreak. As we set
                        out in particular detail elsewhere, each transporter was used again in the
                        24 – 48 hours after their use to transport horses to ECQS, meaning that
                        if a horse subsequently transported were to have become infected its
                        illness would have been obvious and the virus spreading through the
                        general horse population much earlier than it was eventually detected –
                        perhaps as early as 11 or 12 August. Furthermore, if the proposition is
                        accepted that it was one of the horses in consignment six that brought
                        the virus in to Australia only two transporters are relevant for

371
    AQIS.0001.001.0011.
372
    T630/26; T637/4.
373
    T2632/L36.


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                                                                                              SUBS.INQ.001.0078




                        consideration – Mr Craig Atkinson’s and Mr Edwin Clarke’s. Mr Atkinson
                        drove to the Coolmore farm after taking Stravinsky and Rock of Gibraltar
                        to ECQS. The transporter was not used again until 24 August374 and
                        equine influenza did not arrive at that farm until 28 September 2007.375

                        Although Mr Clarke had no recollection of having transported horses on
                        8 August 2007, company records demonstrate that his transporter was
                        used in the Gosford area the following day. Even allowing for a several
                        day incubation period in any domestic horse that could have contracted
                        the virus from Mr Clarke or his vehicle (bearing in mind the very real
                        probability that at least the horse compartment had been disinfected the
                        day before and that Mr Clarke himself would most certainly have
                        showered in the meantime) that horse would most likely have been
                        infected and shedding the virus from about 12 August 2007. Given there
                        was no reported case of an ill horse until the Maitland Event
                        commencing on 17 August 2007 and given the speed with which the
                        virus spread thereafter, that some other horse was infected in the
                        general horse population as much as four or five days beforehand
                        seems unlikely.

            (d)         The airport itself has only basic features for the housing of horses. The
                        LTF is a relatively small space within the confines of the greater airport.
                        Much of its area is taken up by a bitumen landing where the horse
                        transporters are parked. There is a stable which can house a small
                        number of horses, a ramp from which the horses are unloaded from the
                        airstalls and a small demountable office used by the AQIS veterinary
                        officers, Dr Hee Song and Dr Widders. It provides no facility, practically
                        speaking, for the treatment of any injured horse or in which a horse
                        might be held for the purpose of examining it other than in a fairly simple
                        way.

            (e)         Whether entrants to the LTF are consistently given clear instructions
                        about biosecurity measures (primarily that, if not wearing overalls they
                        should shower and change their cloehtes before coming into contact
                        with other horses) is uncertain. Mr Tom Magnier and Mr Adrien O’Brien,
                        both senior employees of Coolmore and who, in Mr O’Brien’s case at
                        least, are regular attendees at SKSA for the arrival of the horses deny
                        being given any such instructions by Dr Widders or Dr Hee Song.376
                        Mr Julian Cornter, a senior employee of IRT however, admitted such a
                        warning had been given to him.377 Dr Hee Song gave evidence that he
                        did not give such a warning to all entrants.378 It appears to have been an
                        instruction developed some year ago to impress the issue upon one
                        particular entrant and at that time included the completion of a written
                        declaration to that effect.379


374
      WIT.COOL.005.0001.
375
      WIT.COOL.014.0001.
376
      T577/L4; T584/L30.
377
      T529/L22.
378
      T599/L13.
379
      AQIS.2005.085.0003.


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                                                                                               SUBS.INQ.001.0079




            (f)         BA had never, prior to the outbreak been asked to review biosecurity
                        arrangements at SKSA, nor for that matter ECQS. When requested to
                        do so, Dr Nunn reported “the impression gained from this inspection is
                        that the arrangements in place at the animal handling facilities for
                        unloading and transport of horses at Sydney Airport, particularly in
                        relation to SOP’s and awareness of biosecurity, require further
                        consideration and enhancement”.380

Foreign PEQ facilities

9.37        For a period ending some 15 or more years ago, a regular inspection of the
            foreign PEQ facilities was commonplace.

9.38        It is not entirely clear when or why this process ceased. Both Dr Patricia Ellis
            who at one time carried out such inspections and Ms Pauline Cushing who has
            considerable experience at PEQ stations over more than 20 years, believe it to
            have been in the early 1990s. Between 1989 and 1993 Dr Ellis travelled to
            PEQ stations and to the transfer facilities at the airports in a number of
            countries. Her role in conducting these inspections was as an AQIS veterinary
            officer and representative of the Australian government for the purpose of
            carrying out these inspections. She and others performing this role would also
            travel on the aeroplane with the consignment to Australia. It was a process that
            had its obvious advantages: it permitted the direct observation by an Australian
            veterinarian of the health of the horses to be imported and the adherence to
            import conditions at the station and it allowed for the relevant person to travel
            with the horses to Australia and to directly observe the horses during this time.
            Such observations would include the matters set out in the import conditions
            and which are not it seems, always strictly met.

9.39        Example may be found in the import condition relevant to Rock of Gibraltar and
            Grandera from Japan.381 Mr Basil Keane is a yearling manager for the
            Coolmore Stud in Australia. He spent some seven or eight weeks with Rock of
            Gibraltar before and during his PEQ which commenced on 17 July 2007 at the
            Japanese Bloodhorse Breeders Association Stallion Station (“JBBA”) at
            Shizunai on the Japanese island of Hokkaido. That JBBA Station is one of four
            of its kind in Japan that operates premises for the pre-export quarantining of
            horses within what is otherwise a thoroughbred horse farm. Mr Keane gave a
            detailed description of the farm and produced a diagram mapping the various
            elements of it and their proximity to each other. Mr Keane noted as follows:382

                   The particular area used by Rock of Gibraltar had a barn, beside which
                   was a small residence and a fenced turnout area. The entrance to the
                   quarantine area was protected by a plastic tape marked ‘do not pass’ but
                   otherwise no particular physical barrier separated the quarantine area
                   from the remainder of the farm. Staying with Rock of Gibraltar was
                   Stravinsky who was being cared for by a Japanese groom, I stayed inside
                   the residence for the duration of the quarantine period. I left the
                   quarantine facility from time to time to go into the local town. On these

380
      AQIS.0002.012.0042.
381
      IRT.0001.004.0077.
382
      WIT.COOL.003.0001.


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                                                                                               SUBS.INQ.001.0080




                   occasions I never had any contact with horses outside the quarantine
                   facility.

9.40        Mr Keane also gave the following evidence:

            (a)         That the horse Stravinsky which completed its PEQ at the same facility
                        was attended by more than one groom from the station, and the station
                        manager who was also a veterinarian. Mr Keane believes they left the
                        quarantine area in the same clothing in which they entered and that it
                        was his observation that they did not always wash their hands and feet
                        before they did so.383

            (b)         Mr Keane himself did not wear any dedicated clothing although as he
                        notes his justification for doing so was that he was resident at the station
                        and changed clothes before leaving for any reason.384

            (c)         That horses were walked some distance from the quarantine area to the
                        loading ramp in the general area the farm before transport to the
                        airport.385

9.41        The significance of these matters is that they suggest the observation of
            practices at Shizunai Station are inconsistent with the terms of the Import
            Conditions for horses held there which required:

            (a)         At paragraph 7 under the heading of “Operation” that “personnel
                        attending the horses must wear outer clothing and footwear used
                        exclusively in the premises during PEQ, and wash hands, before
                        handling the animals”.

            (b)         At paragraph 1 under the heading of “Facilities”, the premises must be
                        surrounded by “two stock-proof fences at least five metres apart except
                        where the wall of a building forms part of the perimeter”.

9.42        Further example of a failure to observe the import conditions lies with the issue
            of the health certificate for the stallion Elusive Quality.386 It was executed
            according to the face of the document on 2 August 2007 for the purpose of
            declaring events – important events concerning the horses treatment for ticks –
            on 3 August 2007. It is a certificate given in respect of a matter that had not
            happened at the time the certificate was given.

9.43        There was no explanation for this inconsistency, however that is not a matter of
            relevance for the present purposes, the point of it is to highlight the fact that at a
            time when Australian officers were in attendance for the PEQ, loading and
            transportation of every horse, such discrepancies were capable of being found,
            investigated and corrected before the horse left the country of embarkation.



383
      T812.
384
      WIT.COOL.003.0001 at para 6.
385
      WIT.COOL.003.0001 at para 8.
386
      AQIS.2002.027.0022.


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9.44        Regular inspections of PEQ premises to test their functioning against
            appropriate procedures is a feature of the quarantine system that has not been
            evident for some years. Ms Ainslee Brown’s evidence was that there had not
            been a regular practice of inspection during the time of her employment (since
            2002). Mr Ironside said that to do so would require additional staff resources
            and would only be in “exceptional” circumstances,387 although it seems he was
            not directed to the fact of there being qualified veterinarians at the Australian
            Embassies in Brussels, Washington, Seoul, Tokyo and in the United Arab
            Emirates.388

9.45        To reinstate a system of full time inspection and travel with horses would
            require undoubtedly a considerable increase in resources, particularly given the
            far greater number of consignments now arriving in Australia than in the early
            1990s.389

ECQS

9.46        Events upon the arrival at ECQS of the six consignments with which the Inquiry
            was concerned must be viewed a little differently from the other more regular
            arrivals throughout the year. In August 2007 the PAQ intake was comprised
            almost exclusively of the shuttle stallions as they are also known. Of the
            approximately 13 quarantine intakes of horses each year, only one or perhaps
            two are reserved for these stallions. They are in the main extremely valuable
            horses that divide their year between the northern and southern hemispheres.
            They travel with a large following of attendants, mostly grooms, and place a
            significant demand on the services at ECQS.

9.47        ECQS has only a limited capacity to house grooms and others wishing to be
            with the horses during the quarantine period. Inside the equine enclosure at
            ECQS there is a small building referred to as the grooms’ quarters which can
            sleep eleven and which provides living and kitchen facilities as well as a space
            reserved for the use by and storage of equipment by veterinarians. During the
            shuttle stallion intake however, it is necessary for this facility to be
            supplemented with portable cabins in which on this occasion at least a further
            seven grooms were required to sleep.390

9.48        On the adjacent fence line between the equine enclosure and the dog and cat
            enclosure is an amenities block. It has a small kitchen and eating area at one
            end and shower and toilet facilities at the other. For many years it was
            available for use by visiting veterinarians and farriers to shower in. The
            circumstances in which it came to be closed to that access are discussed
            below.

9.49        The stables are set out in rows, six in all, capable of holding 90 horses. Behind
            each stable there is a small turnout yard and there are also exercise yards

387
      T346/L1; WIT.DAFF.002.0001, para 61.
388
      T2601/L37.
389
      Since 1998 excluding horses from New Zealand, the number of horses imported into Australia has
      fluctuated between approximately 500 and 750 with an exceptional peak in 2006 of some 897 horses.
      WIT.DAFF.0002.006, para 44.
390
      AQIS.1000.058.0001.


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                                                                                             SUBS.INQ.001.0082




            throughout the equine enclosure as well as a surgery facility and areas for the
            collection and removal of feed and waste. The enclosure itself is surrounded by
            a high chain linked fence although it appears the case that the principal gate
            into that enclosure was not kept locked. That is not of particular concern given
            that the gate leads only into a larger, secured area of the station. To enter and
            leave ECQS it is necessary to pass through two locked gates, the first being the
            main entrance at the roadway, the second being through or via gates adjacent
            to, the administration building some several hundred metres inside the
            entrance.

9.50        The major daily tasks for grooms are the talking and recording of temperatures,
            the exercising of the horses and the cleaning of the stables. In the past the
            recorded temperatures were capable of being monitored by Dr Widders and his
            staff from off-site: a matter Dr Widders considered important to the monitoring of
            horses health. That was stopped when Ms Christesen, who had assumed the
            task of entering the figures into a spreadsheet was told her time could be better
            utilised on other tasks.

9.51        Grooms and others residing at the station temporarily are provided with the
            necessary keys and swipe cards to enable them to come and go as they
            please. For other visitors, however, it was in August 2007 at least, necessary to
            either obtain entry through the administration building or more commonly with
            the assistance with one of the temporary residents.

9.52        Access to and from the equine enclosure became a significant feature of the
            evidence before the Inquiry and was the source of some tension in the evidence
            between what should have been done and what in fact was done.

9.53        We have set out elsewhere a description of the procedures in place at ECQS at
            the time of the outbreak. As we note there, that process was to include an
            induction of each groom during which their responsibilities whilst on the station
            were set out. There was a considerable doubt however, whether those
            inductions were conducted or perhaps appreciated with the requisite interest: at
            the very least the directions in them were not closely followed. We cite the
            following examples in support of these remarks:

            (a)         Ms Kim Maguire, a groom engaged by CBIHT and a regular resident at
                        ECQS during the shuttle stallion intakes could not remember whether
                        she had received an induction in August 2007 or not.391

            (b)         Mr Wayne Chapman, a Darley groom attended at ECQS for the first time
                        on 7 August 2007. He departed the following day but returned after the
                        outbreak. His induction it might be thought as a first time visitor was
                        more important than that to be given to those such as Ms Maguire who
                        had been there several times before. He says he was given a document
                        to sign by Mr Hankins but was given only as part of a group, “a brief talk
                        about it, just to say ‘read through it and tick the boxes as you read
                        through it’”.392 Similar remarks were said by Ms Christesen to another

391
      T1311/L14.
392
      T1273/L35; WIT.DLYA.003.0003, para 12.


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                                                                                              SUBS.INQ.001.0083




                        groom Mr Brad Bowd.393 Mr James Carey, a Coolmore groom
                        recognised the relevant document when it was shown to him but says
                        that he only scanned it.394 Mr Gared Walsh also a Coolmore groom, had
                        no memory of it.395 When it was shown by Ms Christesen to Ms
                        Maguire, she (Ms Christesen) did not explain its contents in the
                        knowledge that Ms Maguire had seen it so often before.396 Ms Maguire
                        however says that she “did not read it, rather just signed it and gave it
                        back”. When examined about the document she said she had little
                        recollection of its contents.397 The document is AQIS.1000.003.0007. It
                        informed grooms that they are, among other things, to sign a register on
                        each occasion they left the station. Mr Chapman left the station on the
                        evening of his first visit without signing the register. He says he did not
                        see it but admitted that he had not gone looking for one either.398 He
                        was not alone in that respect: Ms Maguire signed it only occasionally; 399
                        so to another experienced IRT groom, Mr Tetsuhito Hirose.400 Ms
                        Cushing whose attitude to quarantine is without question said the
                        existence of the book had initially been explained to her as being
                        relevant to fire safety but was simply not always available. This was of
                        obvious concern to her and she raised it and a general lack of respect by
                        grooms for adherence to the rules with Ms Christesen.401 There can be
                        little suggestion of failure to sign the visitors book was causative of the
                        outbreak. What is relevant about drawing attention to this issue
                        however, is that it is indicative of a confused and inconsistent procedure
                        at ECQS. Confused because the rationale of adherence to it is not clear
                        (meaning thereby that some will consider the procedure unnecessary to
                        follow) and inconsistent in both enforcement and in the regularity in
                        which it was followed.

            (c)         The procedures in relation to visitors other than veterinarians and
                        farriers is less clear. Mr Cornter, one of the senior representatives of
                        IRT who has been attending ECQS for several years for example,
                        claimed never to have been asked to sign any form of documentation
                        upon entry to ECQS. He has never showered before leaving ECQS nor
                        has he been told to do so.402 That entry to persons performing non-
                        essential functions in the PAQ process should be restricted, was
                        obviously contemplated by AQIS. In the draft operations manual for
                        example, prepared by Ms Oakes,403 it is contemplated that “non-
                        essential visitors shall not be given authority to enter PAQ”. That non-
                        essential visitors pose a risk to the integrity of quarantine is obvious by
                        their entry without serious objection. It appears to be just one of the


393
      T1283/L2.
394
      T845/L34.
395
      T916/L8.
396
      T1433/L30.
397
      T1314/L42, T1337/L20.
398
      T1247/L27.
399
      T1315/L29.
400
      T770/L27.
401
      T1437/L1; T1501/L39.
402
      T540/L7.
403
      AQIS.0001.001.0080.


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                                                                                                      SUBS.INQ.001.0084




                        unfortunate practices allowed to develop at ECQS over time. It is an
                        observation consistent with Ms Cushing’s impression that:404

                        Over a long period of time ECQS has become more of a ‘clientele
                        quarantine’ (pleasing the client) as opposed to a ‘quarantine’ station, for
                        example, visiting by owners or people inessential to the wellbeing of the
                        horse during PAQ were NOT allowed entry [during the late 1980s],
                        except insofar as people can see their horse from a distance and
                        through a fence, which would be organised through ECQS/IRT for the
                        groom to walk the horse to the fence/gate for viewing, all done under
                        supervision of AQIS staff…overtime however, that procedure has been
                        allowed to relax to the point that there have been occasions when
                        owners/riders were allowed entry by ECQS to visit and exercise ride
                        their   equestrian    horses      in   preparation   for   a    particular
                        competition…eventually the system relaxed to the point where visiting
                        became frequent. Owners and their friends were allowed entry into the
                        LTF to see their horses offloaded from the airstalls onto the horse
                        floats. Owners getting permission for their own Vet or associate to
                        enter ECQS to simply look at the horse to assess its condition,
                        occasionally to do an insurance examination, where they would
                        obviously come into contact with the horse, they were not wearing
                        overalls and did not shower in or out.

9.54        Equally the procedures in relation to the entry and monitoring of veterinarians
            and farriers appears to have been similarly neglected:

            (a)         Veterinarians and farriers entering ECQS in August 2007 appear not to
                        have received an induction or to have been required to sign any
                        documentation acknowledging they had been advised of their
                        responsibilities whilst at the station.

            (b)         The amenities block was locked in around 2005 and although requests
                        could be made to have it open for use, and a key had been given to the
                        head groom for that purpose, it feel into disuse as a consequence and
                        the use of the alternate showering facility in the grooms’ quarters was
                        only rarely taken up. This is despite it seems, the contents of the
                        documents headed “Operating Procedures for Horses – Information for
                        Grooms, Veterinarians, Farriers and Drivers”405 which each of Mr
                        Hankins, Ms Christesen and Mr Ironside claim was in use before the
                        outbreak and which Mr Hankins believed formed part of the groom
                        induction process, suggesting an awareness within AQIS of the
                        importance to be attached to the enforcement of biosecurity measures
                        against visitors, including veterinarians and farriers.

            (c)         It was not commonplace for visiting veterinarians or farriers to shower
                        before leaving or to disinfect their tools and equipment. Veterinarians
                        from the Randwick Equine Centre regularly attend upon horses during
                        the quarantine period. All had minimal awareness of the risk of
                        contamination of themselves by their contact with these horses.
                        Dr Adams had not received any instruction or training from AQIS officers

404
      WIT.IRT.007.0008.
405
      AQIS.0001.001.0056.


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                                                                                                         SUBS.INQ.001.0085




                        in relation to biosecurity.406 Accordingly, he did not consider it necessary
                        to shower, even if he was going to another facility to visit horses.407 Dr
                        Whitfield would not shower out unless he had treated an obviously
                        infected horse.408 His protocol was to wash his hands, forearms and
                        face. He considered this sufficient409 He subsequently accepted such
                        procedures would not adequately protect against the risk posed by
                        equine influenza.410 Dr Whitfield had made no inquiries of AQIS as to
                        the quarantine protocols he ought be following at ECQS. Dr Argyle,
                        from Wollondilly Equine said that he first attended ECQS in 2005. In
                        that first year he says that he routinely showered in the grooms quarters
                        before leaving the station. He explained this and his discontinuance of
                        that practice in his statement.411

                        During the early part of the period that I began attending ECQS I made
                        it my practice to shower in the grooms’ quarters when leaving the
                        station. I do not recall being given a specific instruction to that effect. It
                        may have been suggested by someone at AQIS or I may have
                        considered it a sensible practice to carry out at a quarantine station. I
                        cannot now recall.        However towels were not provided in the
                        veterinarian’s room in the grooms’ quarters and there was no
                        convenient facility for showering. The only available showers that I was
                        aware of were in the grooms’ quarters and were often being used by the
                        grooms who lived there.

                        Over time as a consequence of the inconvenience and as a result of the
                        fact that I observed that no one else handling horses appeared to be
                        routinely showering out of the quarantine station, I ceased showering as
                        a matter of course. However I always used and changed out of the
                        AQIS overalls and gumboots which were provided in the veterinarians’
                        room. On every occasion I attended the quarantine station, I thoroughly
                        washed my hands before leaving if I had been in contact with any
                        horses.

                        Mr Scott Barlow is a farrier who attended ECQS on 13 August and
                        worked on a number of horses, including the Darley stallion Grandera
                        that had arrived from Japan. His evidence was that he always showered
                        out and would use the amenities block to do so.412 There was no
                        contradiction of this evidence.         Indeed Ms Cushing’s belief,
                        corroborating, was that he wore overalls while working and showered
                        before leaving; having obtained the key from Ms Christesen to enable
                        him to gain access to them.413 Mr Barlow however did not – and says he
                        had not been advised or instructed to disinfect his equipment.

                        By contrast, the other farrier to enter ECQS during this period, Mr Brad
                        Hinze, (14 August) did not shower or change his clothes before leaving.

406
      T1705/L4.
407
      T1708/L3.
408
      T1669/L2.
409
      T1671/L25; T1683/L26.
410
      T1672/L39.
411
      WIT.WLYE.001.0001 at paras 9 and 10.
412
      WIT.BARL.001.0001.
413
      T1513/L22.


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                                                                                                SUBS.INQ.001.0086




                        He washed his hands414 but says that he was not required to disinfect
                        his equipment. He had worked on a number of horses in row E,
                        including Encosta De Lago. It was the first time Mr Hinze had been to
                        ECQS. He did not ask anybody what the procedures were that should
                        be followed within the quarantine station,415. His presence there should
                        have been obvious to the AQIS staff, however and he was not given any
                        instructions. It was put to Mr Hankins by counsel appearing for
                        Coolmore, that he had said to Mr St John,, the Coolmore Stallion
                        Manager, who had sought approval for Mr Hinze to come onto the
                        station, that he should “send Brad into the front office where he will have
                        to sign in and the staff in the office will talk to [him]”.416 Mr Hankins had
                        no recollection of the conversation Mr St John’s evidence when given,
                        was challenged by counsel appearing for AQIS on the basis that any
                        such conversation would have been with Ms Cushing and not
                        Mr Hankins.417 Mr St John agreed he had spoken to Ms Cushing about
                        Mr Hinze’s arrival but maintained he had had the conversation with
                        Mr Hankins set out above.

                        Mr Hinze conceded that he had expected he would be required to wear
                        overalls and shower out when he was finished. His explanation for
                        doing neither was that he had not been instructed to do so by the AQIS
                        officers he saw whilst there.418

                        None of this is of course to suggest there is direct evidence any
                        veterinarians or farriers were the cause of the outbreak. As with so
                        many other aspects of the evidence it does though, unmistakably point
                        to deficiencies in the practice and procedures at ECQS and elsewhere.




414
      WIT.COOL.007.0004.
415
      T1834/L4.
416
      T2209/L32.
417
      T3846/L11.
418
      T1836/L20.


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10        EVENTS AT ECQS FROM JUNE 2006 TO MARCH 2007

10.1        From June 2006 until the time of the equine influenza outbreak, Rhonda
            Christesen was the quarantine officer at ECQS principally responsible for the
            duties with respect horses.419 She was a level 4 Senior Quarantine Officer, and
            she fulfilled her role under the supervision of the Animal Quarantine Supervisor
            and the Manager of ECQS.420

10.2        Ms Christesen learned what her duties at ECQS were through training received
            from Nicole Harvey, another level 4 officer employed there. This training took
            place over a couple of months from the time Ms Christesen commenced
            employment at ECQS in June 2006. In respect of horses, the training included
            Ms Christesen being taken through the documentation used for grooms going
            onto the station. Ms Christesen was not provided with, or informed of, any work
            instructions or operating procedures at that time. She was only provided with
            copies of the forms that were used.421 Ms Christesen remained unaware of the
            Live Horse Work Instruction and the Operations Manual until sometime between
            April and June 2007, as discussed elsewhere. Ms Christesen was not told that
            the AQIS intranet was where work instructions or operating procedures could be
            located.422 Prior to the outbreak in August 2007, Mr Christesen received no
            training about equine influenza and was not told how it was contracted, how it
            might spread nor what the symptoms were.423

10.3        After she commenced at ECQS, Ms Christesen used to go over to the horse
            facility regularly. She walked up and down each row, making sure the
            temperatures had been recorded but not specifically noting the particular
            temperatures, had a look at the horses and talked to the grooms she came
            across to find out how things were going. At some time in late 2006, Ms
            Christesen was directed by Mr Hamid (the Manager at ECQS at that time) not to
            go over to the horse facility as much, because she had other duties she needed
            to do and there were “certain budgetary restraints”. He did not elaborate on
            what those constraints were.424 As a result, Ms Christesen stopped going over
            to the horse facility unless it was the beginning of a horse intake and she was
            inducting a groom, or if there was something specific in relation to which the
            Manager or Animal Quarantine Supervisor wanted her to speak to a groom.425
            After Mr Hankins and Mr Holloway commenced at ECQS, Ms Christesen was
            told that she could make occasional visits to the stables.426

10.4        It was never suggested to Ms Christesen that she was required to do anything
            more with respect to horses that what she was doing. For example, she was
            never told she should be taking note of horses’ temperatures or taking other
            steps to monitor their health.427

419
      T1922.
420
      T1415.
421
      T1414.
422
      T1423.
423
      T1415.
424
      T1425 - T1426.
425
      T1481.
426
      T1453.
427
      T1453.


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                                                                                          SUBS.INQ.001.0088




10.5        Mr Holloway became the Animal Quarantine Supervisor at ECQS in February
            2007. Prior to that, that position was filled by Joanne Eddy. Ms Eddy was on
            medical leave and was not able to provide a handover to Mr Holloway.428

10.6        Shortly after Mr Holloway commencing at ECQS, Mr Hankins became the
            Manager of ECQS in March 2007.429 On approximately 20 February 2007, Mr
            Hankins met with Mohammed Hamid, the Manager of ECQS at that time, for the
            purpose of a handover of management of the station.430 The handover did not
            include discussion of technical or biosecurity operational issues431 and Mr
            Hankins was not informed of the documented procedures for the importation of
            live horses at that handover. Mr Hankins had a couple of discussion with Dr
            Widders prior to commencing at ECQS,432 but those discussions also did not
            include reference to the documented procedures.

Events from March to August 2007

Events regarding Live Horse Work Instructions and Operations manual

10.7        In early March 2007, Mr Hankins formed the view that staff at ECQS were not
            familiar with written work instructions relating to horses, cats or dogs. He raised
            the issue, of whether there were national standard operating procedures and
            local instructions, with Mr Holloway on 8 March 2007; and the issue was
            entered as an item requiring action in the ECQS list of matters to be
            addressed.433 Mr Holloway’s evidence was that the item was given a “medium”
            priority, because it was his understanding that the staff were already well
            familiar with the horse intake procedures and there were more pressing
            occupational health and safety issues at that time.434 A search for documented
            procedures at ECQS was undertaken, and inquiries were made of ECQS staff
            and Ms Eddy.435 Those actions resulted in a number of local procedures
            concerning horses being located, but not the Live Horse Work Instruction or the
            Operations Manual.436

10.8        Notwithstanding that neither the Live Horse Work Instruction nor the Operations
            Manual could be located at ECQS, and that ECQS staff were apparently
            unaware of those documents, in March 2007, it is evident that those documents
            were at ECQS prior to March 2007, or that staff at ECQS had at least been
            aware of those documents. This is clear from the events that occurred in the
            development of the Live Horse Work Instruction and the Operations Manual, as
            set out above. Further, a copy of the Operations Manual that contains
            handwritten annotations,437 suggests the document was reviewed at ECQS



428
      WIT.AQIS.012.0001 at 28.
429
      WIT.AQIS.012.0001 at 1 .
430
      WIT.AQIS.012.0001 at 23.
431
      WIT.AQIS.012.0001 at 24.
432
      WIT.AQIS.012.0001 at 26.
433
      WIT.AQIS.012.0001 at 35; T1928 - T1932; WIT.AQIS.007.0018.
434
      WIT.AQIS.007.0001 at 44.
435
      T2543.
436
      T2546.
437
      AQIS.2001.009.0002.


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                                                                                                    SUBS.INQ.001.0089




            when Mr Hamid was the manager.438 Neither Mr Hankins, Mr Holloway or Mr
            Christesen were aware of who had made those handwritten annotations to this
            document.439

10.9        Notwithstanding AQIS policy that the AQIS intranet was the primary source for
            accessing standard operating procedures,440 and that both the Live Horse Work
            Instruction and the Operations Manual were on the AQIS intranet since
            February 2005, none of the staff at ECQS located those documents on the
            intranet. Ms Christesen was not aware that the AQIS intranet was where work
            instructions or standard operating procedures could be located.441 Mr Hankins
            knew that such documents were on the AQIS intranet but he did not look for
            work instructions there because he did not consider the intranet to be a reliable
            source.442 Mr Holloway had looked on the AQIS intranet but had not located the
            Live Horse Work Instruction or the Operations Manual.443

10.10       At some stage prior to the equine influenza outbreak, Mr Hankins and Ms
            Christesen, and probably Mr Holloway, did receive copies of both the Live
            Horse Work Instruction and the Operations Manual. The evidence as to how
            those persons obtained a copy of the Live Horse Work Instruction is not clear,
            as the following paragraphs disclose, but it is more likely than not that each of
            Mr Hankins, Mr Holloway and Ms Christesen were aware of the Live Horse
            Work Instruction by June 2007 at the latest.

10.11       Mr Hankins and Mr Ironside both gave evidence to the effect that Mr Hankins
            contacted Mr Ironside by telephone at some time in late March or early April
            2007, and inquired whether there were any work instructions for the
            management of animals at the quarantine station. Mr Hankins stated to Mr
            Ironside that there were no such documents available at ECQS, and the staff at
            ECQS had informed him that they had not seen any such documents.444

10.12       Mr Ironside’s evidence differs from Mr Hankins’ evidence as to the next
            sequence of events.

10.13       Mr Ironside’s evidence was that he responded to Mr Hankins in that telephone
            conversation that there were a dozen or so work instructions available on the
            AQIS intranet under the “Live Animal Imports” heading; that there may be other
            instructional documents but he was not sure and he would get somebody from
            the program in Canberra to find whatever other documents there were and
            forward those to Mr Hankins.445 At the time of that telephone conversation, Mr
            Ironside was aware that, in respect of the importation of live horses, there were
            work instructions on the intranet which were finalised. He was also aware that
            there were some other documents in existence, but not of how many there were

438
      In the List of Contacts, the quarantine station manager is typed as “Joanne Eddy”. There is a
      handwritten line through Ms Eddy’s name and “Mohammed Hamid” is written above it. There is also
      a handwritten line through Mr Hamid’s name, with “Greg Hankins” above that: AQIS.2001.009.0046.
439
      T2548.
440
      DAFF.0001.507.0132.
441
      T1423.
442
      WIT.AQIS.012.0001 at 36. T1935.
443
      WIT.AQIS.007.0001 at 36.
444
      T259 - 260.
445
      T259 - 260.


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                                                                                            SUBS.INQ.001.0090




            nor of their status.446 Following the telephone conversation, Mr Ironside
            requested Grace Lam to send to Mr Hankins, not the work instructions on the
            intranet but the “other documents”, the status of which he was not sure about—
            ‘whatever was around and useful.’447 In response to that request, Ms Lam sent
            an email to Mr Hankins, copied to Mr Ironside, on 4 April 2007 attaching, among
            other things, the Operations Manual.448 The substance of the email was as
            follows:

                   Subject: Standard Operating Procedures

                   Hi Greg

                   Please find attached the SOP’s for cats, dogs and horses, David has
                   asked me to send them to you.

                   They will be reviewed this year, a job we need to add to the BP plans.

                   Cheers Grace

10.14       Mr Hankins’ best recollection was that Mr Ironside replied, in the telephone
            conversation, that there were work instructions and that he would get back to Mr
            Hankins.449 Mr Hankins’ evidence was that he then had a meeting with Mr
            Ironside on about 3 April 2007 at the AQIS office in Rosebery, during which
            meeting Mr Hankins again asked if there were any work instructions.
            Mr Hankins’ recollection was that Mr Ironside said that there were work
            instructions and standard operating procedures in existence but that Mr Ironside
            did not inform him of where to find them.450 A short time later, Mr Hankins
            received Ms Lam’s email of 4 April 2007 (attaching the Operations Manual).451
            Mr Hankins did not recall when and how he received the Live Horse Work
            Instruction but did not dispute that he had seen it prior to the equine influenza
            outbreak.452 He did not recall having discussed the Live Horse Work Instruction
            with Mr Ironside.453

10.15       In his written statement, Mr Holloway stated that Mr Hankins gave him a copy of
            the Live Horse Work Instruction in March or April 2007.454 In his oral evidence,
            however, he indicated that he was unsure as to whether the document given to
            him was the Live Horse Work Instruction455 and could not say whether he had
            seen the Live Horse Work Instruction prior to the equine influenza outbreak.456
            He received a copy of the Operations Manual from Mr Hankins after, he
            understood, Mr Hankins had made the inquiry of Mr Ironside.457


446
      T260.
447
      T261, T264.
448
      T263, T270; AQIS.INQ.001.0021.
449
      WIT.AQIS.012.0001 at 37.
450
      T1933.
451
      WIT.AQIS.012.0001 at 38.
452
      T1936 - T1937.
453
      T1913.
454
      WIT.AQIS.007.0001 at 40.
455
      T2530.
456
      T2550.
457
      T2547.


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10.16       Ms Christesen’s evidence was that she became aware of the Live Horse Work
            Instruction when Mr Holloway gave her a hard copy of in about June 2007 and
            asked her to review it.458 Shortly after that, she was also given a copy of the
            Operations Manual by Mr Holloway.459

10.17       It is more likely than not that each of Mr Hankins, Mr Holloway and Ms
            Christesen were aware of both the Operations Manual and the Live Horse Work
            Instruction by June 2007 at the latest.

10.18       After receiving the documents and prior to the equine influenza outbreak,
            neither Mr Hankins, Mr Holloway nor Ms Christesen were of the understanding
            that the Live Horse Work Instruction or the Operations Manual had to be
            complied with.

10.19       Mr Hankins did not consider that the Live Horse Work Instruction was required
            to be complied with by AQIS staff at ECQS because he did not believe that it
            was a relevant document for a post entry animal quarantine station.460 To the
            extent that he believed there were any instructions which related to horses at
            the quarantine station, he believed those instructions were not contained in the
            Live Horse Work Instruction but in the Operations Manual.461 Mr Hankins
            considered that the section about quarantine stations in the Live Horse Work
            Instruction was very brief, and the Operations Manual was a more expansive
            document that would cover the requirements to be met at ECQS. He
            considered that the Live Horse Work Instruction did not offer anything more
            than the Operations Manual.462 Mr Hankins maintained the view that the Live
            Horse Work Instruction did not need to be complied with at ECQS,
            notwithstanding that he agreed that “the general position on work instructions”
            was that it would not be within his power to decide that a work instruction
            promulgated by the national program would not be complied with.463

10.20       Mr Hankins believed that the Operations Manual was not a document that had
            to be complied with because it had not been issued as a final document, it was
            in an incomplete draft form, parts of it were expressed to be for use only in
            Spotswood Quarantine Station and it did not correctly reflect the procedures at
            ECQS.464

10.21       Mr Hankins did not seek guidance from Dr Widders, or Mr Ironside or anyone
            else in the national program in Canberra, as to whether the Live Horse Work
            Instruction or the Operations Manual had to be complied with.465 Instead, Mr
            Hankins, Mr Holloway and Ms Christesen commenced a review of the
            procedures that were being undertaken at ECQS with respect to horses, to
            enable a comparison to be made with what was contained in the Operations


458
      WIT.AQIS.010.0001 at 109; T1416, T1452.
459
      WIT.AQIS.010.0001 at 110.
460
      T1910, T1923.
461
      T1910.
462
      T1924 - T1926.
463
      T1925.
464
      WIT.AQIS.012.0001 at 39 - 42, T1923, T1927.
465
      T1926.


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            Manual. Mr Hankins’ intention was that comments would then be provided to
            the national program for advice.466

10.22       Ms Christesen’s evidence was that she was also asked by Mr Holloway to
            review the Live Horse Work Instruction to see:

                   whether there was relevance to what we were doing and … whether any
                   of the attachments … pertained to what we were doing and whether we
                                                                467
                   might be able to utilise them in the future.

10.23       She was not told by Mr Holloway that the Live Horse Work Instruction had to be
            complied with.468 She could not recall what Mr Holloway said to her about the
            status of the Operations Manual. Her understanding was that it was a
            document that had been generated possibly for Spotswood quarantine station
            and she was to go through it and record her knowledge of what was being done
            at ECQS in relation to what was in the document.469

10.24       Ms Christesen made annotations on hard copies of the Live Horse Work
            Instruction and the Operations Manual, noting parts that were consistent with
            what was happening at ECQS and parts which were not, and returned the
            documents to Mr Holloway prior to going on leave at the beginning of July
            2007.470 Ms Christesen was not involved in any further discussion about the
            documents from that time up to the equine influenza outbreak.471 Mr Holloway
            and Mr Hankins also made annotations on copies of the Operations Manual.
            The ECQS review of the Operations Manual and the Live Horse Work
            Instruction was not completed by the time of the equine influenza outbreak.472

10.25       At the time of the telephone conversation with Mr Hankins around the beginning
            of April 2007, Mr Ironside considered that the Live Horse Work Instruction was
            to be followed at the quarantine station because it was a finalised document.
            He was not entirely sure of the status of the documents sent to Mr Hankins by
            Ms Lam (including the Operations Manual) but he:

                   felt that those, even if they weren’t finalised, would be useful to Greg
                   [Hankins] as background documents or as providing some sort of
                                                                                    473
                   guidance or instruction, and that’s why I had those sent to him.

10.26       He later conceded that staff at the government quarantine stations ‘weren’t
            technically required to follow [the Operations Manual], because it was a draft’.474

10.27       Regardless of Mr Ironside’s views as to whether or not the Operations Manual
            should be complied with, he does not appear to have informed Mr Hankins that
            it should be complied with, nor to have otherwise informed him what use should

466
      WIT.AQIS.012.0001 at 42 - 43.
467
      T1452.
468
      T1416.
469
      T1429.
470
      WIT.AQIS.010.0001 at 111; T1452.
471
      T1452.
472
      WIT.AQIS.007.0001 at 44.
473
      T268 - 269.
474
      T291.


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                                                                                                SUBS.INQ.001.0093




            be made of it.475 Also, there is no evidence of Mr Ironside having taken any
            steps, in the period from April 2007 to the time of the equine influenza outbreak,
            to follow up on whether the staff at ECQS had any queries in respect of the
            documents, or to confirm whether the Live Work Horse Instruction and the
            Operations Manual were being complied with.

10.28       Further, Mr Ironside did not take any action to address what could be seen as a
            systemic breakdown, manifest in the manager and staff at ECQS being
            unaware of the documented procedures with which they were required to
            comply. For example, Mr Ironside did not bring the situation to the attention of
            any person senior to Mr Hankins in NSW having responsibility for ECQS;476 he
            did not take steps to ascertain the adequacy or otherwise of any hand–over
            received by Mr Hankins;477 and, despite finding it difficult to believe that the staff
            at ECQS were unaware of the Live Horse Work Instruction given the level of
            involvement of regional personnel in its development and the length of time that
            some of the staff had been at ECQS,478 he did not investigate how that
            circumstance had come about and put measures in place to avoid a
            recurrence.479

10.29       To the contrary, Mr Ironside considered that the issue of staff in ECQS not
            being aware of the documented procedures was resolved by Mr Hankins being
            informed of where the Live Horse Work Instructions could be located, and being
            provided with the Operations Manual.480 As at 1 June 2007, Mr Ironside
            regarded the position with respect to work instructions for horses as
            satisfactory:

                   with the single exception that the operations manual, which was in draft
                   form, was in a draft form and that it needed to be finalised and put up on
                                                         481
                   the intranet as a finalised document.

Access to the quarantine station

10.30       No security guard was present at the station,482 and security measures mainly
            consisted of reliance on fencing and locked gates.483 Grooms, private vets,
            caterers and cleaners had access cards for the main gate at ECQS,484 and
            grooms, some vets and the caterer had keys to the gates to the equine
            facility.485 It was therefore possible for visitors to access the horse facility
            without the knowledge of AQIS officers, and those with keys could also access




475
      T267 - 269, T322.
476
      T270.
477
      T319.
478
      T269.
479
      T340 - T341.
480
      T294.
481
      T276 - T277.
482
      T2555.
483
      WIT.AQIS.012.0001 at 108.
484
      WIT.AQIS.007.0001 at 21.
485
      T1992.


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                                                                                           SUBS.INQ.001.0094




            the horse facility without the prior knowledge of the grooms. Records were kept
            of all access swipe cards and keys issued to grooms and vets.486

10.31       No process for the prior authorisation of visitors to the quarantine station
            appears to have been in place. Also, there appears to have been no monitoring
            of whether grooms and other visitors were signing in upon entry to the station
            and signing out upon departure.487 Ms Christesen believed that the grooms
            would inform her or Mr Holloway if a private vet or farrier was coming onto the
            station during office hours, but not if they were coming outside of office hours.488

Arrival procedures

10.32       The procedures involved with the arrival of the horses at the quarantine station,
            including the cleaning and disinfection of transport vehicles, 489 were generally
            consistent with the relevant procedures set out in the Live Horse Work
            Instruction and the local Operating Procedures document; although were
            perhaps not as stringent as that required by the Operations Manual. AQIS
            officers were not signing the Declaration (regarding the arrival, unloading,
            cleaning and disinfection of truck) contained in the Operations Manual.

Induction of grooms

10.33       On the day of the groom’s arrival at ECQS, an AQIS officer would conduct an
            individual induction with each of the grooms who were to be residing at ECQS
            for the duration of the post–arrival quarantine period. The induction procedure
            involved four documents, each of which is discussed elsewhere:

            (a)         Groom Induction Checklist & Induction Record490

            (b)         Authorisation for Groom to enter Eastern Creek Post Entry Quarantine
                        Station491

            (c)         Operating Procedures for Horses492

            (d)         AQIS Expectations of Horse Grooms at ECQS.493

10.34       In the induction, Ms Christesen would give the Operating Procedures document
            only to ‘first-time’ grooms.494 She would give the Groom Induction Checklist and
            the Groom Authorisation to each groom, although she would only go through
            those documents with a ‘first–time’ groom.495 For experienced grooms, she
            would still make sure they filled in the documents and signed them.496 Ms

486
      WIT.AQIS.012.0001 at 90.
487
      T1437.
488
      T1417 - 1418.
489
      WIT.AQIS.010.0001 at 41 - 64; T1443; WIT.AQIS.012.0001 at 69.
490
      AQIS.1000.003.0045.
491
      AQIS.1000.003.0050 - 0051.
492
      AQIS.0001.001.0056 - 0059.
493
      AQIS.0002.014.0044.
494
      T1431.
495
      T1434.
496
      T1460.


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            Christesen agreed, under cross-examination, that for experienced grooms, she
            was relying on the person who had first gone through the Groom Authorisation
            and the Groom Induction Checklist with the groom to have done so in detail.497
            [She also agreed that the “induction of grooms was a perfunctory and
            mechanical process on [her] part”].498

10.35       In respect of the Groom Authorisation document, Ms Christesen’s evidence was
            that she did not know whether a horse’s health record existed and, therefore, in
            an induction she would not refer to the requirement that the senior groom had to
            details certain matters on such a record.499 Also, she could not find any
            documents matching the description of “conditions of Post Arrival Quarantine
            Procedures and Code of Conduct”. In an induction, she related these things to
            behavioural matters (such as the prohibition on alcohol) rather than to
            procedures relating to biosecurity.500

10.36       The Expectation of Grooms document was provided to grooms for the first time
            at the inductions in August 2007.501

10.37       Mr Hankins’ evidence was that he considered the Groom Induction Checklist
            was superfluous to requirements and he did not require it to be used in
            inductions.502 His evidence was that the induction consists of going through the
            induction forms and informing and/or reminding the grooms, as the case may
            be, of their responsibilities while on the station.503

Monitoring of horses’ health

10.38       An AQIS veterinary officer, usually Dr Widders, attended each horse at ECQS,
            usually within 3 days of arrival, to undertake a veterinary inspection. The
            inspection involved confirming the horse’s identity against a graphic in the
            health certificate; assessing the health and condition of the horse by
            observation, discussion with the groom and review of the twice-daily
            temperature record; and collecting a blood sample for the national serum bank.
            A clinical health examination of the horse to the extent required in the Live
            Horse Work Instruction was not undertaken504

10.39       Ms Christesen checked that the horses’ temperatures were being recorded on
            the stable doors, but did not actually read, or record, what the temperatures
            were.505 She was not checking any document meeting the description of an
            AQIS health record sheet.506 Mr Hankins’ evidence was that AQIS received a
            horse health record sheet from the senior IRT groom to go on file at the end of
            the post-arrival quarantine period, but that a daily record of the horse’s


497
      T1460.
498
      T1460.
499
      T1451.
500
      T1454 - 1455.
501
      T1467.
502
      T1955.
503
      WIT.AQIS.012.0001 at 73.
504
      T1209.
505
      T1415.
506
      T1416 - 1417, T1422.


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                                                                                        SUBS.INQ.001.0096




            temperature was not kept by AQIS. Further, AQIS was not monitoring the
            health of the horses on a daily basis.507

Monitoring of grooms

10.40       Ms Christesen did not take steps to ensure that the grooms were showering and
            changing clothes before they left the station. She had not considered whether it
            was part of her responsibility to ensure that they were showering and changing
            clothes.508 Mr Hankins acknowledged that there was no process in place that
            would ensure and directly monitor whether grooms were showering before
            leaving the station,509 and that the station did not have staff dedicated to
            monitoring and supervision in respect of horses.510

10.41       Mr Hankins was not aware of there having been any monitoring, by AQIS staff
            outside of normal business hours, of whether the grooms resident at ECQS had
            observed the requirement that they not allow visitors on to the station.511

Private vets and farriers

10.42       No process for the induction of private vets and farriers by AQIS appears to
            have been in place.512 Ms Christesen was not making private vets and farriers
            aware of post arrival quarantine requirements,513 and was not requiring them to
            complete and sign an authorisation or any other form before coming onto the
            station.514 Mr Hankins believed that private vets did not undergo an induction
            each time they attended the station because they were generally familiar with
            AQIS’s requirements of them.515

10.43       Ms Christesen’s evidence was that generally she had nothing to do with the
            private vets and farriers who came onto the station. She did not consider an
            AQIS officer would supervise the activities of private vets—the vets would deal
            directly with the Manager of ECQS if there was an issue, and would otherwise
            deal with the relevant groom.516    Mr Hankins was also not aware of there
            having been any direct supervision by AQIS staff of vets or farriers attending at
            ECQS.517

10.44       Ms Christesen believed that vets wore protective clothing which they left on the
            station, and showered prior to leaving the station. She had never observed the
            vets doing anything which suggested they were showering, but she had been
            informed (by a source she could not recall) that the vets were showering each
            time they left the facility.518 Mr Hankins expected that the senior groom for IRT

507
      T1946.
508
      T1439.
509
      T1957.
510
      T1961.
511
      WIT.AQIS.012.0001 at 78.
512
      WIT.AQIS.012.0001 at 81, 83; T1903.
513
      T1418.
514
      WIT.AQIS.010.0001 at 91 – 92; T1430.
515
      WIT.AQIS.012.0001 at 81.
516
      WIT.AQIS.010.0001 at 91 – 92; T1446–T1447.
517
      WIT.AQIS.012.0001 at 82 – 83; T1940.
518
      T1427 - 1428.


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                                                                                       SUBS.INQ.001.0097




            would have brought to the attention of AQIS staff any non-compliance by private
            vets with the requirements to wear protective clothing and to shower prior to
            leaving the station.519

Other visitors

10.45       Mr Holloway’s evidence was that ECQS is attended to by maintenance
            contractors who are required to go near the horse compound. He was unsure if
            they had ever been given any instructions or supervision when doing so. He did
            not give them instructions and did not see anyone else giving them instructions.
            Also, he had not seen any document containing instructions to maintenance
            contractors.520    Mr Hankins’ evidence was that access by maintenance
            contractors was usually arranged to occur during business hours and entry to
            the station is gained via the station office under the supervision of staff.521

10.46       Mr Hankins’ evidence was that caterers and cleaners who attended the horse
            facility were provided were not provided with any instructions in respect of
            biosecurity. They were not considered a biosecurity risk since their functions
            did not give them any reason to come into direct contact with the horses.522




519
      WIT.AQIS.012.0001 at 82.
520
      T2538.
521
      WIT.AQIS.012.0001 at 71.
522
      WIT.AQIS.012.0001 at 86.


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11         THE SIX CONSIGNMENTS COMPRISING THE AUGUST 2007 INTAKE

Overview

11.1        Between 3 and 8 August 2007, 52 horses from Ireland, the United Kingdom, the
            United States and Japan arrived at Eastern Creek to undergo post-arrival
            quarantine (PAQ). Those horses arrived in six consignments between those
            dates. A summary of the dates, countries of origin and numbers of horses
            involved is set out below.

             Consignment       Consignment    Consignment     Consignment   Consignment   Consignment
                  1                 2              3               4             5             6
 Arrival
                03.08.07          04.08.07      07.08.07        07.08.07      07.08.07      08.08.07
 Date
 Time of
                5:15pm           12:00 noon     9:00am          3:50pm        4:04pm        3:00pm
 Arrival
 No of
                    3                  12          16              5            12            13*
 Horses.
                 USA                             UK (10)          USA
 Origin                                UK                                     Ireland        Japan
             (Los Angeles)                     Ireland (6)     (Kentucky)
 Flight         QF7558            SQ7296        DUB008         FedEx9512      MP9177      CX23/CX22
* 9 to Spotswood, 4 to Eastern Creek


11.2        Between 8 and 11 August 2007, the 9 horses from Japan (who were part of
            consignment six) and a further 18 horses from the United States arrived at
            Spotswood Quarantine Station to undergo PAQ. Those 9 horses (three
            stallions and six mares) arrived at Spotswood on 8 August. The remaining 18
            horses were standard bred stallions from the United States. They arrived at
            Spotswood on 11 August.

Consignment 1 (3 horses from United States)

11.3        This consignment consisted of three general traffic horses: Teddy Bear, a
            Welsh pony x gelding; Fox & Firkin, an Irish draught colt, and Sheer Kingston, a
            thoroughbred gelding. The importation of these horses was arranged by Crispin
            Bennett International Horse Transport Pty Ltd (CBIHT) under import permit
            number IP07013647 for private owners.

11.4        Under the conditions of their import permits each of the horses was required to
            be held in pre-export quarantine (PEQ) premises for 21 days immediately prior
            to export and during the four months before the PEQ period to have been
            vaccinated against equine influenza using an ‘approved inactivated vaccine’
            either twice at an interval recommended by the manufacturer or once as a
            booster to a certified primary course of vaccination.523 The reference to an
            ‘approved’ vaccine is understood as being to one registered or licensed by the
            Government or appropriate authority of the export country.524


523
      see eg Permit IPO7013544; CBHT.0001.001.0068 pp 6, 7.
524
      CORR.0005.002.0056.


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11.5        Pursuant to the conditions of the import permit, each of the horses undertook
            PEQ at Bruno de Berdt, Canyon Country, California, USA for the period from 11
            July 2007 to 2 August 2007. The vaccination details for each of the horses are
            as follows:

                Name of                         Vaccine and Date                                      Vaccine and Date
                 Horse
                                     West Nile, Prestige
                                                                                         Fluvac Innovator DbI-E
           Fox & Firkin                II with Hovlogen              31/01/2007                                                8/07/2007
                                                                                                   FT
                                           (Rhino-flu)
           Sheer                      Fluvac Innovator                                   Fluvac Innovator DbI-E
                                                                     14/01/2007                                                8/07/2007
           Kingston                         DbI-E FT                                               FT
                                      West Nile, EEW,                                    Fluvac Innovator DbI-E
           Teddy Bear                                                20/06/2007                                                8/07/2007
                                     Flu, Rhino, Tetanus                                           FT
          * Each of these horses was certified in their health certificate as being vaccinated as a booster to a certified primary course of
            vaccination.

11.6        There is evidence before the Inquiry in relation to the transport of these horses
            to Los Angeles International Airport where they were loaded for carriage to
            Sydney on Qantas flight QF7558. The evidence is from Mr Peter Russell
            Anderson, a flying groom contracted by CBIHT. On the day of departure,
            Anderson attended the PEQ facility in Canyon Country, California. On entering
            the PEQ facility, Anderson showered and changed his clothing which was put
            into a plastic bag and secured. Anderson assisted in loading the three horses
            into a transport vehicle. Lucerne hay and water was also loaded into the
            transport vehicle. Anderson travelled in the transport vehicle with the horses to
            the Los Angeles International Airport, approximately 65 kilometres from the
            PEQ facility. On arrival at the airport, the horses exited the transport vehicle
            and were loaded with the lucerne hay and water into one air stall. Mr Anderson
            was present during this process and rode with the horses into the cargo hold.
            This process was supervised by officials from the United States Department of
            Agriculture. From Los Angeles International Airport the flight landed in Honolulu
            to take on fuel. The horses were not offloaded at this location. The aircraft then
            continued on to Sydney Kingsford Smith Airport (SKSA).525

11.7        The aircraft arrived in Sydney at approximately 5.00pm on 3 August. On arrival
            at the airport, Robert Dell’Armi, Customs Officer, boarded the aircraft to clear
            Anderson and the crew for customs purposes. Mr Kevin Gallagher, Quarantine
            Officer also boarded the aircraft and cleared Anderson and the crew for
            quarantine purposes then checked that the aircraft had been disinsected. Mr
            Gallagher explained that as part of his duties he inspected Anderson’s shoes on
            the aircraft and found them to be clean. Mr Anderson subsequently got into an
            air stall to accompany one of the horses off the aircraft, Mr Gallagher was not
            instructed however by his Controller526, and therefore did not go to the LTF to
            inspect the grooms’ shoes again despite the potential transfer of contaminated
            material after travelling inside the air stall. On this occasion, there were no
            other Quarantine Officers at the LTF to attend to this issue.




525
      WIT.CBHT.004.0001.
526
      T713 - 714.


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                                                                                          SUBS.INQ.001.0100




11.8        Mr Andrew Baudille was the Aero-Care officer who attended the LTF.527 His
            responsibility was to open and close the entry and exit points to the LTF,
            allowing transport vehicles, importers representatives and AQIS officers through
            the gates. He was also responsible for cleaning up the facility once the
            transport vehicles had departed.

11.9        Doctor Yan Hee Song was the AQIS veterinary officer who supervised
            quarantine clearance of the horses at the airport. Present at the airport to assist
            in the unloading of the horses was Ms Kim Maguire, a groom engaged at that
            time by CBIHT. The horses were to be transported from the Airport to ECQS in
            one transport vehicle driven by Mr Paul Watene of Sydney Horse Transport.
            Prior to the aircraft landing, Dr Hee Song gave Mr Watene a pair of overalls
            which he put on. Ms Maguire was not provided with a pair of overalls.

11.10       At the LTF, Anderson and Ms Maguire led the horses from the air stall into the
            transport vehicle. Dr Hee Song carried out an identity check and visible
            inspection for injuries. The hay nets were emptied into the air stall and the
            water containers were emptied on the grass inside the LTF. The empty hay
            nets and water bucket were placed into the groom’s compartment on the truck
            together with horse rugs and horse travel boots also removed from the air stall.

11.11       Ms Maguire travelled to Eastern Creek with Mr Watene in the driver’s cab.
            Mr Anderson walked to the international terminal then caught a bus to the long
            term car park where his private car had been parked. Mr Anderson went
            straight home to his property in Kulnura.

11.12       At Eastern Creek the unloading of the vehicles was supervised by
            Ms Christesen. Ms Maguire had a copy of the stall plan and knew the location
            of where each horse was to be secured. Mr Watene assisted Ms Maguire in
            unloading the horses from the transport vehicle. He was still wearing the
            overalls that he had been given at the LTF. All three horses were placed in
            Row F: Teddy Bear in stall number 12, Sheer Kingston in stall number 13 and
            Fox & Firkin in stall number 14.

11.13       Once the horses were unloaded Mr Watene drove the transport vehicle to the
            cleaning bay and used a high pressure hose to wash out the interior of the
            vehicle including the dividers, rubber floor, roof and bars. He then used a high
            pressure disinfectant on the interior of the horse compartments, but did not
            clean or disinfect inside the driver’s cab. He was supervised by Ms Christesen.
            Mr Watene then removed his overalls and left them at the wash bay.

11.14       Mr Watene did not come into contact with, or transport, horses again until
            6 August 2007. Between 6 August and 10 August 2007, Mr Watene transported
            horses to and from a variety of locations in Sydney, the Southern Highlands, the
            South Coast and the Central Coast.528 Enquiries made by the Commission in
            relation to the horses transported by Mr Watene subsequent to the quarantine
            run demonstrate that none of the horses carried by him contracted equine
            influenza immediately following that transportation leading to the conclusion

527
      WIT.AERO.001.0001, LTF Booking Request SAC.0001.001.0099_R.
528
      AQIS.1001.002.0002 - 0010.


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                                                                                                     SUBS.INQ.001.0101




           that there is no link between these transport vehicles and the Carroll’s Ranch
           Event at Maitland.

Consignment 2 (12 horses from United Kingdom)

11.15      This consignment consisted of five stallions and seven general traffic horses.
           The importation of these horses was arranged by IRT under import permit
           number IP0713195. All 12 horses were imported on behalf of private owners or
           studs.

11.16      All 12 horses undertook PEQ at The National Stud, Newmarket Suffolk from 11
           July 2007 to 2 August 2007. The vaccination details for each of the horses from
           the United Kingdom are as follows (health certificates certify vaccination against
           equine influenza during four months before PEQ using approved inactivated
           vaccine, either once as a booster or twice at an interval of four to six weeks):

             Name of Horse                Vaccine and Date                    Vaccine and Date
                                                                           Equilis
                    Danbird           Prevac Pro       14/07/2006                         03/07/2007
                                                                        Prequenza TE
                                     Duvaxyn IE-T
                  Indesatchel                          14/06/2007        Prequenza        11/07/2007
                                        Plus
                                     Duvaxyn IE-T                       Duvaxyn IE-T
                  Trade Fair*                          06/06/2007                         09/07/2007
                                        Plus                               Plus
                    Denon*            Prevac Pro       14/07/2006        Prequenza        11/07/2007
                                        Equilis
                  Desert King                          15/02/2007        Prequenza        11/07/2007
                                      Equenza T
                                     Duvaxyn IE-T
              Wells High Class*                        03/06/2007        Prequenza        11/07/2007
                                        Plus
                                     Duvaxyn IE          2007
             Jorrit fan Stal Redia                                       Prequenza        11/07/2007
                                       Plus T        (date illegible)
              Ainthorpe Graceful     Duvaxyn IE-T                          Equilis
                                                       05/06/2007                         09/07/2007
                   Sonnet*              Plus                            Prequenza TE
                                     Resequin NN                        Resequin NN
                  Doringcourt                          17/01/2007                         26/06/2007
                                       Plus DE                            Plus DE
              Morton Hall Go For     Duvaxyn IE-T
                                                       10/07/2006        ProteqFlu         18/06/2007
                    Broke               Plus
                                     Duvaxyn IE-T
                  Woodsbee                             07/12/2006        Proteq Flu        18/06/2007
                                        Plus
                Faltstermeyer           IET Plus        01/02/2007        Equip F          21/06/2007
           Those horses marked with an asterisk were certified in their health certificates as vaccinated
           twice at an interval of four to six weeks (rather than once as a booster to a certified primary
           course of vaccination).

11.17      There is no evidence before the Inquiry in relation to the PEQ period or
           transport of these horses to Heathrow Airport. Mr Bruce “Snow” McDonald, a
           professional flying groom with 30 years experience who was contracted by IRT
           to accompany the horses to Australia provided evidence in relation to the set-up
           at Heathrow Airport and loading process. Horses are unloaded directly from the
           transport vehicles into the aircraft as there is no airside livestock transfer facility.
           The air stalls are sprayed with disinfectant solution by a quarantine officer



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                                                                                        SUBS.INQ.001.0102




            immediately prior to the loading of the horses. A government veterinarian is
            present to supervise the loading process.

11.18       Mr McDonald travelled with the horses from Heathrow Airport on Singapore
            Airlines flight SQ7296 with David Surry and Andrew Palmer, also professional
            flying grooms, and Ivan Bridge, a veterinarian contracted by IRT.

11.19       The aircraft arrived in Sydney at approximately 12.00pm 4 August. Doctor Yan
            Hee Song was the AQIS veterinary officer who supervised quarantine clearance
            of the horses at the airport. The aircraft was cleared by Mr Dioscoro Nunez
            who supervised three staff from the cleaning contractor clear grass and hay
            from the floor of the aircraft and spray the inside of the aircraft with a
            disinfectant. Nunez then completed the Certificate of Disinfection. Nunez did
            not undertake quarantine clearance of the passengers or crew.                 The
            passengers and crew were cleared for customs purposes by Customs Officer
            Mr Robert Otto. Mr Cornter, IRT Flight Operations Manager, and Mr Hirose,
            flying groom contracted by IRT both attended SKSA to assist in the unloading of
            the horses. Shortly after the aircraft arrived they both walked on the tarmac and
            boarded the aircraft. Other than a high visibility vest and safety boots, they
            were not wearing any other personal protective equipment.

11.20       Mr Osama Adlouni, a Security Officer with SNP Security attended the
            Singapore Airlines Flight and recorded the movements of all persons entering
            the aircraft.529 Both Mr Cornter and Mr Hirose had their own aviation security
            identification cards (ASIC) and were allowed entry onto the aircraft. Mr Cornter
            collected the paperwork for the horses from Mr McDonald and then walked to
            the LTF.

11.21       Three transport vehicles were used to transport the horses to Eastern Creek.
            All three drivers, Blake Smith, Justin Murphy and Darren Bell worked for
            Livestock Transport Group (LTG). Many of the drivers gave evidence about the
            decontamination of the transport vehicle at the LTG depot in Rosebery prior to
            collecting the horses from SKSA. Whilst the drivers in a general sense
            appeared to have taken care to mix the Virkon disinfectant solution
            appropriately, at least one driver, in particular Smith, did not consult the
            instructions on the bottle to determine the appropriate concentration.

11.22       It is probably each of the drivers was given overalls to wear by Dr Hee Song on
            arrival at the LTF. Dr Hee Song did not give the importer’s representative, in
            particular Mr Cornter, overalls to wear when inside the LTF.530 It was Dr Hee
            Song’s practice, although not consistently, to advise the importer’s
            representative to shower and change clothes after leaving the airport and
            before coming into contact with other horses.531

11.23       The air stalls were brought into the LTF and unloaded. Mr Hirose travelled off
            the aircraft inside the air stall carrying Wells High Class and on arrival at the
            LTF walked the horse directly across to the transport vehicle. Messrs
            McDonald, Surry, Palmer and Murphy assisted with the unloading of the other
529
      AQIS.1001.006.0001.
530
      T598.
531
      T598-599.


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                                                                                         SUBS.INQ.001.0103




            horses. Mr Cornter assisted the grooms to lower the doors to the air stalls and
            then directed the horses as they were led out by placing his hand on the horses
            hind to prevent it from colliding with the air stall and injuring themselves. Mr
            Smith assisted by opening and closing the doors on the truck. There is no
            evidence before the Inquiry to demonstrate which horses were carried in which
            transport vehicle. Hirose travelled to Eastern Creek with Mr Murphy and Mr
            Smith both travelled without passengers.

11.24       None of the passengers who had travelled with the horses on the aircraft went
            to Eastern Creek. Mr Cornter drove Mr Surry and Mr Palmer to a hotel,
            dropped Mr McDonald at the domestic terminal to catch a flight to Brisbane, and
            dropped Mr Bridge at the international terminal as he was returning to New
            Zealand on a commercial flight that same day.532

11.25       At Eastern Creek, Mr Hirose and Mr Murphy unloaded the horses from the
            transport vehicles under the direction of Ms Christesen. Mr McGuire also
            assisted with the unloading of the general horses, but did not touch the
            stallions. Mr Smith did not unload any horses. The five stallions were taken to
            stables in Row C, stalls numbers 1 to 5 and stall number 6. The general horses
            were placed in Row F, stall numbers 1 to 4 and 6 to 8, separated by 3 empty
            stalls from the horses which had arrived the previous day from the USA.533

11.26       All three drivers washed out their trucks with disinfectant at the wash bay and
            the vehicles were inspected by Ms Christesen prior to their departure from
            Eastern Creek.

11.27       Mr Murphy did not have any contact with horses until 6 August 2007. He drove
            for LTG during that week transporting horses around Scone, Kempsey and
            Newcastle, and also worked at Rosehill as a track worker.534 Mr Smith next
            used the transport vehicle on 6 August 2007 transporting horses in and around
            Scone.535 The Inquiry’s investigations suggest that none of the horses
            transported by Mr Murphy, Mr Smith or Mr Bell after 4 August 2007 contracted
            equine influenza immediately following that transportation and that no link can
            be established between these transport vehicles and the Carroll’s Ranch Event
            at Maitland.

Consignment 3 (10 horses from the United Kingdom and 6 horses from Ireland)

11.28       This consignment consisted of 16 stallions arranged by IRT under two import
            permits. The 10 stallions from United Kingdom were imported under import
            permit number IP070131846 and the six stallions from Ireland were imported
            under import permit number IP07013186. All 16 stallions carried to Sydney
            were consigned to Darley Stud. The first 10 United Kingdom stallions were
            loaded onto the aircraft at Stansted Airport in the United Kingdom. The aircraft
            then flew to Shannon Airport in Ireland where the final six stallions were loaded.

11.29       All stallions undertook PEQ for the period from 14 July 2007 to 5 August 2007.

532
      T495.
533
      AQIS.2001.007.0011.
534
      LTG.0001.001.0072 - 0082.
535
      LTG.0001.001.0083 - 0095.


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                                                                                                   SUBS.INQ.001.0104




11.30       The six stallions from Ireland undertook PEQ at Kildangan Stud, Kildare,
            Ireland.536 The 10 stallions from the United Kingdom undertook PEQ at two
            different premises as follows:

            (a)         Dalham Hall Stud, Duchess Drive Newmarket, Suffolk (Dubawi,
                        Librettist, Dubai Destination, Red Ransom, Tiger Hill, Tobougg, Country
                        Reel)537; and

            (b)         Nunnery Stud Thetford, Norfolk (Ekraar, Storming Home, Mujahid)538

11.31       The vaccination details for each of the horses in this consignment are as follows
            (health certificates certify vaccination against equine influenza during four
            months before PEQ using approved inactivated vaccine, either once as a
            booster or twice at an interval of four to six weeks):

               Name of Horse             Vaccine and Date                   Vaccine and Date
             IRISH HORSES
             Exceed and              Prevac Pro       1/06/2006      Proteq Flu - TET     30/05/2007
             Excel
             Cape Cross             Duvaxyn IE-T      13/06/2006        ProteqFlu         09/06/2007
             Noverre                Duvaxyn IE-T      13/06/2006     Proteq Flu - TET     09/06/2007
             Sharmardal             Duvaxyn IE-T      13/06/2006      Proteq Flu-Tet      09/06/2007
             Refuse to Bend         Duvaxyn IE-T      13/06/2006      Proteq Flu-Tet      09/06/2007
             Ifraaj                 Duvaxyn IET       19/12/2006     Proteq Flu - TEV     09/06/2007
             UK HORSES
             Dubawi                  Prevac Pro       01/06/2006        Prevac Pro        03/05/2007
             Librettist             ProteqFlu-TE      13/10/2006        Prequenza         14/07/2007
             Dubai                   Prevac Pro       03/05/2007        Prequenza         04/06/2007
             Destination*
             Red Ransom             Prevac Pro         01/06/2006        Prevac Pro         03/05/2007
             Tiger Hill             Prevac Pro         03/05/2007         Prequenza         04/06/2007
             Ekraar                  Prevacun          14/02/2007         Prequenza         13/07/2007
                                        NNT
              Tobougg *             Prevac Pro         03/05/2007         Prequenza         04/06/2007
              Storming Home        Prevac T Pro        08/01/2007         Prequenza         13/07/2007
              Country Reel          Proteq Flu -       14/01/2007         Prequenza         14/07/2007
                                         Te
              Mujahid              Prevac T Pro        08/01/2007         Prequenza         13/07/2007
            Those UK horses marked with an asterisk were certified in their health certificates as
            vaccinated twice at an interval of four to six weeks (rather than once as a booster to a
            certified primary course of vaccination). The health certificates for the Irish horses did
            not indicate whether the horses had been vaccinated twice at an interval of four to six
            weeks or once as a booster to a certified primary course of vaccination.




536
      DLYA.0001.004.0044.
537
      DLYA.0001.004.0051.
538
      DLYA.0001.004.0023, DLYA.0001.004.0024.


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                                                                                           SUBS.INQ.001.0105




11.32      There is evidence before the Inquiry in relation to the PEQ and the transport of
           these horses to Stansted Airport, UK and Shannon Airport, Ireland where they
           were loaded for carriage to Sydney on Dubai Air Wing flight DUB008.

11.33      Messrs Matthew Jackson, Chris Deschamps and Dan Halford were assigned to
           care for the seven horses in PEQ at Dalham Hall Stud and accompany them to
           Australia. The stallions were quarantined in a barn within an isolation yard
           enclosed by fencing. The quarantine yard was located about 1.5 kilometres
           from the main farm. Footbaths were provided at the entrance of the PEQ for
           visitors to dip their boots in upon entry and exit. The stallions all appeared to be
           in good health throughout PEQ.

11.34      On the final day of quarantine, three trucks came to collect the horses. Also
           present during the loading of the horses were Dalham Hall staff members;
           Mr Michael Rowe and Mr Michael Keegan, both flying grooms contracted by
           Janah; and Dr Patrick Leadon, a veterinarian contracted by Janah Management
           Co Ltd (Janah). D Leadon inspected the horses to ensure that the horses were
           fit to travel. A government vet was also present to supervise the loading. Mr
           Jackson, Mr Deschamps and Mr Halford loaded the stallions into the waiting
           transport vehicles, and along with Mr Rowe and Mr Keegan, travelled in the
           transport vehicles to Stansted Airport. Dr Leadon travelled to the airport in a
           separate vehicle. The trip took approximately 45 minutes.

11.35      Mr Allan Knight and Mr Ward Balloch, professional flying grooms contracted by
           Janah, both attended Nunnery Stud on the day of departure to accompany
           three stallions, Ekraar, Storming Home and Mujahid, to Stansted Airport and on
           to Sydney. At the PEQ facility, Mr Knight assisted to load the horses into the
           transport vehicles while Balloch stayed inside vehicle.          Mr Knight and
           Mr Balloch travelled in one of the vehicles directly to the airport. The trip took
           approximately two hours.

11.36      On arrival at the airport, the transport vehicles entered an area known as the
           Border Inspection Point (BIP). The horses were inspected by a government
           veterinarian prior to being loaded into the air stalls. With the assistance of
           Christopher Webster, a professional groom contracted by Janah who joined the
           flight at Stansted Airport, the grooms loaded the horses into the air stalls, along
           a trolley, and onto the aircraft via a high loader. Each stallion on the flight had
           its own air stall, and, except for take-off and landing, was travelled loose with its
           head free to drop to the floor level at will in order to reduce the incidence of
           transit related respiratory disease. The Boeing 747 aircraft, known as the Dubai
           Air Wing, was owned by Sheik Mohammed and had been specially designed to
           carry horses.

11.37      The flight stopped at Shannon Airport in Ireland to load more stallions.

11.38      Mr Mark Delaney, Mr Jerry Keegan and Mr Mark Deering, stallion men
           employed by Darley, were assigned to care for the six Irish stallions during PEQ
           and to accompany them to Australia. The stallions undertook PEQ and a
           dedicated quarantine barn located on the Kildangan stud. The barn was in an
           enclosed area and only accessible through a single gate. The horses were
           monitored by security cameras 24 hours per day. Only authorised persons


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                                                                                        SUBS.INQ.001.0106




           could enter the quarantine area, and any visitors such as vets or farriers had to
           be accompanied by Mr Delaney, Mr Keegan or Mr Deering. Authorised persons
           and visitors were required to sign in the visitors’ book and dip their shoes in a
           foot bath on entry and exit. Each of the stallion men could not have any contact
           with horses other than those that had been assigned to them in PEQ. The
           horses all appeared to be in good health during PEQ.

11.39      On 5 August 2007, the seven stallions were prepared for transport to the airport.
           Four transport vehicles were used to transport the stallions to Shannon Airport.
           Representatives from stud management, drivers, a government veterinarian,
           and the three stallion men were all present in the quarantine area to assist in
           loading the stallions into the transport vehicles. Darley groom Mr Wayne
           Chapman also attended Kildangan stud that day to accompany the horses on
           their transport to Sydney. The vehicles were disinfected prior to the horses
           being loaded. Messrs Delaney, Keegan and Chapman travelled in the transport
           vehicles to the airport. There is no evidence before the Inquiry to indicate
           whether Mr Webster also travelled to the airport in one of the transport vehicles.
           The trip took approximately two hours. On arrival at the airport the transport
           vehicles parked in the Shannon Airport BIP, an enclosed area about 100 metres
           from the aircraft used for loading. Within the enclosed area was a loading bay
           with a roller system. The horses were led from the vehicles into air stalls with
           the assistance of Mr Keegan and Mr Webster who had disembarked to assist
           with the loading. Leadon also disembarked and went to the BIP to inspect the
           Irish stallions being loaded onto the aircraft.

11.40      After departing Shannon Airport, the aircraft stopped in Dubai and Singapore.
           The horses remained on board the aircraft inside the air stalls during both these
           stops.

11.41      The aircraft arrived at Sydney Kingsford Smith Airport at approximately 9.00am.

11.42      When the aircraft arrived, Customs Officers Mr Kalyani Mani and Mr Gavin
           Myers boarded the aircraft and audited the documents of the 13 grooms and
           eight crew who had arrived on the flight. Customs clearance took place on the
           upper deck of the aircraft and Mr Mani and Mr Myers did not go into the cargo
           hold where the horses were being prepared for unloading. Quarantine Officers
           Mr Dennis Kladis, Mr Gary Howard, Ms Debbie Farrell and Ms Denise Thomas
           were allocated to clearance of the flight. Ms Farrell and Ms Thomas were
           officers in training. They all boarded the aircraft after the Customs Officers.

11.43      Mr Howard gave evidence in relation to the usual procedure once the
           Quarantine Officers and Customs Officers board the aircraft. A Quarantine
           Officer checked that the aircraft had been disinsected and the Customs Officer
           cleared the flight crew and grooms by checking their passports and incoming
           passenger cards (IPCs). The IPC’s were then handed to the Quarantine Officer
           who checked them to see whether any passengers had declared any
           quarantine risk material. On this occasion, Mr Kladis went to the upper deck to
           clear the flight crew and perform the disinsection clearance, a process which
           involved collecting the empty insecticide spray cans and the disinsection
           certificate. While Mr Kladis checked the crew for quarantine declarations, Mr
           Howard, Ms Thomas and Ms Farrell started clearing the grooms. Mr Kladis


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                                                                                           SUBS.INQ.001.0107




           gave evidence that he did not allow anyone from outside to board the aircraft
           while the AQIS Quarantine Officers were on board, although he accepted that
           people may have boarded after the Quarantine Officers had left the aircraft.539

11.44      Present at the airport was Mr John Sunderland, Darley Stud Manager;
           Ms Tanya Henry-May, Darley Head of Marketing; Mr Stuart McKay and
           Mr Aaron Goodworth, both Darley grooms; and Mr Paul Ryan, the Darley float
           driver who had driven the Darley truck to the airport. Mr Cornter and LTG
           manager Mr Nicholas Eastlake were also present inside the LTF.

11.45      Mr Sunderland, Ms Henry-May, Ms McKay and Mr Goodworth walked to the
           aircraft accompanied by Cornter after obtaining visitors’ passes from Gate 27540
           where their names were recorded in a book. AQIS veterinary officers had no
           control over the issuing of passes.541 Mr Cornter did not seek permission from
           any AQIS Officer before escorting the Darley personnel to the aircraft542 and in
           Dr Widders’ evidence, he stated that he was not aware that people, other than
           Mr Cornter were visiting the aircraft.543 The group did not board the aircraft until
           AQIS and Customs Officers allowed them to do so. Sunderland and Henry-May
           did not enter the body of the aircraft.544 After a short period, Mr Cornter, Mr
           Sunderland and Ms Henry-May walked back to the LTF. Mr Goodworth and Ms
           McKay stayed on board the aircraft to assist with the unloading of the horses.
           Mr Eastlake did not go to the aircraft and did not assist with the unloading of the
           horses.

11.46      Doctor Widders was the AQIS veterinary officer who supervised the quarantine
           clearance of the horses at the airport. A tug delivered the air stalls to the LTF
           two at a time. Mr Delaney accompanied Sharmadal, Mr Deering took two trips,
           accompanying Noverre and Mujahid, Mr Keegan accompanied Cape Cross, Mr
           Deschamps accompanied Country Reel, Mr Chapman accompanied Exceed
           and Excel and Storming Home doing two trips, Ms McKay accompanied Dubai
           Destination.    Messrs Jackson, Rowe, Webster, and Goodworth also
           accompanied stallions off the aircraft to the LTF.

11.47      The LTG drivers present at the airport to transport the horses to Eastern Creek
           were Mr Graeme Walker, Mr Richard Chomley, Mr Andrew Burnett, Mr Frank
           Worboyes, Mr Warwick Foster and Mr Edwin Clarke. Dr Widders gave each
           truck driver a pair of overalls. The truck drivers did not assist in the unloading of
           the horse stalls, but may have come in contact with the horses in the process of
           closing and securing the doors in the vehicle.545 Ms Sidney Roberts of LTG
           also briefly attended the LTF at the request of Eastlake to deliver shavings
           which were put in on the floor of Mr Walker’s transport vehicle.546 Mr Eastlake
           subsequently departed with M Roberts in her vehicle.547

539
    T935; T939 - T940.
540
    T549.
541
    T601.
542
    T496.
543
    T1024 - 1025.
544
    T549.
545
    WIT.LTG.005.0001 at para 17; T2393 - T2394.
546
    WIT.LTG.010.0001 para 21.
547
    T2343.


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                                                                                        SUBS.INQ.001.0108




11.48       After clearing the aircraft, the four Quarantine Officers had driven to the LTF
            where they set up a workstation behind the shed where they inspected the
            grooms’ luggage and cleaned the grooms’ footwear and equipment. Quarantine
            Officer Mr Craig Blackburn also attended the LTF before all the transport
            vehicles to collect Mr Farrell and Mr Thomas who had finished their shift. Many
            of the grooms who had travelled from the UK and Ireland gave evidence to the
            effect that they had been asked to remove their shoes at the LTF so that they
            could be cleaned and disinfected.

11.49       Mr Franc Saule, a cameraman employed by Sportscolour Pty Ltd was present
            in the LTF to film the arrival of the horses for ThoroughVisioN Pty Ltd. Mr Saule
            was at the airport for approximately three hours but did not touch any of the
            horses during that time. The footage taken by Mr Saule was made available to
            the Inquiry and tendered into evidence. An edited version was played to the
            Inquiry during Mr Cornter’s oral evidence.548

11.50       Mr Deschamps, Mr Deering, Mr Chapman, Mr Keegan, Mr Mckay and Mr
            Goodworth all travelled to Eastern Creek in the transport vehicles. Mr Ryan did
            not transport any horses in the Darley truck but drove some horse equipment to
            Eastern Creek. The truck remained parked outside Eastern Creek in the car
            park and the cargo was not unloaded. Mr Ryan eventually collected the truck
            on the morning of 8 August 2007 and drove the vehicle to Aberdeen farm,
            collecting two Darley race horses, one from Warwick Farm and one from
            Randwick, on the way.

11.51       Each transport vehicle travelled directly to Eastern Creek. At Eastern Creek,
            the unloading of the vehicles was supervised by Mr Hankins who directed the
            grooms to the various stalls allocated to each horse. The grooms unloaded the
            horses from the transport vehicles. The six Irish stallions were placed in Row A,
            stall numbers 8 to 13. The 10 United Kingdom horses were placed in Row A,
            stall numbers 1 to 7 and Row B, stall numbers 7 to 9 in the centre of the row.
            Other Darley horses were later placed in Row B, however they were separated
            from the UK horses by at least one empty stall.

11.52       Mr Sunderland and Ms Henry-May travelled to Eastern Creek to watch the
            unloading of the horses. Messrs Halford, Keegan, Deering, Deschamps,
            Jackson, Delaney and Chapman (only for one night) remained at Eastern Creek
            to attend to the horses during PAQ. Dr Leadon and Messrs Knight, Balloch,
            Rowe, Webster and Keegan did not travel to Eastern Creek.

11.53       The evidence was, without exception that the interior of the horse compartment
            of each truck was washed and sprayed with pre-mixed Virkon disinfectant
            solution at the wash bay at Eastern Creek immediately after the horses were
            unloaded. The drivers would often assist each other to clean the trucks.
            Although grooms regularly travelled in the driver’s cabin from the airport to
            Eastern Creek, the drivers’ evidence was that the cabin was not disinfected at
            this time. Evidence from the drivers supports the conclusions that an AQIS
            officer either supervised the cleaning, or inspected the vehicles prior to their
            departure from Eastern Creek.

548
      EII.0005.001.0045; T498 - T499.


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                                                                                                SUBS.INQ.001.0109




11.54       Investigations conducted by the Inquiry support the conclusion that none of the
            horses transported by these drivers after 7 August 2007 were infected by
            equine influenza immediately following transportation in any of these vehicles549
            and therefore no link can be established between these transport vehicles and
            the Carroll’s Ranch Event at Maitland.

Consignment 4 (5 horses from United States)

11.55       This consignment consisted of five stallions. The importation of these horses
            was arranged by IRT under import permit number IP07013194. The horses
            were consigned to Darley Stud.

11.56       Pursuant to the conditions of the import permit, each of the horses undertook
            PEQ at Jonabell Farm, Lexington Kentucky USA for the period from 16 July
            2007 to 6 August 2007.550

11.57       The vaccination details for each of the horses are as follows (health certificates
            certify vaccination against equine influenza using approved inactivated vaccine
            during four months before PEQ although there was no indication of whether the
            horses had been vaccinated twice at an interval of four to six weeks or once as
            a booster to a certified primary course of vaccination):

              Name of Horse       Vaccine and Date                  Vaccine and Date
              Elusive Quality     Fluvac Innovator     14/06/2007   Fluvac Innovator 4   13/07/2007
              Henny Hughes        Fluvac Innovator     14/06/2007   Fluvac Innovator 4   13/07/2007
              E Dubai             Fluvac Innovator     14/06/2007   Fluvac Innovator 4   13/07/2007
              Bernadini           Fluvac Innovator     14/06/2007   Fluvac Innovator 4   13/07/2007
              Consolidator        Fluvac Innovator     14/06/2007   Fluvac Innovator 4   13/07/2007




11.58       There is evidence before the Inquiry in relation to the PEQ and transport of
            these stallions to Cincinnati Airport. Mr Derek Fowler, a stallion man employed
            by Darley cared for the horses during PEQ. The stallions were kept in a barn
            on James Lan Farm, about five minutes driver from the main Jonabell Farm
            stud. Fowler was not allowed to come into contact with any horses during the
            quarantine period. Mr Jim Zajic, Darley USA stallion manager visited James
            Lane farm about three time every day to check on the stallions. On Mondays,
            Fowler had a day off and was relieved by another stallion groom Rafael
            Hernandez. Mr Fowler, Mr Zajic and Mr Hernandez were the only people who
            had access to James Lane Farm. Any visitors had to be accompanied by one
            of them. The stallions were treated by a veterinarian, Dr Mark Eslick and a
            farrier on a number of occasions during the PEQ period. The vet and farrier
            sometimes wore disposable overalls. They were also required to dip their
            shoes in disinfectant footbaths located at both entrances to the stallion barn. Mr


549
      LTG.0001.001.0158 - 0168; LTG.0001.001.0121 – 0130; LTG.0001.001.0180 – 0181;
      LTG.0001.001.0182 - 0190; LTG.0001.001.0141 – 0157; LTG.0001.001.0131 – 0140;
550
      DLYA.0001.004.0002.


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                                                                                             SUBS.INQ.001.0110




            Fowler and Mr Zajic gave evidence that the stallions appeared to be in good
            health throughout PEQ.

11.59       On the day of departure, two transport vehicles arrived at James Lane Farm. A
            USDA official inspected the vehicles to make sure they were clean. In addition
            to Mr Fowler and Mr Zajic, Mr Norman Myers and Mr David Pope, professional
            flying grooms employed by Janah, and Darley veterinarian Dr Mariann Klay
            were also present at the farm to assist with the loading of the stallions. Dr Klay
            observed each of the horses prior to them being loaded into the transport
            vehicles. They appeared to her to be in excellent condition and good health.551
            Dr Rowe, a government veterinarian was also present to supervision the
            loading and transport of the stallions to the airport. Stud manager Mr Michael
            Banahan also came to watch the horses being loaded.

11.60       Once the horses had been loaded, the vehicles travelled directly to Cincinnati
            Airport. Mr Pope and Mr Myers both travelled to the airport in the transport
            vehicles. The USDA Official travelled in a car behind the transport vehicles.552
            Dr Klay also followed in a car with Mr Simon Glennie, the US representative of
            IRT. The trip to Cincinnati Airport took between 1 and 1½ hours.

11.61       On arrival at the airport, the transport vehicles entered the dedicated livestock
            loading area, which Mr Myers described as a shed.553 The horses were loaded
            into the air stalls. Each stallion had its own air stall. The loading area operated
            on ‘a roll on/roll off’ system. As each horse was loaded, the air stable would be
            rolled off onto a waiting palette then towed in a convoy to the aircraft which was
            approximately 100-200 metres from the loading facility. At the aircraft the air
            stalls were rolled off the palettes and onto a hydraulic lift into the aircraft. There
            was one groom in each air stall during this process. Accompanying the horses
            on the flight to Australia were Messrs Zajic, Fowler, Myers, Pope and Dr Klay.
            The flight first stopped in Honolulu, Hawaii for two hours. The grooms stayed
            on board with the horses

11.62       Flight number FedEx 9512 arrived at Sydney Kingsford Smith Airport at 3.50pm.
            Mr Peter Twomey from was at the airport to meet the aircraft following a request
            by Mr Cornter to assist with the unloading. Mr Cornter walked out to greet the
            aircraft and shortly after, telephoned Mr Twomey on his mobile asking him to go
            out to the aircraft to assist with the unloading of the horses. Mr Cornter
            collected the horses’ documentation and after 15 or 20 minutes, disembarked
            from the Fed Ex flight to attend the Martin Air aircraft which had just arrived
            from Ireland. Mr Cornter later returned to the LTF to assist with the unloading of
            the air stalls from the Fed Ex flight. Mr Twomey remained on board to assist
            with the unloading of the horses.

11.63       Dr Widders was the AQIS veterinary officer who supervised quarantine
            clearance of the horses at the airport. Dr Widders checked the identity of the
            stallions and their physical condition as they were unloaded. Two truck drivers
            attended this consignment. They were Mr Graeme Walker and Mr Frank
            Worboyes of LTG. Mr Walker and Mr Worboyes did not assist with the
551
      WIT.JANA.007.0001 at para 8.
552
      WIT.JANA.002.0001 at para 8.
553
      WIT.DLYA.015.0001 at para 12.


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                                                                                         SUBS.INQ.001.0111




            unloading of the horses. In his evidence, Mr Walker stated that AQIS had run
            out of overalls that afternoon and so he did not wear any protective clothing
            while waiting for the horses to be unloaded.554 Dr Widders did not indicate in
            his evidence that there had been a shortage of overalls during the occasions he
            attended at the LTF on 7 August 2007.555

11.64       Messrs Sunderland, Ryan and McKay had travelled from Eastern Creek to the
            airport together to meet the horses. They did not go up to the aircraft but waited
            inside the LTF.

11.65       Mr Fowler, Mr Myers, Mr Zajic, Mr Pope and Dr Klay each accompanied one of
            the horses inside an air stall to the LTF. Mr Twomey did not accompany a
            horse but got a lift back to the LTF on one of the tugs. The horses were then
            loaded it onto one of the waiting transport vehicles. Twomey helped move the
            air stalls off the tug and onto the unloading area. He also helped push the hay
            and feed towards the back of the empty air stall and move the air stalls back
            onto the tug.

11.66       Once the Darley stallions had been loaded into the transport vehicles, they
            departed for Eastern Creek. Fowler travelled in the transport vehicle with
            Worboyes, Walker drove unaccompanied,556 and Sunderland drove Zajic in his
            car to Eastern Creek. Pope, Myers and Klay did not go to Eastern Creek.

11.67       Mr Hankins supervised the unloading of the transport vehicles at Eastern Creek,
            assisted by Ms Cushing. As each horse was unloaded Mr Hankins advised the
            grooms unloading the horse of the details of its stall.

11.68       Again, the evidence from Mr Walker and Mr Worboyes was that the interior of
            the horse compartment of each truck was washed and sprayed with pre-mixed
            Virkon disinfectant solution at the wash bay at Eastern Creek immediately after
            the horses were unloaded then departed after permitted to do so by the
            supervising AQIS officer, understood to be either Mr Hayter or Mr Hennessey
            who were both supervising the cleaning of the transport vehicles on that day.557

11.69       Mr Worboyes next transported horses on 9 and 10 August 2007. He
            transported horses to and from various locations including Wyong Creek,
            Randwick Equine Centre, Currockbilly, Randwick, Warwick Farm, Berrima,
            Muskoka, Chiltern and Rosehill.558

11.70       Investigations conducted by the Inquiry support the conclusion that none of the
            horses transported by Mr Walker and Mr Worboyes after 7 August 2007 were
            infected by equine influenza immediately following transportation in any of these
            vehicles559 and therefore no link can be established between these transport
            vehicles and the Carroll’s Ranch Event at Maitland.


554
      WIT.LTG.010.0001, para 26.
555
      WIT.AQIS.006.0001, para 24.
556
      WIT.LTG.010.0001, para 26.
557
      WIT.AQIS.012.0001 at para 96.
558
      LTG.0001.001.0182 - 0190; LTG.0001.001.0158 – 0168.
559
      LTG.0001.001.0158 - 0168 LTG.0001.001.0182 – 0190.


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                                                                                          SUBS.INQ.001.0112




11.71       The import documentation handed to Dr Widders was taken to the AQIS office
            at Rosebery where an AQIS veterinarian completed a veterinary audit report.560
            With respect to the import documentation relating to Elusive Quality, in
            particular the health certificate561, the Inquiry discovered an anomaly in the
            certification process. Veterinary officer Dr Eslick had certified certain things
            listed in the health certificate including: that the horse had been treated with a
            board-spectrum parasiticide on 3 August 2007; that the horse was examined by
            an official veterinarian within 24 hours prior to leaving PEQ; that the vehicle for
            the transport of the horse to the port of export was cleaned and disinfected prior
            to loading; that during transport to the port of export the horse had no contact
            with equines and that the compartment of the aircraft occupied by the horse had
            been cleaned and disinfected prior to loading. Yet the signed health certificate
            was dated 2 August 2007, the day before the horse was to be treated with the
            parasiticide and apparently three days before the horse finished PEQ and was
            transport to the airport. Dr Widders indicated in his evidence that often
            additional certificates are provided in the case of US imports.562

11.72       Mr Adrien O’Brien, Coolmore assistance stud manager, Mr Tom Magnier from
            Coolmore Stud, Mr Craig Atkinson, Coolmore truck driver, and Mr Peter Clark
            and Mr John Ryan of LTG were also present at the LTF during the unloading of
            this flight as they were waiting for the Martin Air flight due to arrive around the
            same time as the FedEx flight.

Consignment 5 (12 horses from Ireland)

11.73       This consignment consisted of 12 stallions. The importation of these horses
            was arranged by IRT under import permit number IP07014144. Ten of the
            horses were consigned to Coolmore Stud and two horses, Golden Snake and
            Rakti, were consigned to private owners.

11.74       Eleven of the stallions undertook PEQ from 12 July 2007 to 5 August 2007
            while Rakti entered PEQ on 26 June 2007. The stallions undertook PEQ at four
            different premises as follows:

            (a)         Danehill Dancer, Antonius Pius, Oratorio, Encosta de Lago, Aussie
                        Rules, Holy Roman Emperor and Ad Valorem at Fairy King Farm,
                        Tipperary Ireland.

            (b)         Statue of Liberty, Ivan Denisovich and Choisir at Prospect Farm,
                        Tipperary Ireland.

            (c)         Golden Snake at Greentree Stud, Tipperary Ireland

            (d)         Rakti at Irish National Stud, Kildare Ireland.

11.75       The vaccination details for each of the horses are as follows (health certificates
            certify vaccination against equine influenza using approved inactivated vaccine
            during four months before PEQ although there is no indication of whether the
560
      AQIS.1000.028.0006.
561
      WIT.AQIS.009.0001. T622.
562
      T1030 - T1031.


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                                                                                             SUBS.INQ.001.0113




           horses had been vaccinated twice at an interval of four to six weeks or once as
           a booster to a certified primary course of vaccination):

             Name of Horse        Vaccine and Date                Vaccine and Date
             Danehill Dancer      Prevac T Pro       29/06/2006   Equip FT            20/06/2007
             Choisir              Duvaxyn IE-T       05/07/2006   Duvaxyn IE-T Plus   25/05/2007
                                  Plus
             Antonius Pius        Prevac T Pro       05/07/2006   Equip FT            20/06/2007
             Oratorio             Prevac T Pro       30/06/2006   Equip FT            20/06/2007
             Encosta de Lago      Equip FT           01/05/2007   Equip FT            20/06/2007
             Aussie Rules         Prevac T           11/11/2006   Equip FT            20/06/2007
             Holy Roman Emperor   Prevac T Pro       22/12/2006   Equip FT            20/06/2007
             Ivan Denisovich      Prevac T           15/12/2006   Duvaxyn IE-T Plus   25/05/2007
             Statue of Liberty    Prevac T Pro       25/06/2006   Duvaxyn IE-T Plus   25/05/2007
             Ad Valorem           Prevac T           10/11/2006   Equip FT            20/06/2007
             Golden Snake         Equip FT           07/01/2007   Equip FT            29/06/2007
             Rakti                Duvaxyn IE-T       16/05/2006   Duvaxyn IE-T Plus   14/05/2007



11.76      Fairy King and Prospect farms are Coolmore satellite farms situated about 7 or
           8 kilometres from the main Coolmore stud at Fethard in County Tipperary. 563
           Access to the farms was restricted: there was perimeter fencing around the
           farms and locked gates at the access points. Any visitors to the farm were
           recorded in a diary.

11.77      Mr Gabriel Walsh, Mr James Carey, Mr Benjamin Faulkner and Mr Gerard St
           John attended to seven the horses at Fairy King Farm during the PEQ period.564
           There were also six or seven part time grooms who worked at the PEQ facility
           during the day. A 24 hour presence was required on the farm. There were two
           access points to the Farm, one of which was always locked, and the other
           unlocked only for people to leave and enter the farm. There was a footbath at
           the entrance to the main barn and also at the two gates entering the quarantine
           area.565 Grooms were instructed not to come into contact with any other horses
           during the PEQ period but were not required to shower in or out of the farm.566
           A night watchman was also present on the farm. During the PEQ period a
           Coolmore veterinarian visited the horses on a number of occasions. A
           government veterinarian also attended the farm to inspect the horses and the
           facility. Mr St John kept a diary in relation to the stallions from the
           commencement of the PEQ period.567 Mr St John had spoken to each of the
           grooms, except Mr Carey, about the quarantine procedures568 and what to




563
      COOL.0001.002.0001_R.
564
      COOL.0001.002.0002.
565
      T831 - T832.
566
      T834.
567
      AQIS.1000.044.0004.
568
      T3836.


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                                                                                        SUBS.INQ.001.0114




            expect at Eastern Creek, paying particular attention to the inexperienced
            grooms.569

11.78       Thomas Heaney attended to the three horses undertaking PEQ at Prospect
            Farm, Statue of Liberty, Ivan Denisovich and Choisir, assisted by two other
            grooms.570 During this time, Mr Heaney was the only groom living on site.
            During the PEQ period, a Coolmore veterinarian, a government veterinarian and
            inspectors from the Department of Agriculture attended the farm at various
            times.571 There were two access roads to Prospect farm: one was permanently
            padlocked, the other padlocked but opened in the morning to allow Heaney and
            the attending grooms to enter the facility, as they stayed off-site overnight,
            although there was a night watchman who stayed on Prospect Farm. There
            were footbaths at the access gates for visitors to use.

11.79       Early in the morning on 5 August 2007, Dr Denis Crowley, a veterinarian
            employed by O’Byrne & Halley attended Fairy King Farm and then Prospect
            Farm and gave the 10 Coolmore horses antibiotics and treated them with
            insecticide.

11.80       At each farm, the horses were loaded into transport vehicles by the Coolmore
            grooms under the supervision of a Department of Agriculture vet, Dr Martin
            Hanrahan, who checked the identification of each horse. At Fairy King Farm,
            Mr Faulkner, Mr Walsh and Mr Carey loaded the stallions into two transport
            vehicles. Mr Gerard Ryan also arrived at Fairy King Farm that morning to
            accompany to the horses on their flight to Australia. Mr Ryan and Mr Walsh
            travelled to the airport together in one transport vehicle and Mr Faulkner and Mr
            Carey travelled in the other. At Prospect Farm, Mr Heaney, with the assistance
            of two other Coolmore employees, loaded the three horses into one transport
            vehicle for carriage to the Airport.

11.81       Dr Crowley travelled in a car with two Coolmore employees. The trip to
            Shannon Airport took between 1½ and 2 hours. On arrival at the airport,
            Dr Crowley was advised that the Martin Air flight had been delayed and a
            decision was made to return the horses to the quarantine stations. The
            Government vet returned to the quarantine stations to unseal the trucks and the
            horses were unloaded under the supervision of and Dr Crowley.

11.82       Once the horses had been unloaded at Fairy King Farm, the vehicles were
            cleaned at Coolmore by the drivers in Anglims yard. At Prospect Farm,
            Mr Heaney also gave evidence that on return to the farm, the vehicles were
            washed and cleaned.

11.83       Golden Snake and Rakti, horses belonging to other studs, had also arrived at
            Shannon Airport accompanied by grooms employed by IRT and were returned
            to their respective quarantine stations when advised about the delay.

11.84       Later that evening, Dr Crowley again supervised the loading of the horses at
            Fairy King and Prospect Farms for transport to the airport. At the airport, the
569
      WIT.COOL.009.0001 at para 21.
570
      T3828 - T3829.
571
      T3826 - T3827.


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                                                                                         SUBS.INQ.001.0115




            horses were loaded into the air stalls inside a facility similar to the LTF and on
            to the aircraft. The grooms were assisted by other Coolmore employees
            including the farm manager, transport manager and truck drivers. There were
            two horses in each air stall. The loading was supervised by Dr Seamus Ryan, a
            Departure of Agriculture veterinarian.

11.85       There were six Coolmore grooms on the flight. They were Mr Carey, Mr St
            John, Mr Faulkner, Mr Heaney, Mr Walsh and Mr Ryan. Dr Crowley also
            accompanied the horses on the flight. There were also three IRT professional
            flying grooms on the flight: Mr John McGregor, Mr Ian Mackenzie-Smith and Mr
            Christopher Denness, and two other grooms, Mr Antonio Phillips and Mr Luis
            Ignacio Martin.572

11.86       Martin Air flight MP9177 left Shannon Airport at approximately 6.15am on 6
            August.

11.87       The aircraft stopped at Dubai and Singapore. None of the passengers left the
            airport at Dubai or Singapore. The flight arrived at Sydney Kingsford Smith
            Airport at 4.04pm.

11.88       Dr Widders was the AQIS veterinarian present at the airport to clear the horses.
            The Coolmore horses were the first to be unloaded. Mr Ryan accompanied
            Encosta de Lago off the aircraft and loaded him onto the transport vehicles.
            Walsh led Holy Roman Emperor from the air stall on to the truck. Mr Heaney
            accompanied Ad Valorem and Statue of Liberty inside the air stall to the LTF.
            Mr O’Brien assisted in unloading Antonius Pius from the air stall and leading it
            to a transport vehicle. As the FedEx and Martin Air flights had arrived almost at
            the same time, Cornter and some of the grooms from the FedEx flight also
            helped open up the air stalls and unload the Irish horses from the Martin Air
            flight.573

11.89       There were three truck drivers who attended this consignment. They were
            Mr Clark and Mr Ryan of LTG and Mr Atkinson, a driver employed by Coolmore
            Stud. All three drivers were provided with overalls to wear. Mr Clark, Mr Ryan
            and Mr Atkinson did not assist in the unloading of the horses.

11.90       Mr Atkinson took seven horses in his truck: Danehill Dancer, Aussie Rules,
            Choisir, Encosta de Lago, Oratorio, Holy Roman Emperor and Ad Valorem. Mr
            St John, Dr Crowley, Mr Carey and Mr Walsh travelled to Eastern Creek in the
            Coolmore truck with Mr Atkinson. Mr Heaney and Mr Faulkner travelled in the
            transport vehicle driven by Clark with Antonius Pius, Statue of Liberty and Ivan
            Denisovich. Mr Ryan transported Golden Snake and Rakti to Eastern Creek.

11.91       Mr Ryan did not go to Eastern Creek but left with Mr O’Brien and Mr Magnier.
            Mr Magnier was dropped off at the William Inglis Auction Centre and Mr O’Brien
            and Mr Ryan continued on to Coolmore. Mr Cornter dropped Mr Twomey at the
            domestic terminal to catch a flight to Melbourne that evening. The Inquiry was
            not successful in its attempts to contact Messrs Mackenzie-Smith, Denness,

572
      AQIS.1000.022.0010; WIT.IRT.001.0001 at paras 80 and 86.
573
      T502.


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                                                                                         SUBS.INQ.001.0116




            Phillips or Martin to obtain statutory declarations. These grooms did not travel
            to Eastern Creek and it is understood that Mr Cornter dropped at least the three
            IRT grooms to a hotel.574

11.92       At Eastern Creek Mr Hankins supervised the unloading of the horses, assisted
            by Mr Tetsuhito who directed the grooms which stall each horse was to be
            placed. All 12 Coolmore horses were placed in stalls in Row E, stall numbers 5
            - 14. Golden Snake was placed in Row C, stall number 7 and Rakti in Row C,
            stall number 9 under the care of Mr Tetsuhito and Ms Cushing.

11.93       Once the grooms had unloaded the horses, Mr Clark, Mr Ryan and Mr Atkinson
            cleaned and disinfected the trucks in the wash bay at Eastern Creek using the
            solution pre-prepared by AQIS. In their evidence, the drivers stated that they
            were supervised by a female AQIS officer at the wash bay and it is understood
            from Mr Hankins evidence that Mr Hayter was supervising the cleaning on that
            day.575 Each of the drivers left their overalls in a pile at the wash bay. After
            delivering the horses to Eastern Creek, Mr Ryan and Mr Clark collected a
            number of horses from Wilberforce which were part of an outbound
            consignment to the Philippines and drove them to SKSA.

11.94       Further investigations conducted by the Inquiry support the conclusion that
            none of the horses transported by these drivers after 7 August 2007 were
            infected by equine influenza immediately following transportation in any of these
            vehicles576 and therefore no link can be established between these transport
            vehicles and the Carroll’s Ranch Event at Maitland.

Consignment 6 (13 horses from Japan)

11.95       This consignment consisted of seven stallions and six mares. The importation
            of five of the stallions was arranged by IRT under three import permits. They
            were import permit numbers IP07013544 (Stravinsky, Rock of Gibraltar),
            IP07013542 (Snitzel, Black Hawk) and IP07013535 (Grandera). The four
            stallions carried to Sydney were consigned to Coolmore Stud (Rock of Gibraltar
            and Stravinsky), Arrowfield Stud (Snitzel) and Darley Stud (Grandera).

11.96       The importation of the six mares and remaining two stallions was arranged by
            Crispin Bennett International Horse Transport Pty Limited (CBIHT) under import
            permit number IPO7014837 (the stallions Zenno Rob Roy and Jungle Pocket
            and the mares Orchid Oasis, Acoustics, Western World, TH Dancer, Full of
            Laughter and Royal Successor). Two other mares which were included in the
            import permit (Derobe and Citronee) experienced problems during PEQ and did
            not travel to Australia.577

11.97       The vaccination details for each of the horses from Japan are as follows (health
            certificates certify vaccination against equine influenza during six months before


574
      AQIS.1000.022.0010; WIT.IRT.001.0001 at para 86.
575
      WIT.AQIS.012.0001 at para 96.
576
      LTG.0001.001.0158 - 0168; LTG.0001.001.0121 - 0130; LTG.0001.001.0180 - 0181;
      LTG.0001.001.0182 - 0190; LTG.0001.001.0141 - 0157; LTG.0001.001.0131 - 0140.
577
      T1358.


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                                                                                                           SUBS.INQ.001.0117




           PEQ using approved inactivated vaccine twice at an interval of four to six
           weeks):

             Name of Horse          Vaccine and Date                       Vaccine and Date
             Stravinsky*               Nisseiken           12/03/07           Nisseiken           09/04/07
             Rock of Gibraltar*        Nisseiken           12/03/07           Nisseiken           09/04/07
             Snitzel*                 Kaketsuken           25/04/07          Kaketsuken           25/05/07
             Grandera*                Kaketsuken           11/06/07          Kaketsuken           12/07/07
             Black Hawk*               Nisseiken           07/06/07           Nisseiken           07/07/07
             Zenno Rob Roy            Kaketsuken           01/05/06          Kaketsuken           25/04/07
             Jungle Pocket            Kaketsuken           01/05/06          Kaketsuken           25/04/07
             Orchid Oasis*            Kaketsuken           23/05/07          Kaketsuken           29/06/07
             Acoustics*               Kaketsuken           23/05/07          Kaketsuken           29/06/07
             Western World*           Kaketsuken           23/05/07          Kaketsuken           29/06/07
             TH Dancer*               Kaketsuken           23/05/07          Kaketsuken           29/06/07
             Full of Laughter*        Kaketsuken           23/05/07          Kaketsuken           29/06/07
             Royal Successor*            Kaketsuken           23/05/07        Kaketsuken            29/06/07
           Those horses marked with an asterisk were certified in their health certificates as vaccinated
           twice at an interval of four to six weeks (rather than once as a booster to a certified primary
           course of vaccination).

11.98      Under the conditions of their import permits each of the horses was required to
           be held in PEQ premises for 21 days immediately prior to export. The six
           mares undertook PEQ at Northern Farm Kuko, Chitose, Hokkaido in the period
           from 17 July to 6 August 2007.

11.99      The seven stallions undertook PEQ at four different premises as follows:

           (a)          Snitzel, Zenno Rob Roy and Jungle Pocket from 17 July to 6 August at
                        the Shaddai Stallion Station which is near the towns of Abira and
                        Atsuma, Hokkaido.578

           (b)          Stravinsky and Rock of Gibraltar from 17 July to 6 August at the
                        Japanese Blood Horse Breeder’s Association’s Shizunai Stallion at
                        Shinhidaka, Hokkaido.

           (c)          Grandera from 17 July to 6 August at the East Stud near Urakawa,
                        Hokkaido.

           (d)          Black Hawk from 17 July to 6 August at the Breeders’ Stallion Station at
                        Hidaka, Hokkaido.579

11.100 Each of these PEQ premises except Northern Farm, Kuko, Chitose, was in an
       area which was subsequently the notification of an outbreak of equine influenza
       to the OIE. Those notifications of outbreaks on farms on Hokkaido were as
       follows:


578
      WIT.SHAD.003.0001.
579
      EII.0006.001.0142.


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                                                                                       SUBS.INQ.001.0118




            (a)         Farms at Urakawa on 14 August, 18 August, 20 August and 29 August.

            (b)         Farms at Shinhidaka on 16 and 17 August.

            (c)         A farm at Abira on 26 August.

            (d)         A farm at Atsuma on 22 August.

            (e)         Farms at Hidaka on 18 August, 20 August, 22 August and 6 September.

11.101 With one exception (the outbreak at Urakawa on 18 August) the affected
       population as notified was described as “race horses”.

11.102 There is evidence before the Inquiry in relation to the PEQ and the transport of
       these horses to Chitose Airport where they were loaded for carriage to
       Melbourne on Cathay Pacific cargo flight CX023. The charter of that flight was
       organised by CBIHT. The aircraft departed Chitose Airport at about 6:15pm
       local time on 7 August. The evidence as to what happened in PEQ and during
       the subsequent road and air transport is from six grooms and a vet.

11.103 Mr Basil Keane, an employee of Coolmore Stud, looked after Rock of Gibraltar
       during its period of PEQ at Shizunai Stallion Station.580 A Japanese groom
       looked after Stravinsky. Those two horses were kept in a quarantine area
       which was fenced. That area contained a quarantine barn and two fenced
       turnout areas. The horses were in adjacent stalls in the barn but were not in
       close contact. Mr Keane stayed at a residence in the quarantine area. His
       evidence indicates that biosecurity measures were in place and that people
       having contact with the horses were required to wear overalls and to wash their
       hands and use a footbath when entering and leaving that area.581 However his
       evidence leaves open the possibility that vets, farriers and others who had
       contact with the horses during PEQ may not always have worn protective
       clothing or properly washed before entering.582 Although Mr Keane left the
       quarantine facility from time to time he did not have contact with horses outside
       it. To his observation Rock of Gibraltar had a normal appetite and temperature
       and did not behave unusually during the quarantine period.

11.104 Mr Emmett Jolley and Mr Aaron Goodworth, grooms employed by the Darley
       Stud organisation spent three weeks in quarantine with Grandera at the East
       Stud.583 The quarantine area was enclosed by a boundary fence and secured
       by a locked gate. It included a stable and a turnout paddock. Mr Jolley and Mr
       Goodworth lived in a house outside the quarantine area. They used a footbath
       when entering and leaving that area but were not required to shower before
       entering or leaving. During the quarantine period a farrier tended to Grandera.
       That farrier did not wear overalls and was not observed to clean or disinfect his
       equipment before use. However, it is unlikely that the farrier had contact with
       other horses on that day because he apparently commenced work at the


580
      EII.0006.001.0018.
581
      WIT.COOL.003.0001 paras 4, 5, 6.
582
      T811 - T813.
583
      EII.0005.002.0019; T1257 - T1260.


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            quarantine area at about 6am.584 During the quarantine period Grandera was
            observed to be in good health. His temperature was taken twice a day and was
            observed to be normal. Mr Goodworth left the East Stud on the last day of the
            quarantine period (ie 6 August) and returned to Australia.585 Mr Jolley
            accompanied Grandera to the airport and onto the aircraft and then handed him
            to Mr McDonald who accompanied the horse to Australia.

11.105 Mr McDonald was contracted by International Racehorse Transport (IRT) to be
       responsible for three of the horses travelling to Sydney (i.e. Stravinsky,
       Grandera and Snitzel).586 He met the horses at the cargo loading area at
       Chitose Airport on 7 August before they were loaded onto the aircraft. He did
       not attend any of those horses in PEQ.

11.106 Dr Nobuo Tsunoda is a veterinarian and the manager of Shaddai Stallion
       Station. Mr Masayuki Noomote and Mr Kazushi Kudo are grooms employed at
       that station. Each of these persons gave answers to written questions prepared
       by counsel assisting the Inquiry. That evidence was not tested by cross
       examination. It was to the following effect. Mr Noomote was the head groom
       looking after Snitzel during its PEQ. Mr Kudo looked after Jungle Pocket during
       PEQ. Those stallions and Zenno Rob Roy underwent quarantine in individual
       stalls with adjoining turnout paddocks in a quarantine barn at the Shaddai
       Stallion Station. Each stall and turnout paddock was physically isolated from
       the other to prevent one horse coming into contact with another. Each of the
       grooms and other persons attending the horses during quarantine was required
       to wear protective clothing and headwear and to disinfect footwear on entering
       and leaving the quarantine barn. The quarantine was supervised by officers of
       the Animal Quarantine Service which is a division of the Japanese Ministry of
       Agriculture, Forestry and Fisheries. Each of the witnesses did not know what
       steps the Animal Quarantine Service took to verify that quarantine was being
       performed appropriately and in accordance with required procedures. During
       the quarantine period none of the three stallions exhibited any symptoms of
       equine influenza such as fever, runny nose or coughing.587

11.107 On 7 August the stallions and mares were transported to Chitose Airport. The
       road transportation of Jungle Pocket, Zenno Rob Roy, Snitzel and Black Hawk
       was undertaken by the Sato Horse Co Limited in two horse floats. Black Hawk
       was loaded into one float at the Breeder’s Stallion Station at Hidaka. The float
       then proceeded to the Shaddai Stallion Station where Snitzel was loaded into
       that float with Black Hawk. Jungle Pocket and Zenno Rob Roy were loaded into
       the other horse float. The two horse floats then travelled to Chitose Airport.588
       Stravinsky and Rock of Gibraltar were transported in separate trucks from the
       Shizunai Station to Chitose Airport.589 Grandera was also transported in a
       separate vehicle from Urakawa to the airport. The evidence before the Inquiry
       does not indicate by whom the six mares were transported by road to the
       airport.

584
      WIT.DLYA.002.0001, paras 3-7; T1259 - T1262.
585
      WIT.DLYA.009.0001.
586
      WIT.IRT.0005.0001, para 13.
587
      WIT.SHAD.003.0001.
588
      WIT.SHAD.003.0001.
589
      WIT.COOL.003.0001, para 8.


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11.108 At Chitose Airport, the horses were loaded into air stalls inside a large cargo
       shed at an isolated part of the airport. The transport vehicles drove into the
       shed one by one and the horse or horses were walked from the vehicle up a
       loading ramp and straight into an air stall at the other end of the ramp. When
       loaded, the air stalls were pulled by a tug out of the shed and to the aircraft
       where they were loaded onboard.590 Each of the stallions was placed into a
       separate air stall. The mares travelled together in air stalls. A number of
       people assisted in this loading process. They included the transport vehicle
       drivers, Japanese representatives of IRT and the grooms. The stallions were
       loaded at the front of the aircraft so that they were separated from the mares.591

11.109 The evidence of what occurred in relation to the transport of these 13 horses to
       the airport and their loading onto the aircraft does not enable any findings to be
       made that there was no possibility of contamination of any of the horses by
       equine influenza during that process. What can be said is that during the
       process of transportation and loading there were opportunities for the horses to
       come into contact with the virus by means of contaminated people, equipment
       or horse transport vehicles and possibly other horses.

11.110 The aircraft travelled to Melbourne via Hong Kong. At Hong Kong some cargo
       was loaded and the grooms and vet left the aircraft to wait in an airport lounge.
       They had no contact with horses. The aircraft arrived in Melbourne at
       approximately 11am on 8 August. At Melbourne Airport, the quarantine
       clearance of the horses was undertaken by Quarantine Officers, rather than a
       veterinary officer.592 Quarantine Officers Mr Benjamin Wajcman and Mr Dennis
       Alegre attended flight CX23 for the purposes of clearing the aircraft. Mr Alegre
       and Mr Wajcman inspected the aircraft interior and containers, including air
       cans and the air stalls, looking for signs of quarantine risk material. Mr Alegre
       say some hay on the floor of the aircraft, and did not check the passenger’s
       personal effects as he considered that the next port of call would deal with this
       since the aircraft was continuing on to Sydney. Mr Alegre did not have any
       contact with Sydney AQIS in relation to the aircraft.593

11.111 Mr Crispin Bennett and two grooms contracted to CBIHT (Mr John Jeffrie and
       Mr Alex Papandreaou) assisted with the unloading of the six mares and two of
       the stallions (Zenno Rob Roy, Jungle Pocket). Brooke Matthews, IRT
       Operations Manager and Mr Kevin Best, an IRT groom, were at the airport and
       assisted with the unloading of the stallion imported by IRT, Black Hawk.

11.112 The horses were transferred from the air stalls to two transport vehicles on the
       bitumen adjacent to the Menzies Cargo Facility using an unloading ramp owned
       and supplied by CBIHT.594 The unloading area was not surrounded by a fence
       but an effort was made to contain the area through the positioning of the
       unloading ramp and the trucks against the building. The horses had to walk
       approximately ten metres from the ramp to the transport vehicles.595

590
      T817 - T819; T895 - T896.
591
      T897.
592
      T642.
593
      WIT.AQIS.026.0003, para 13 and 25.
594
      WIT.CBIHT.0001.001, paras 9 – 21.
595
      WIT.AQIS.028.0001 at para 14.


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                                                                                                     SUBS.INQ.001.0121




           Mr Wajcman and Mr Alegre identified the horses with assistance from
           representatives from IRT and Mr Crispin Bennett, by checking the horses
           against the identification documents obtained from the Controller’s diary. The
           Quarantine Officers also checked to make sure there were no visible signs of
           injury, illness, or distress.

11.113 There were two truck drivers who attended this consignment. They were
       Mr Tony Hore of Sydney Horse Transport (SHT) and Mr Lloyd Baxter of J.G
       Goldner Pty Ltd (Goldner). The truck drivers were both wearing disposable
       protective overalls which had been provided by Mr Bennett. Mr Bennett and Mr
       Jeffrie also wore overalls.596 Mr Hore transported the mares to Spotswood in
       his transport vehicle and Baxter transported the three stallions.

11.114 Once the horses had been loaded, a female IRT employee probably
       Ms Matthews swept a quantity of horse waste off the ground in the unloading
       area. Mr Wajcman gave evidence that he did not know what happened to the
       waste and spade. Mr Wajcman and Mr Alegre also cleaned a small amount of
       hay manure from the unloading area and ramp which was subsequently placed
       into a quarantine bin. Both Quarantine Officers were unsure whether the
       unloading ramp and bitumen unloading area were disinfected after the horses
       had departed.

11.115 On arrival at Spotswood the three stallions were placed in the stalls numbered 2
       (Black Hawk), 4 (Rob Roy) and 6 (Jungle Pocket) in the main stables. The six
       mares were placed in temporary horse stables in the cattle shed area. The
       transport vehicles were cleaned and disinfected with Virkon by Angelo
       Ravaneschi, assistant manager of Spotswood Quarantine Station.597 In his
       evidence, Mr Gundry stated that all persons who had contact with the horses
       were required to observe shower-out procedures except for the truck drivers,
       which Mr Gundry agreed was one of the biggest downfalls of the process at
       Spotswood.598

11.116 Twenty standard-bred stallions from the United States arrived on 11 August and
       were placed in stall numbers 13, 14 and 16 to 33 in the main stables.599 The
       horses were accompanied from New York by Ms Cushing.600

11.117 The aircraft then flew on Sydney having changed status to domestic flight CX22
       and arrived at Sydney Kingsford Smith Airport at about 3pm. Ms Gianna
       Bucciarelli was the Australian Customs Service Officer responsible for clearing
       the crew and passengers on Cathay Pacific flight CX22. Ms Bucciarelli told the
       Inquiry that she was informed that the passengers on the flight had to be
       cleared in Sydney because they had not been cleared for customs and
       immigration purposes in Melbourne. This was unusual as passengers were

596
    CBHT.0001.001.0179.
597
    T3155 - T3156, T3165, T3233.
598
    T3202; T3231 - T3232).
599
    DAFF.0001.012.0298: T3140.
600
    Once the horses had been unloaded from the aircraft Cushing did not travel to Spotswood Quarantine
    Station but went to a hotel at the airport where she showered and changed clothes before boarding a
    domestic flight at lunchtime that day to Sydney where she caught a taxi directly to Eastern Creek.
    WIT.IRT.003.0001 at paragraph 24.


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                                                                                          SUBS.INQ.001.0122




            usually cleared on arrival at the aircraft’s first destination within Australia. Ms
            Bucciarelli gave evidence that she had discussions with an AQIS officer before
            boarding the aircraft during which she queried whether AQIS would be boarding
            the aircraft with her. Ms Bucciarelli was told that AQIS wasn’t required to board
            the flight as it was a domestic flight from Melbourne.                Ms Vasantha
            Pedagandham was the AQIS Quarantine Officer on duty on the afternoon of 8
            August 2007. Ms Pedagandham gave evidence that her Controller did not tell
            her that there was a flight from Melbourne that she was required to clear. Ms
            Pedagandham did not recall having a conversation with a Customs Officer
            during which she was told that there were grooms on board a flight from
            Melbourne which were being cleared by Customs.601

11.118 Mr Bennett had chartered the flight to from Japan to Melbourne with Cathay
       Pacific although the flight also continued on to Sydney with four horses. On of
       the conditions of the charter was that there could only be a single airway bill.
       Accordingly, to satisfy this condition Mr Bennett had arranged for all the horses
       to be cleared off the single airway bill in Melbourne and for Customs and
       Quarantine clearance to also take place in Melbourne. Mr Bennett understood
       that the four IRT horses remaining on the aircraft would then come up as
       domestic freight from Melbourne to Sydney.602

11.119 Dr Hee Song was the AQIS veterinary officer who supervised quarantine
       clearance of the horses at the airport. There were two truck drivers who
       attended this consignment. They were Mr Atkinson of Coolmore and Mr Edwin
       Clarke of the Livestock Transport Group (LTG). Dr Hee Song gave them
       overalls to wear in the LTF which they put on. By the time the aircraft was
       parked on the tarmac near the LTF there were representatives of Coolmore (Mr
       Tom Magnier and Mr Jim Carey), Darley Stud (Mr John Sunderland and Mr
       Stuart McKay) and Arrowfield (Mr Martin Story and Mr Brad Bowd) present. Mr
       Cornter of IRT was also present. Mr Cornter accompanied Mr Magnier, Mr
       Carey, Ms McKay and Mr Storey onto the aircraft. Mr Magnier did not recall
       being given any visitors pass prior to boarding the aircraft.603 Dr Hee Song did
       not know that Mr Cornter was taking people onto the aircraft before the horses
       were unloaded. Nor was he aware that those people were having contact with
       the horses on the aircraft.604

11.120 Mr Storey did not enter the aircraft or touch any of the horses. Mr Keane
       showed Mr Magnier the horses inside the aircraft. Mr McKay and Mr Bowd
       went onto the aircraft to accompany the horses when they were unloaded. At
       sometime before the horses were unloaded, Messrs Cornter, Magnier, Carey,
       Dr Tsunoda, Mr Noomote and Mr Kudo left the aircraft. Mr Bowd and Mr McKay
       remained on board with Mr Keane and Mr McDonald to accompany the horses
       in the air stalls as they were unloaded and transported to the LTF. Mr Keane
       came off the aircraft with Rock of Gibraltar.605 Mr Bowd travelled in the air stall



601
      T705.
602
      T1358 - T1359.
603
      T576.
604
      T602, T620.
605
      WIT.ARRO.003.0001 at paras 29, 30.


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            with Snitzel.606     McDonald travelled with Stravinsky and McKay unloaded
            Grandera.

11.121 The air stalls were brought into the LTF one at a time and unloaded. Stravinsky
       and Rock of Gibraltar were loaded onto the Coolmore transport vehicle driven
       by Mr Atkinson. Snitzel and Grandera were loaded onto the LTG truck driven
       by Mr Clarke. Mr Carey accompanied Rock of Gibraltar and Stravinsky in the
       Coolmore truck to Eastern Creek. Mr Bowd and Mr McKay travelled with
       Snitzel and Grandera in the LTG truck to Eastern Creek. Dr Hee Song
       inspected the horses as they were loaded into the transport vehicles. There
       was some confusion at the LTF during the unloading of these horses as Dr Hee
       Song believed that there would be five horses on the flight however only four
       horses were unloaded. Dr Hee Song did not have a copy of the import permit
       but considered the difference in the horse numbers was not an issue as he
       believed the horses on the aircraft had been cleared when they passed through
       Melbourne and that a decision to unload the fifth horse in Melbourne must have
       been made at short notice.607

11.122 Each vehicle travelled directly to Eastern Creek. At Eastern Creek the
       unloading of the vehicles was supervised by Ms Christesen. As each horse
       was unloaded she checked its identity and advised the grooms unloading the
       horse its assigned stall number. Rock of Gibraltar and Stravinsky were placed
       in Row E in stall numbers 15 and 4 at each end of the row of Coolmore horses
       which had arrived from Ireland in consignment 5 on 7 August. Snitzel was
       placed in Row C in stall 8 between Rakti and Golden Snake. Grandera was
       placed in Row B in stall 12. The stalls on either side of that stall were not
       occupied by horses.

11.123 The import documentation handed to Dr Hee Song was taken to the AQIS office
       at Rosebery where an AQIS veterinarian prepared a veterinary audit report.608
       Various discrepancies were discovered at that time between the conditions of
       the import permit and the various matters certified in the health certificates.
       While the import permit required vaccination within 4 months of PEQ, but the
       health certificate certified that vaccination had taken place within 6 months of
       PEQ. Equine Influenza vaccinations for Rock of Gibraltar and Stravinsky had
       occurred just outside the four month period required by the import permit. Drs
       Widders and Hee Song were notified by the veterinary officer about this
       particular issue and referred the query to Dr Ainslie Brown in Canberra.609 It is
       understood that the vaccination timeframe was subsequently accepted by the
       National Program.610




606
      WIT.ARRO.003.0001 at para 9.
607
      T639 - T640.
608
      Luana Ferrara commenced the veterinary audit but did not finalise it. AQIS.2002.008.0010 See
      WIT.AQIS.009.0001. Catherine Schuller completed the veterinary audit - see WIT.AQIS.025.0001.
609
      T625 - T626 and T1027 - T1029.
610
      T626 and T1029 - T1030.


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12         ATTENDANCE BY VETERINARIANS AND FARRIERS AND ACTIVITIES
           OF GROOMS

Coolmore - Veterinarians

12.1        Dr Crowley was responsible for the clinical examination and treatment of all
            Coolmore horses in the early stages of PAQ. Mr St John kept a diary recording
            the health status of the Coolmore stallions and details of any veterinary
            treatment.611

12.2        In the early morning on 8 August 2007, Dr Crowley attended ECQS with Mr St
            John to collect blood samples for a full haematology and biochemistry analysis
            of each of the 10 Irish stallions. Dr Crowley gave the blood to Dr Greg Nash
            from the Randwick Equine Centre (REC) for analysis at the Equine Diagnostic
            Laboratory at REC. The results were considered normal except for an elevated
            white cell count in the blood taken from Danehill Dancer.612 Later in the day, Dr
            Crowley returned to ECQS and administered an initial dose of prophylactic
            antibiotics (Engemycin) to Stravinsky and Rock of Gibraltar, who had just
            arrived from Japan. Dr Crowley also administered a second dose of antibiotics
            to each of the 10 Irish stallions.

12.3        In the early morning on 9 August 2007, Dr Crowley again attended ECQS to
            take blood from Stravinsky and Rock of Gibraltar for full haematology and
            biochemistry analysis and gave the samples to Dr Joe Bruyn from REC for
            analysis. Dr Crowley also took additional blood from Danehill Dancer for further
            analysis. According to Dr Crowley, the results of all blood samples taken from
            the Coolmore horses were normal. That morning, Dr Argyle examined
            Stravinsky and took blood samples at the request of IRT (see below).

12.4        Dr Crowley returned to ECQS in the afternoon on 9 August 2007 and
            administered a final dose of antibiotics to the 10 Irish stallions and the second
            dose of antibiotics to Stravinsky and Rock of Gibraltar. He also treated Oratorio
            for swollen bag legs. The next day, 10 August 2007, Dr Crowley attended
            ECQS in the afternoon to administer the final dose of antibiotics to Stravinsky
            and Rock of Gibraltar. Dr Crowley did not conduct and further examinations or
            administer any veterinary treatment to the Coolmore horses after 10 August
            2007.

Darley and Arrowfield

12.5        Darley engaged Randwick Equine Centre (REC) to provide veterinary services
            to the 22 stallions in PAQ. REC was also engaged by Arrowfield to provide
            veterinary services to Snitzel while the stallion was at ECQS.

12.6        Dr Bruyn and Dr Whitfeld attended ECQS at around midday on 7 August 2007
            to conduct an initial clinical examination of the 16 Darley stallions that had
            arrived that day from the UK and Ireland (consignment 3). The initial
            examination was conducted in the horse stables with 2 grooms present and

611
      CALO.0001.009.0367
612
      See paragraph 35 of St John’s statement (WIT.COOL.009.0009).


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           included checking the stallions’ temperature. The details of these examinations
           were recorded in the REC Clinical Examination form for each horse.613 Later
           that day, Dr Bruyn returned to ECQS to conduct an initial clinical examination of
           the 5 stallions that had arrived that evening from the USA (consignment 5). The
           stallions were all stabled in Row B.

12.7       Dr Bruyn attended ECQS early the next morning, 8 August 2007, with Dr Nash
           and Dr Whitfeld to re-examine all of the Darley stallions and take bloods. No
           blood was taken from Cape Cross in Row A because he was considered too
           dangerous to handle. Dr Nash recalled that all the stallions appeared to be
           healthy and were not showing any significant ill effect from travel.614 Dr Bruyn
           delivered the blood samples to the Equine Diagnostic Laboratory at REC for
           analysis later that day. Dr Bruyn returned to ECQS in the evening to conduct an
           initial clinical examination of 2 of the stallions, Grandera (Darley) and Snitzel
           (Arrowfield) that had subsequently arrived from Japan (consignment 6). As
           noted above, Grandera was stabled in Row B and Snitzel was stabled in Row
           C.

12.8       Dr Bruyn returned early the next morning (9 August 2007) to re-examine
           Grandera and Snitzel and collect blood samples. The same morning, Dr Argyle
           examined Storming Home, Iffraaj and Ekraar in Row B and took blood samples
           at the request of IRT (see below). Dr Bruyn returned later that day to discuss
           the results of the blood samples he had collected with the grooms and did not
           treat any horses.

12.9       Dr Bruyn and Dr Whitfeld returned to ECQS early in the morning on 14 August
           2007 to take further health bloods from the 22 Darley stallions (except Cape
           Cross) and Snitzel. According to Dr Bruyn, all the Darley stallions were in good
           health and he did not expect any further veterinary treatment or attendances
           would be needed for the rest of PAQ.

Other horses

12.10      On 4 August 2007, Dr Argyle from Wollondilly Equine, attended ECQS at the
           request of IRT to conduct initial clinical examinations and take blood samples
           from 5 of the horses that had arrived that day from the UK (consignment 2).615
           The 5 stallions were all stabled in Row C and were, at that stage, under the
           care of Mr Hiro Tetsuhito from IRT. Mr Tetsuhito assisted Dr Argyle during his
           examinations. Dr Argyle treated Desert King for a temperature and harsh lung
           sounds with fluids and antibiotics.

12.11      Dr Argyle returned to ECQS the following day in the morning. He conducted a
           further examination of the 5 stallions in Row C. Dr Argyle administered further
           antibiotics to Desert King and observed that his temperature was back to 38
           degrees. Dr Argyle also examined Ainthorpe Sonnet Graceful (Ainthorpe) and
           treated the horse for a swollen lower jaw. Dr Argyle returned later in the day on
           5 August 2007 to administer further doses of antibiotics to Desert King and
           Ainthorpe.
613
    Insert ref.
614
    WIT.REX
615
    Trade Fair, Danbird, Denon, Idesatchel and Desert King.


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                                                                                       SUBS.INQ.001.0126




12.12      On 6 August 2007, Dr Argyle attended ECQS to take a further blood sample
           from Idesatchel, in Row C, as there had been an anomaly in the result from the
           earlier test. He also administered further antibiotic doses to Desert King and
           Ainthorpe. He returned later in the day to continue antibiotic treatment for both
           horses. Dr Argyle again attended ECQS in the morning on 7 August 2007 to
           continue their antibiotic treatment. He returned later in the afternoon and
           conducted a re-examination of both horses. By that time the horses in
           consignment 3 had arrived at ECQS. At the request of IRT, Dr Argyle conducted
           a standard initial examination of the 2 non-Coolmore stallions that had arrived
           with that consignment, (Golden Snake and Rakti in Row C). Dr Argyle treated
           both horses with antibiotics for travel sickness.

12.13      On 8 August 2007, Dr Argyle attended ECQS in the morning and conducted a
           re-examination of Rakti and Golden Snake and collected blood samples from
           both horses. He also reviewed Desert King. All three horses were stabled in
           Row C. Later in the afternoon, Dr Argyle returned to ECQS to continue
           treatment of the same three horses.

12.14      IRT requested that Dr Argyle take blood samples from 6 horses at ECQS in
           preparation for their shipment to New Zealand.616 Dr Argyle attended on 9
           August 2007 to collect the samples. The horses sampled included Stravinsky, a
           Coolmore stallion in Row E, Dorringcourt and Woodsbee in Row F and three
           Darley stallions, Storming Home, Iffraaj and Ekraar, in Rows A and B. Dr Argyle
           also treated Rakti and Golden Snake in Row C. He returned to ECQS later in
           the afternoon to continue treatment of these 2 horses.

12.15      On 10 August 2007, Dr Argyle continued treatment of Rakti and Golden Snake
           in the morning and also examined Falstermeyer in Row F. He returned to ECQS
           and treated the same three horses that afternoon and twice the following day
           (11 August 2007).

12.16      Dr Argyle next attended ECQS in the morning on 14 August 2007 to collect
           further blood samples from the 5 stallions in Row C (Trade Fair, Danbird,
           Denon, Idesatchel and Desert King).

12.17      The three horses imported by CBHIT in Row F did not have a clinical
           examination on arrival or receive any veterinary treatment in the early stages of
           PAQ.

AQIS veterinary inspection

12.18      On 8 August 2007, Dr Widders attended ECQS between 12.30pm and
           4.30pm617 to conduct veterinary inspections of all the horses that had entered
           PAQ over the preceding 4 days. He was unable to obtain a sample from Cape
           Cross and Ad Valorem because they were unmanageable at the time.618 Dr
           Widders attended ECQS again between 1pm and 4pm on 13 August 2007 to



616
    WLYE.0001.001.0140
617
    CI.0001.037.0025.
618
    T 1289


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           carry out veterinary inspections of the 4 Japanese stallions, which were located
           in Rows B, C and E.619

12.19      The veterinary inspection consisted of identifying each horse and collecting
           blood samples.620 The samples were sent to the Elizabeth Macarthur
           Agricultural Institute with a request that sera be extracted and the serum sent to
           the Australian Animal Health Laboratory (AHHL) in Geelong for storage in the
           National Serum Bank.621 Dr Widders told the Inquiry that these samples were
           not collected for the purpose of immediate testing but rather as a reference of
           the health status of the horses on arrival in Australia for use in the event of an
           identified disease concern.622

12.20      According to Ms Maguire, Dr Argyle wore overalls and gumboots when
           attending horses at ECQS. On each occasion that she saw him during the
           August intake, he was wearing overalls and gumboots although she did not
           observe whether or not he showered at the grooms’ quarters.

Attendances by farriers

Scot Barlow

12.21      Mr Scott Barlow, a self-employed farrier, attended ECQS on 13 August 2007 at
           the request of Ms Cushing and Mr Zajic from Darley. It was Ms Cushing’s
           practice to advise ECQS management of any pre-arranged visits by
           veterinarians or farriers. As Mr Barlow had undertaken farrier work at ECQS for
           at least 5 years he was also known to ECQS staff.

12.22      On this occasion, Mr Barlow announced his arrival over the intercom at the
           main gate, which was opened remotely by a staff member at the main office. Mr
           Barlow drove his vehicle to the administration block and signed in the visitor’s
           book at 1.20pm (although his recollection is that he arrived at around
           midday).623 Mr Barlow asked an AQIS officer, known to him as ‘Pat’, to escort
           him through the locked gates and into the equine enclosure. It is likely that
           Mr Barlow was referring to Mr Patrick Hennessy who is the Level 3 AQIS officer
           responsible for overseeing maintenance at ECQS. Mr Barlow then drove his
           vehicle into the equine enclosure and parked near the Staff Amenities Block
           where he met Ms Cushing. Because Ms Cushing was not issued with a key to
           the Staff Amenities Block for the August intake, another AQIS officer unlocked it
           for him. None of the AQIS witnesses that gave evidence had any recollection of
           unlocking the Staff Amenities Block for a farrier during the August intake (prior
           to the outbreak of EI). However, Ms Cushing’s recollection was the Ms
           Christesen unlocked it for Mr Barlow when he attended ECQS on 13 August
           2007.624 Ms Cushing was well aware of the requirement that farriers were

619
    CI.0001.037.0020
620
    T 991
621
    T 1242
622
    T 1049
623
    See ECQS visitor’s book (AQIS.1000.036.0010) and WIT.BARL.001.0002.
624
    Ms Christesen did not recall Mr Barlow’s attendance at ECQS on 13 August 2007 and, more
    specifically, unlocking the staff amenities block so that he could change his clothes and have a
    shower (T1441-1442).


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              required to wear overalls and gumboots while working at ECQS and told the
              Inquiry that she had taken on the responsibility of ensuring that Mr Barlow
              complied with this requirement.

12.23         In any event, Mr Barlow was given access to the Staff Amenities Block. Mr
              Barlow told the Inquiry that overalls and gumboots for farriers were kept in
              cupboards in a room adjacent to the shower. Mr Barlow said that he could not
              locate a clean pair of overalls so he put on an already worn pair that he
              recognised as having been the same as he had used on a previous visit to
              ECQS. He also put on AQIS gumboots and wore his own leather work apron
              over the overalls. Dr Widders told the Inquiry that he had observed that Mr
              Barlow generally complied with the requirements for farriers attending ECQS.625
              The evidence supports a finding that Mr Barlow did in fact comply with the
              requirement to wear overalls and gumboots on each occasion that he attended
              ECQS.

12.24         Ms Cushing gave Mr Barlow instructions about which horses required attention.
              Mr Barlow started working in Row B. He gave a ‘light trim’ to Grandera followed
              by Elusive Quality. He was assisted by some of the Darley grooms. Mr Barlow
              then drove his vehicle around into Row C to the stable of Golden Snake. Ms
              Cushing led the horse into the yard where Mr Barlow took off the horses shoes,
              gave him a trim and refitted his shoes. Mr Barlow then went to the end of Row F
              to trim and manicure Moreton Hall Go For Broke and Woodsbee with the
              assistance of Ms Kim Maguire. Ms Maguire told that Inquiry that Mr Barlow
              always wore overalls and gumboots and certainly did so on this occasion. Ms
              Maguire recalled that Mr Barlow worked on Doringcourt but this is not supported
              by the evidence of Mr Barlow or the work records that he produced to the
              Inquiry. Mr Barlow did not clean or disinfect his farrier tools in between his
              attendances on the 5 horses at ECQS that day.

12.25         When Mr Barlow had finished in Row F, Ms Cushing arranged for the Staff
              Amenities Block to be unlocked once again so that he could change and shower
              before leaving ECQS. Again, Ms Cushing was aware of the requirement that
              farriers shower before leaving ECQS and felt that she was responsible for
              ensuring that Mr Barlow did so. As noted above, Ms Cushing recalled that Ms
              Christesen came around to unlock the door for Mr Barlow.

12.26         Mr Barlow placed his farrier tools in the back of his vehicle without cleaning or
              disinfecting them and drove from Row F to the Staff Amenities Block where he
              showered and changed.626 He left the gumboots and overalls in the change
              room.

12.27         Mr Barlow left ECQS at about 3.30pm, without signing out, and went directly to
              a client’s property in Londonderry where he shod two horses using the same
              tools and equipment that he had used earlier in the day. Mr Barlow told the
              Inquiry that he did not perform any other farrier work that day. It is likely that he
              stopped off in Windsor to feed his partner’s Clydesdales on his way home from
              Londonderry. It is also likely that he fed another horse called ‘Charlie’ after

625
      T1113
626
      T1539


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           returning to his residence in Yarramundi. Mr Barlow did not have any other
           contact with horses that day and showered and changed when he arrived
           home. Mr Barlow gave evidence that the Clydesdales did not contract equine
           influenza until about 12 or 13 September 2007 and Charlie remained free of the
           virus until October 2007.

12.28      In the next 2 weeks, Mr Barlow attended various properties with horses in North
           Western Sydney and the Lower Blue Mountains to perform farrier work. He also
           worked numerous shifts as a driver of a horse drawn restaurant in Windsor
           operated by his partner. Mr Barlow was questioned at length about these horse
           contacts. Mr Barlow was able to give a full account of his movements during this
           period by reference to his diary and business records. He told the Inquiry that
           his core clients primarily owned polo horses, draught horses, American horses
           and ponies and that he had not carried out any farrier work on eventing horses
           in the last 12 months.

12.29      Mr Barlow also gave evidence that once he became aware of the outbreak of
           equine influenza at ECQS, he contacted as many of his clients as possible and
           was told that none of their horses had contracted equine influenza within a
           week or so of him treating them during the period 13 and 17 August 2007. The
           Inquiry also made enquires of Mr Barlow’s clients to verify whether he had
           attended any properties where horses had displayed early signs of respiratory
           illness.

12.30      On the available evidence, the Inquiry is unable to make any findings in respect
           of possible pathways linking Mr Barlow’s attendance at ECQS on 13 August
           2007 to the subsequent introduction of the virus into the general horse
           population.

Bradley Hinze – 14 August 2007

12.31      Mr Bradley Hinze, a farrier employed by Coolmore, attended ECQS on 14
           August 2007 to trim the Coolmore stallions in Row E. Mr Hinze arranged his
           visit through the head groom for Coolmore at ECQS, Mr Gerard St John, and
           discussed what work he was required to perform with Adrian O’Brien, the
           assistant stud manager at the Coolmore Stud in Jerry’s Plains. He was told to
           drive down to ECQS and tidy up all the Coolmore stallions in preparation for the
           stallion parade, which was scheduled to occur at the stud following their release
           from quarantine.

12.32      Mr Hinze left his home in Muswellbrook at about 4am on 14 August 2007 and
           drove to ECQS. He stopped briefly on the way for breakfast and then continued
           towards ECQS. Mr Hinze arrived at ECQS at about 8.20am and stopped his
           vehicle at the main gate. He told the Inquiry that a person at the gate opened it
           for him once he had explained that he was the Coolmore farrier. That person
           told him to go into the office and sign in. Mr Hinze said that he then drove up to
           the main office, went inside and completed a sign in sheet or form. No
           document has been produced to the Inquiry to verify this aspect of his evidence.
           There is no entry for Mr Hinze on 14 August 2007 in the regular ECQS




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           visitor’s.627 After allegedly signing in, Mr Hinze was joined by Mr Jim Carey at
           the main office and the two men drove around to the equine enclosure in Mr
           Hinze’s car, which he parked at the end of Row E. Mr Hinze told the Inquiry that
           as he had never attended ECQS he had been expecting to receive directions
           about any specific biosecurity measures, such as wearing protective clothing or
           showering, that applied at ECQS.628 As neither the Coolmore grooms nor any
           member of ECQS staff gave him any such instructions, he simply commenced
           working on the stallions and did not observe any specific biosecurity
           precautions. Unlike Mr Barlow, it is clear that Mr Hinze did not change into
           overalls and gumboots while he was at ECQS. He wore his ordinary work
           clothes and a cap.629

12.33      The order in which Mr Hinze trimmed the horses is unclear because the
           Coolmore grooms had already brought some of them into the yards. However,
           Mr Hinze had direct contact with all the Coolmore horses in Row E at some
           point during the day. He recalled that he had trim and shod Statue of Liberty
           and Ad Valorem last and had definitely worked on the 2 Japanese horses,
           Stravinsky and Rock of Gibraltar, outside their stables in the yards. Mr Hinze
           was working continuously in Row E for over 4 hours.

12.34      Mr Hinze told the Inquiry that he washed his hands and face after he finished
           working but did not shower or change his clothes. Nor did he clean or disinfect
           his equipment and tools. Before leaving the quarantine station m Mr Hinze
           drove his vehicle back around to the main office and signed out. Again, no
           record has been produced to the Inquiry to verify this evidence. Mr Hinze said
           that he asked a lady behind the desk in the main office ‘Am I right to go now’
           and she answered ‘yes’. As he left ECQS, Mr Hinze was conscious of the fact
           that he had gone into the quarantine station without wearing overalls and had
           not showered out. However, he assumed that if he had presented a risk of
           spreading disease he would not have been allowed to leave without
           decontaminating. He told the Inquiry that in hindsight he should have taken it
           upon himself to inform ECQS staff of the nature of his visit before leaving the
           station.

12.35      Mr Hinze returned to his car and drove with Mr Carey to the Lone Pine Tavern
           where they met Mr St John for lunch. Mr Hinze said that he made some calls to
           the Coolmore Stud and his apprentice, Mr Badenhorst, at 1.49pm and 1.50pm.
           Under questioning, Mr Hinze rejected the proposition that when he had made
           these calls he had already left the tavern and was in his car on the way back to
           Newcastle. Mr Hinze recalled making the calls during lunch and leaving the
           tavern at some time between 2pm and 2.30pm.

12.36      Mr Hinze was questioned at length about the route that he took to Newcastle
           and the various telephone calls that he made during his journey. The version of
           events that Mr Hinze’s gave in oral evidence was that he drove directly from the
           Lone Pine Tavern in Rooty Hill to Newcastle to collect a suit for his wedding.
           The only stop that he made along the way was a 5 minute rest break at a

627
    AQIS.1000.036.0010-0011
628
    T 1835 (Hinze)
629
    T 1843 (Hinze)


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                                                                                        SUBS.INQ.001.0131




            service centre on the F3 Freeway between Wyong and Warnavale. He then
            continued along the Freeway without any further stops and arrived at the
            Gentleman’s Outfitters in central Newcastle at about 4.30pm.

12.37       On the basis of Mr Hinze’s mobile phone records and the route he apparently
            followed from Rooty Hill to Newcastle via the F3 Freeway, a period of about half
            and hour to three-quarters of an hour remained unaccounted for. Mr Hinze
            rejected any suggestion that he had in fact stopped during this period at an
            unidentified location to treat a horse. Mr Hinze maintained that he had gone
            directly to Newcastle, collected his suit and driven back to Muswellbrook. Other
            than the Coolmore horses at ECQS, the only horses that he came into contact
            with that day were his own horses, which he fed after he arrived home at about
            7.30pm or 8pm. Mr Hinze said that these horses did not show signs of equine
            influenza until 29 September 2007.

12.38       Approximately 12 weeks after giving oral evidence before the Inquiry, Mr Hinze
            made a statutory declaration in which he stated that on his way from the Lone
            Pine Tavern to Newcastle on the afternoon of 14 August 2007 he had in fact
            stopped off at the premises of a dressmaker, Ms Jennifer Rose, in Tudor Street,
            Hamilton to collect a bridesmaids dress for his wedding.630 Tudor Street,
            Hamilton, is between 3 and 4km from the centre of Newcastle.

12.39       Mr Hinze stated that he had only been reminded of this fact by his wife after he
            had given evidence. Mr Hinze said that he now recalled parking outside the
            dressmaker’s premises in Hamilton and paying for the dress with his debit card.
            According to the Westpac EFTPOS transaction record, the payment from Mr
            Hinze’s debit card was processed at 3.58pm.631 Mr Hinze stated that he left the
            premises in Hamilton after about 5 or 10 minutes and travelled directly to the
            Gentleman’s Outfitters in the centre of Newcastle. This new evidence is relevant
            in explaining partially, if not completely, Mr Hinze’s movements that afternoon
            and, in particular, the 30 to 45 minute period that he was unable to account for
            when he gave oral evidence.

12.40       There is no evidence before the Inquiry to contradict the version of events put
            forward by Mr Hinze in his oral evidence and in his two statutory declarations to
            the Inquiry.

12.41       The following day, 15 August 2007, Mr Hinze returned to his farrier duties at
            Coolmore Stud in Jerrys Plains and treated a horse, Miss Precisely, and a
            number of foals. He told the Inquiry that in the week after his visit to ECQS, he
            only performed farrier work on horses at Coolmore Stud and did not treat any
            horses for private clients. According to the head veterinarian at Coolmore Stud,
            Dr John Freestone, no horses at the stud displayed symptoms of equine
            influenza until 28 September 2007. In his opinion, the virus was introduced to
            Coolmore Stud by the large volume of mares brought onto the stud each day
            during the breeding season. On this basis, it is unlikely that Mr Hinze was a
            source of indirect transmission of the equine influenza virus from horses at


630
      WIT.COOL.015.0001
631
      WIT.COOL.015.0003


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               ECQS to horses at Coolmore Stud that he treated in the days immediately
               following his attendance at the quarantine station on 14 August 2007.

Activities of grooms during PAQ

IRT/CBHIT

Tetsuhito Hirose

12.42          Mr Tetsuhito Hirose was contracted to perform the role of head groom for IRT
               prior to the arrival of Ms Cushing on 11 August 2007. Mr Hirose had been in
               residence with horses undertaking PAQ at ECQS on up to 15 previous
               occasions and said that he was aware of the requirement that grooms shower
               and change their clothes before leaving the station. Mr Hirose recalled leaving
               ECQS on about 5 occasions during his stay in August 2007. He told the Inquiry
               that he showered and changed his clothes on each of these occasions. He also
               stated that when he arrived at ECQS on 4 August 2007, he was aware that
               there was a book to be signed on the way in and out of the grooms’ quarters.
               He agreed that he did not sign in and out each time he left the quarantine
               station.

12.43          Mr Hirose gave evidence that he did not have contact with horses outside
               quarantine during his stay at ECQS between 4 and 11 August 2007.

Pauline Cushing

12.44          Ms Cushing arrived in Melbourne with a consignment of horses from the USA
               on 11 August 2007. On the same day, she travelled from Melbourne to Sydney
               on a domestic flight and took a taxi straight to ECQS. Immediately after arriving
               at ECQS, Ms Cushing had a shower, changed into her work clothes and went
               down to the horse stables. Ms Cushing replaced Mr Tetsuhito as the head
               groom responsible for all the IRT horses at ECQS as well as the groom directly
               responsible for the day to day care of the IRT horses in Row C.

12.45          Ms Cushing has spent a large amount of time over a number of years in
               residence at ECQS. She told the Inquiry that it was commonplace for grooms to
               go out throughout the day to the local shops or to the pub for lunch without
               showering and changing their clothes.632 Although Ms Cushing was aware of
               AQIS requirements, she personally did not always shower out before leaving
               the quarantine station for short periods during the day. However, she always
               changed her clothes. During the August 2007 intake, Ms Cushing observed that
               some of the Coolmore and Darley grooms showered and changed before going
               out and some did not. Ms Cushing told the Inquiry that she did not regard
               herself as responsible, in her capacity as head groom for IRT, for ensuring the
               grooms employed by the studs complied with AQIS requirements such as the
               requirement to shower and change immediately prior to leaving ECQS.633

12.46          Ms Cushing was aware of the grooms’ book but gave evidence that the
               requirement to sign in and out was not routinely followed by grooms at ECQS.
632
      T 1500
633
      T 1501


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            Ms Cushing made an entry in the grooms’ book on only 2 occasions prior to the
            outbreak of equine influenza.

Kim Maguire

12.47       Ms Kim Maguire was responsible for the care of 10 horses in Row F (3 for
            CBIHT and 7 for IRT). Ms Maguire reported to Ms Cushing in her capacity as
            IRT head groom. Despite her previous periods in residence at ECQS, Ms
            Maguire told the Inquiry that she was not aware of the requirement to shower
            and change before leaving the quarantine station.

12.48       According to Ms Maguire, it was commonplace for onsite grooms to go out for
            short periods during the day to buy items from the local shops or service station
            or go out for lunch or a drink. Consistent with Ms Cushing’s evidence, Ms
            Maguire said that on these occasions she was aware that grooms would leave
            without showering or changing their shoes or clothing. Under questioning, Ms
            Maguire was not able to identify any of the grooms in the August intake who did
            not regularly shower out. In her view, there was no ‘hard and fast rule’ regarding
            showering out. Ms Maguire did not shower and change before going out to the
            local shops. She would only change her shirt if it was particularly dirty and
            perhaps change out of her work boots into thongs.

12.49       Ms Maguire knew about the groom’s book and said that some of the grooms did
            not complete an entry prior to leaving the quarantine station.634 Ms Maguire was
            one of the few grooms that regularly signed in and out in the grooms’ book.

Arrowfield

12.50       Mr Bowd was the sole groom responsible for the Arrowfield stallion, ‘Snitzel’, in
            Row C. Mr Bowd told the Inquiry that during his stay at ECQS he went out on a
            number of occasions to visit the local shops, buy carrots for the horses or go out
            in the evening with the other grooms. Mr Bowd would sometimes accompany
            the Coolmore or Darley grooms because they had access to the vehicles owned
            by their studs. Mr Bowd recalled going out to the pub for lunch a couple times
            with the other grooms for up to an hour while he was on duty.

12.51       Mr Bowd told the Inquiry that he always took a shower and changed his clothes
            before leaving ECQS, even if he was only going out for a short period.
            However, he would not always shower immediately before leaving ECQS, for
            example, if he was waiting around for other grooms to join him before going out.
            Mr Bowd gave equivocal evidence as to whether or not he observed other
            grooms leaving ECQS without showering or changing out of their work clothes.

12.52       Although Mr Bowd was ‘inducted’ by Ms Christesen on the day of his arrival, he
            told the Inquiry that he was not aware of the existence of the grooms’ book until
            about 4 days later. He acknowledged receiving and reading the ‘AQIS
            Expectations’ document, which referred to the requirement for grooms to sign in
            and out but said he was ‘unsure’ about the grooms’ book until some time later.


634
      WIT.CBHIT.0005


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           Subsequent to that, Mr Bowd made 3 entries in the grooms’ book between 13
           and 25 August 2007.

Coolmore

12.53      There were 4 Coolmore grooms in residence at ECQS in the first 2 weeks of
           PAQ (Benjamin Faulkner, Thomas Heaney, Jim Carey and Gabriel Walsh).
           Although, Mr Faulkner and Mr Heaney had been in quarantine at ECQS before,
           the most senior of the onsite grooms was Mr Carey. Mr Gabriel Walsh was the
           only groom that had never previously been to ECQS.

12.54      Although the 4 onsite grooms had some recollection of being told about rules
           and procedures when they first arrived at ECQS on 7 August 2007, the
           evidence they gave about their awareness of the requirement to sign in the
           grooms’ book and to shower and change each time they left the quarantine
           station was rather vague. Nonetheless, they each signed groom authorisations
           on the day of their arrival, in which they agreed to adhere to the requirement to
           shower out and change. Mr Heaney was the only one who was able to
           confidently recall being informed by Mr Hankins about the requirement to sign in
           and out.

12.55      Mr Faulkner gave evidence that he signed in and out somewhere in the grooms’
           quarters on at least a few occasions. However, according to grooms’ book
           produced to the Inquiry, no Coolmore employee made an entry during the
           period between 4 and 25 August 2007.

12.56      The grooms all gave evidence that they left ECQS from time to time to visit the
           local shops or to go out in the evening to the pub. They also spent time on their
           days off at shopping centres in Western Sydney and sightseeing in the city.
           They gave evidence that they always showered and changed their clothes
           before leaving ECQS even if they were only going out for a short period. For
           example, Mr Heaney said that he would often leave ECQS in the morning to go
           out and buy a paper but he would always shower and change first. He would
           then change into his work clothes when he returned to the quarantine station
           and start his daily duties. None of the grooms said that they observed other
           grooms leaving the station in their work clothes or without showering.

12.57      With the exception of Mr Carey, the grooms stated that on the occasions that
           they left ECQS they did not go near other horses. Mr Carey confirmed that he
           attended the Randwick Racecourse on 11 August 2007 with the Coolmore
           veterinarian, Dr Crowley, but that neither of them had any direct contact with
           horses. Mr Carey said that he showered and changed into a brand new suit and
           pair of shoes before leaving ECQS to attend the races.

12.58      The senior groom responsible for the 12 Coolmore stallions during PAQ was Mr
           Gerard St John. Mr St John stayed offsite at a nearby hotel and attended ECQS
           each day to supervise the 4 onsite grooms. Mr St John told the Inquiry that he
           would shower and change at his hotel before arriving at ECQS at about 6am in
           the morning. He would then change into his work clothes and boots. He kept his
           work clothes and boots in a locker near the showers in the grooms’ quarters. Mr
           St John recalled being told about the requirement to shower out by Ms


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             Christesen on the night of his arrival at ECQS. He said that he showered and
             changed out of his work clothes in the grooms’ quarters on each occasion that
             he left the station. Mr St John was aware that the grooms’ book was kept
             somewhere in the grooms’ quarters but he did not use it to sign in and out each
             time he attended or left the quarantine station.

Darley

12.59        Darley had 9 grooms in residence at ECQS for the first two weeks of PAQ. This
             does not include Mr Wayne Chapman, who stayed overnight at ECQS on 7
             August 2007 and then returned to the Darley Stud in Aberdeen with Mr John
             Sunderland and Mr Stuart McKay.

12.60        Most, but not all, of the Darley grooms said that they were aware of the grooms’
             book and the requirement to sign in and out. Some of the grooms also recalled
             being told when they arrived about the requirement to shower out when leaving
             the quarantine station.

12.61        Like all the onsite grooms, the Darley grooms were permitted to leave the
             quarantine station during the day when they were not working. A number of the
             Darley witnesses said that they would often go out for short periods to the local
             shops to buy everyday items or use the internet café. On their days off some of
             the grooms went further a field, for example, to the Parramatta shopping mall or
             sightseeing around Sydney. Mr Zajic said that it was not unusual for the grooms
             to go out together in the evening for a meal or a drink.

12.62        The evidence of the Darley grooms and the entries in the grooms’ book
             demonstrate that as a group they did not strictly comply with the requirement to
             sign in and out. There are approximately 9 entries made by Darley employees
             in the grooms’ book between 4 and 25 August 2007.635 This is despite their
             evidence that they would often leave ECQS at least once each day.

12.63        Compliance by the Darley grooms with the requirement to change and shower
             out when leaving the quarantine as group was not consistent. Four of the
             grooms (Daniel Halford, Mark Delaney, Mark Deering and Derek Fowler) said
             that they always showered and changed each time they left ECQS. The
             remaining Darley grooms (Aaron Goodworth, Jerry Keegan, Jim Zajic and
             Matthew Jackson) said that they did not always shower out and change their
             clothes especially if they were only leaving the quarantine station for short
             periods during the day. Most of the grooms in the latter category said that they
             always showered out and changed if they were going out at the end of the day
             for a meal or drinks.

12.64        None of the Darley grooms appear to have had any contact with horses outside
             quarantine on the occasions that they left ECQS. Generally speaking, the
             Darley grooms were aware that they were not permitted to have contact with
             other horses while they were caring for the horses in PAQ.


635
      The Darley grooms that made entries in the grooms’ register were Matthew Jackson, Jim Zajic, and
      Daniel Halford.


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Clinical signs of respiratory illness emerge at ECQS

12.65      In the morning and evening of 12 August 2007, Ms Cushing observed that
           Danbird, a stallion in Row C, had a temperature of 38.8º. Ms Cushing had only
           just taken over the care of the IRT horses in Row C from Mr Tetsuhito. Ms
           Cushing attributed Danbird’s elevated temperature to it being ‘an excitable
           horse’ and did not feel it was necessary to notify AQIS.636

12.66      At about 7am on 17 August 2007, Mr St John noted that Encosta de Lago had a
           temperature of about 38.5º or 38.6º together with slight coughing and a little
           nasal discharge. Mr St John made a note of his observations in his dairy entry
           for that day. Dr Freestone, the head veterinarian at the Coolmore stud in Jerry’s
           Plains, advised Mr St John in a telephone call that blood should be taken and a
           scan of the horse’s chest and lungs carried out. Mr St John requested that Dr
           Whitfeld from REC attend ECQS to collect the blood sample. Dr Whitfeld was
           unavailable so he asked Dr Greg Nash to attend ECQS instead. Dr Nash had
           not had any contact with the Coolmore stallions in Row E on his previous
           attendances at ECQS in August 2007 because REC had not been specifically
           engaged by Coolmore.

12.67      Dr Nash arrived at about 10am and went to Row E to conduct an examination of
           Encosta de Lago. He was assisted by Mr St John. Dr Nash also performed an
           ultrasound examination and took 2 blood samples from the stallion, which he
           later delivered to the Equine Diagnostic Laboratory at REC. Dr Nash returned to
           ECQS in the late afternoon to re-examine Encosta de Lago. Following
           consultation with Dr Freestone, Dr Nash decided to commence antibiotic
           treatment.

12.68      The following day, Dr Adams attended ECQS in the morning to continue
           treatment of Encosta de Lago as Dr Nash was not working over the weekend.
           Dr Adams conducted an examination in the yard and was also assisted by Mr St
           John. Later in the evening, Dr Adams returned to ECQS and administered
           penicillin and gentamycin to Encosta de Lago.

12.69      On 19 August 2007 at about 10am, Dr Adams attended ECQS and performed a
           clinical examination of Encosta de Lago and took a blood sample for pathology
           analysis. While Dr Adams was treating to Encosta de Lago in Row E he was
           approached by a Darley groom and asked to examine Elusive Quality, an
           American stallion in Row B. The stallion had an elevated temperature (39.9º)
           and a slightly elevated heart rate.637 Dr Adams conducted an examination and
           concluded that the horse had a respiratory infection or colitis.638 Dr Adams
           placed the stallion on a course of antibiotics and fluids and collected a blood
           sample. Dr Adams was assisted by Mr Zajic and Mr Stuart McKay during his
           examination. Dr Adams returned to REC with the blood samples that he had
           collected from Encosta de Lago and Elusive Quality. The results suggested that
           Elusive Quality was mildly dehydrated. According to Dr Adams, the results were
           otherwise within normal parameters.

636
    T 1521
637
    Adams para 27
638
    para 27


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12.70      Later that afternoon, Dr Adams returned to ECQS to continue treatment of
           Encosta de Lago and Elusive Quality. He subsequently called Mr John
           Sunderland to discuss the health of Elusive Quality.

12.71      At 4.30am on 20 August 2007, Dr Adams was advised by telephone that
           Elusive Quality was ill. He agreed to attend ECQS with Dr Nash. Dr Adams
           arrived at ECQS at about 6.30am in the morning and examined Elusive Quality.
           Dr Nash arrived shortly after and also conducted an examination. The stallion
           had a high temperature, noisy lungs, and pulses in both feet and was
           dehydrated. He did not have a cough or any nasal discharge.639 The stallion
           was transferred to the surgery stall to allow for treatment with intravenous fluids
           and blood samples were collected. Dr Nash left ECQS at about 8am. He called
           Professor Hutchins, a REC consultant, to arrange for him to provide a second
           opinion on the stallion’s condition. Dr Adams remained at ECQS to monitor the
           stallion.640

12.72      At some stage that day, blood samples were taken (probably by Dr Nash) from
           Encosta de Lago, Danehill Dancer and Elusive Quality. Dr Widders advised
           Dr James Watson at AHHL that these three horses were showing pyrexia and
           respiratory symptoms and that plain sera would be sent to him for analysis
           against the samples in the National Serum Bank taken on 8 August 2007.641 Dr
           Watson received the samples direct from ECQS at around 8am the following
           day.

12.73      In addition, Dr Nash submitted blood samples to the REC laboratory for
           pathology analysis. According to Dr Nash, a pathology report on these samples
           was handed to him at some stage during the afternoon.642 Dr Nash told the
           Inquiry that the pathology results for Encosta de Lago did not raise any
           concerns. The results for Danehill Dancer indicated that the horse was
           ‘recovering’ rather than suffering any major problem. However, the results for
           Elusive Quality indicated that the horse was definitely sick, probably from a
           bacterial infection, and in obvious need of treatment.643

12.74      Dr Nash attended ECQS for the second time that day at 11am and met with Dr
           Adams and Professor Hutchins to discuss treatment options for Elusive Quality.
           They decided to increase the level of penicillin and recommended the use of
           Lily Pads (orthotic boots) to treat the pulses. Dr Nash was then approached by
           Mr St John and advised that 3 Coolmore stallions, Antonius Pius, Aussie Rules
           and Stravinsky, had slightly elevated temperatures and slight nasal discharge.
           On examination, Dr Nash noted very mildly elevated temperatures and some
           slight nasal discharge.

12.75      While at ECQS, Dr Nash received a telephone call from Dr Widders requesting
           that he collect nasal swabs and blood samples from all the horses in Row B and
           Row E for testing at AHHL.644 Dr Nash and Dr Adams collected a total of 21

639
    WIT.REX.001.0006-0007
640
    para 31
641
    REX.0001.003.0067
642
    REX.0002.002.0095
643
    T 1585-1586
644
    The instructions were also contained in a facsimile sent by Dr Widders to ECQS (CI.0001.020.0002).


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            blood samples and 19 nasal swabs during the afternoon. Two Coolmore
            stallions, Rock of Gibraltar and Statue of Liberty, could not be nasal swabbed.
            The samples were placed into eskies and collected by a courier at about
            4.30pm for delivery to AHHL in Geelong.

12.76       Dr Nash returned to ECQS in the morning on 21 August 2007 to examine
            Elusive Quality. The horse had further deteriorated and had an elevated
            temperature, nasal discharge, occasional cough and slight pulses in his front
            feet. Dr Nash also administered antibiotics to Encosta de Lago before leaving
            ECQS. He returned later in the afternoon to continue treatment of both horses.
            Dr Nash examined Danehill Dancer at the request of Mr St John and observed
            that the horse had swelling in its limbs and a temperature of 38.2. He
            recommended treatment with oral bute. Dr Nash told the Inquiry that by the end
            of 21 August 2007, he was of the view that Elusive Quality was suffering from
            an upper respiratory infection that was most likely bacterial and that Encosta de
            Lago had a low-grade upper respiratory tract infection. He did not suspect
            equine influenza in either case.

12.77       Mr Zajic called Dr Nash early in the morning on 22 August 2007 and expressed
            concerns about Elusive Quality. Dr Nash arrived at ECQS to examine the horse
            and was very concerned about his condition. He contacted Dr Bruyn, Dr Begg
            and Professor Hutchins for second opinions. Dr Nash also met Dr Edgar and Mr
            Sunderland from Darley at the grooms’ quarters to discuss the condition of the
            horse. Both were wearing overalls and boots. The group visited Elusive Quality
            but did not handle the horse. During their visit, Dr Edgar suggested that Dr
            Nash contact the Animal Health Trust to discuss the possible presence of
            equine influenza at ECQS.

12.78       Whilst at ECQS, Dr Nash went to Row E to examine Danehill Dancer for a
            second time. He found the horse’s condition slightly improved and collected a
            blood sample for pathology analysis. Dr Nash then examined Antonius Pius,
            also in Row E. He observed a slight nasal discharge and collected a blood
            sample from the horse. He also examined Aussie Rules but found nothing of
            concern.

12.79       Dr Widders called Dr Nash on 22 August 2007 and advised that he should be
            showering out after each of his attendances at ECQS. Dr Nash told the Inquiry
            that he commenced showering out from that point onward.

12.80       Later that morning, Dr Nash attended ECQS and met with Dr Begg and
            Professor Hutchins. All three wore protective clothing. The consensus was that
            Elusive Quality was suffering from a lung infection and that the current
            treatment should continue. Dr Nash attended ECQS at various times throughout
            the day to monitor Elusive Quality. He also advised Mr St John that the
            pathology results for Danehill Dancer and Antonius Pius appeared normal.

12.81       Dr Widders told the Inquiry that he received a report from AHHL on 22 August
            2007 containing the results of the blood sera samples collected from Encosta
            de Lago, Danehill Dancer and Elusive Quality on 20 August 2007.645 In Dr

645
      REX.0001.003.0067


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            Watson’s view, Encosta de Lago’s antibody level on 8 August 2007 suggested
            that he had not previously been effectively vaccinated against equine influenza
            while his antibody level as at 22 August 2007 showed that he had
            seroconverted to the virus. Dr Watson considered that the results for Danehill
            Dancer and Elusive Quality did not reveal any significant changes.

12.82       After receiving Dr Watson’s report, Dr Widders advised Dr Nash by telephone
            that Encosta de Lago had elevated titre levels suggesting that equine influenza
            was a consideration.

12.83       On 23 August 2007, AHHL provided a further report on the blood sera samples
            and nasal swabs collected from horses in Row B and Row E some of which
            indicated a positive result to equine influenza.646




646
      AQIS.1000.010.0018


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13        THE MAITLAND EVENT

The Carroll’s Ranch Event

The circumstances of the outbreak of equine influenza at the Maitland Event

13.1        On 17, 18 and 19 August 2007 the Ranch Riding Club conducted an equestrian
            event (the “Carroll’s Ranch Event”) using facilities at the Rutherford Polocrosse
            ground (“the polocrosse ground”) and a private equestrian facility known as
            Carroll’s Ranch. Evidence before the Inquiry has identified the Carroll’s Ranch
            Event as an important means by which equine influenza was rapidly spread into
            the general horse population of New South Wales and Queensland. The
            Carroll’s Ranch Event is a reference point for potentially tracing back the spread
            of equine influenza to discover the means by which it was released from the
            quarantine system.

13.2        Approximately 220 entrants competed in the Carroll’s Ranch Event. With the
            exception of one competitor who could not be located,647 the competitors at the
            Carroll’s Ranch Event were each interviewed and (together with other
            corroborative witnesses and Judges at the event) their evidence has been
            placed before the Inquiry. Each competitor gave evidence about the location of
            their horse or horses in the weeks prior to the Carroll’s Ranch Event. They also
            gave evidence about the contact their horse or horses had prior to the
            competition with any farriers, veterinarians, horse dentists, chiropractors,
            remedial therapists, feed suppliers, commercial horse transporters, the
            Randwick Equine Centre, the Wollondilly Equine Centre, the Coolmore or
            Darley Studs or officers from AQIS. The competitors described their travel
            details to the Carroll’s Ranch Event, their movements during and after the event
            and when their horse or horses first contracted equine influenza (if they did).

13.3        Competitors were asked to describe the health of their horse or horses in the
            lead up to and during the Carroll’s Ranch Event. They were also asked to
            describe if they observed or heard of any other horses at the event with specific
            symptoms (which were all characteristics of a horse infected with equine
            influenza).

13.4        The information supplied by competitors and the further investigations which it
            prompted, has been unable to identify a link to the quarantine system and an
            explanation for how the disease was released into the general horse
            community.

An infected horse at the Carroll's Ranch Event

13.5        In the weeks following the Carroll’s Ranch Event there was an outbreak of
            equine influenza in New South Wales and Queensland which could accurately
            be described as an explosion. By 10 October 2007 the total area infected was
            278,000 km² with over 4500 infected premises.648 Epidemiological tracing back
            of the disease as it spread through the general horse population of New South

647
      Amy Maddock.
648
      DAFF.1000.032.0313.


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            Wales and Queensland showed the outbreak to be spread by horses that had
            competed in the Carroll’s Ranch Event.649

13.6        Although Equine influenza is required by law to be reported, there had been no
            reports of equine influenza in the general horse population prior to the Carroll’s
            Ranch Event.650

13.7        Following the Carroll’s Ranch Event, the earliest date of equine influenza
            symptoms known to the Inquiry were on 21 August 2007. They occurred at
            three geographically separate locations. A horse owned by Aimee Small at
            Cooranbong on the Central Coast of New South Wales, two horses owned by
            teenagers, Hannah and Clare Anderson, at Arcadia near Galston in the north
            western suburbs of Sydney and a horse owned by Mrs Cheryl Grant near
            Tamworth, exhibited symptoms of equine influenza. On the following day, the
            first two horses with equine influenza at CPEC started to show symptoms.
            Those horses were owned by Millie Beardmore.

13.8        More than another 30 horses geographically spread over a significantly large
            area of New South Wales and Queensland each started to show symptoms of
            equine influenza within a few days of 21 August. These horses had a common
            link with each other. They had all attended the Carroll’s Ranch Event. In
            addition, each of the early cases (except for Jessica Farrell) had stayed at the
            Rutherford Polocrosse grounds on the evening of 18 August 2007.

13.9        In the opinion of Dr Britton, an epidemiologist, the extent of spread of infection
            during the Maitland event (as indicated by the large number of symptomatic
            horses shortly afterwards) was too great to have been caused by anything other
            than an infected horse or horses attending the Carroll’s Ranch Event. A
            person, equipment or transport vehicle with fomites of the virus could not have
            infected such a large number of horses at the Carroll’s Ranch Event. In all
            likelihood, a horse that was subclinical or with early signs of the disease was
            likely to have attended the Carroll’s Ranch Event.651 A number of witnesses
            gave direct evidence consistent with a horse exhibiting symptoms of equine
            influenza at the Carroll’s Ranch Event. One of the symptoms of the influenza is
            a distinctive cough.

13.10       At about 5.30 am or 6.00 am on Saturday 18 August, Aimee Small who had
            stayed on Friday night at the polocrosse ground, walked from her float towards
            portaloo toilets at the eastern end of the Over the Top Yards. While walking in
            that direction, Ms Small heard a horse with a cough. The cough came from
            east of the centre of the Southern Cross Yards in the row of the yards closest to
            the Over the Top Yards. The area identified by Ms Small was occupied by
            horses brought to the event by Nichola Richardson and Norman Hindmarsh.
            Ms Small observed the horse that coughed was covered in blankets and had a
            hood over its head. The other horses in that area also had rugs over them. Ms
            Small was not able to give evidence of any distinctive features of the horse that



649
      See AQIS.0001.043.0335 – 0336 and DAFF.1000.032.0308 - 0345.
650
      WIT.DPI.002.0001.
651
      DPI.0001.002.0019.


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            was coughing. She recalled that the horse had a hacking cough which sounded
            as it it was clearing its lungs.652 She did not know the horse or its owner.

13.11       About six or seven hours later, at about 12.30 pm, Christine Bates, a competitor
            at the event, went to a tap located at the western end of the Over the Top
            Yards. While she was at the tap, she heard a distinctive cough coming from a
            stall in the Southern Cross Yards. She described the cough as dry and with a
            roughness which was unusual. As she looked up, the horse coughed again in
            the same manner. Ms Bates was about 20 metres away from the horse. She
            recalls that it was chestnut in colour with another horse next to it that was also
            chestnut in colour. She recalls that one of the horses had a rug on and the
            other did not. She recalls a woman between the age of about 20 and 30 came
            up and stood in the general vicinity of the coughing horse. She had dark hair
            and was wearing a t-shirt and jodhpurs. Ms Bates did not recognise the woman
            or the horses. Ms Bates identified an area of the Southern Cross Yards.653
            From other evidence, this was an area that was occupied by Julie Allen,
            Kathleen Chadderton and Michael Goddard. Julie Allen’s horse was chestnut
            and Kathleen Chadderton’s horse was bay in colour. Michael Goddard had a
            grey horse.654

13.12       Ms Carolyn Murphy, another competitor at the event, heard a coughing horse at
            about the same time. As Ms Murphy was walking her horse from a float to the
            show jumping area, she heard a coughing horse. She could not recall whether
            the horse was in a yard or tied to a float. She looked over her shoulder as she
            had never heard a horse cough like that before. She looked at the horse. By
            the time she came to give evidence, she could not recall what the horse looked
            like. She did not think it was an unusual breed or colour as those are matters
            which would likely have stayed in her memory. She marked on a plan the
            approximate place where she heard the coughing horse.655 That was an area
            near the south-eastern area of the Over the Top Yards. From other evidence it
            is an area that was occupied during the evening (but not necessarily at this
            time) by Michael Chamberlain, Emma Cudmore and Cheryl Grant. The area
            identified by Mrs Murphy is a significant distance from the area identified by Ms
            Bates.

13.13       Between about 1.00 pm and 2.00 pm on the same day Patricia Chadwick
            telephoned her friend Deborah Hornby and told her that she could see “a horse
            coughing up a lung”. Ms Hornby gave evidence of this conversation.656 The
            conversation was overheard by Mrs Chadwick’s daughter, Stacey, who was a
            competitor at the event.657 Stacey did not actually see or hear the horse her
            mother was speaking about to Mrs Hornby. Mrs Chadwick gave evidence by
            way of statement and orally. Mrs Chadwick recalled ringing Mrs Hornby on a
            number of occasions during the weekend. Mrs Chadwick did not recall a
            conversation with Mrs Hornby whereby she made observations about a
            coughing horse. Mrs Chadwick also could not recall seeing a coughing

652
      WIT.MAIT.003.0004, EII.0001.001.0008_1.
653
      WIT.MAIT.023.0001 – 0002; EII.0001.001.0204.
654
      EII.0006.001.0261.
655
      WIT.MAIT.067.003; WIT.MAIT.067.0006.
656
      WIT.MAIT.035.0002.
657
      WIT.MAIT.028.0003.


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            horse.658 Mrs Chadwick presented as an honest witness and there was no
            reason to disbelieve her absence of recollection.

13.14       Late that afternoon, just before dark, Jodie Hine, a mounted police officer who
            was privately competing at the event, walked her horse between the Southern
            Cross and Over the Top Yards in a westerly direction. While she was walking in
            the area of the Southern Cross Yards she heard a horse cough. The horse in
            the yard made a single cough only. Ms Hine described the cough as unusual.
            Since the outbreak of equine influenza Ms Hine has come to recognise that
            cough as the type made by horses infected with the disease. She described the
            cough as a long, deep and dry cough. She had never heard a cough like that
            prior to 18 August 2007 and it immediately took her attention. Ms Hine did not
            look at the horse closely and could not describe the horse, other than by
            identifying its general location in the Southern Cross Yards. She can recall that
            the horse’s head was up and it was not eating at the time that it coughed.659
            The area which she identified included stalls occupied that evening by one of
            the Hindmarsh group and Dr Josie Holmes.

13.15       At about dusk, Susan Oram, another mounted police officer privately competing
            at the event, was walking in the vicinity of the Southern Cross and Over the Top
            Yards. Ms Oram heard a horse in the Southern Cross Yards cough several
            times. She looked in the direction of the cough and saw a grey horse with a
            purple or maroon blanket on it. Since 18 August she has heard horses cough
            that are infected with equine influenza. She thought that the horse that evening
            made a similar sound to the cough of an infected horse. Ms Oram identified the
            coughing horse to be in an area in the Southern Cross Yards.660 From other
            evidence that area was occupied that evening (although not necessarily at this
            time) by Emma Hindmarsh, Matthew Constance and Katelee McTaggart.
            Neither of those persons had a grey horse. A few stalls west of the area
            identified by Ms Oram, stalls were occupied that evening by two grey horses
            owned by Dr Josie Holmes and Chloe Cook.

13.16       In the evening at about 9.30 or 10.00 pm, Kelly Tompson was in the vicinity of
            the Southern Cross Yards watering horses that were part of the Morgan Crane
            group. Ms Tompson heard a horse cough. The horse coughed on a single
            occasion. Ms Tompson looked up and saw a grey horse with a purple or blue
            rug over it. The horse had brown spots with grey. Ms Tompson identified the
            area of the horse.661 From other evidence, this was an area that was occupied
            by a horse belonging to the Hindmarsh group.

13.17       Ms Tompson gave evidence that she recognised the horse as being one that
            she had seen earlier in the day. She said that the rider of the horse was
            smoking and that stuck in her memory. She also remembered the rider of the
            horse had a German short-haired pointer dog which was white and chocolate
            brown in colour. She thought the dog’s name was Coco. Ms Tompson gave
            evidence that the man riding the grey horse that she saw cough was recorded
            on a piece of video taken by her father at the Carroll’s Ranch Event. That piece
658
      WIT.MAIT.032.0003 – 0004; T2084.
659
      WIT.MAIT.007.0003; EII.0001.001.0186.
660
      WIT.MAIT.008.0003; EII.0006.001.0223.
661
      WIT.MAIT.009.0003; EII.0001.001.0198.


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            of video was shown to several witnesses. Dr Josie Holmes identified the
            person in the video as being her work colleague, Mr Michael Goddard.662

13.18       Later that night at about 10.00 pm or 12.00 am Jamie Birkett was restless and
            went for a walk from the eastern half of the polocrosse ground towards the
            western half. As he left the float he was sleeping in, he heard a horse in the
            direction of the Southern Cross or Over the Top Yards noticeably coughing. He
            recalled that the cough was very dry. His float was parked about 30 metres
            from the nearest point of the Southern Cross Yards in a south-easterly direction
            from the yards. After Mr Birkett returned to his float, he continued to be
            unsettled. At some time later he left the float and tried to sleep in his car. He
            remembers hearing the horse cough again at about 4.00 am. The horse
            coughed two or three times. It was the same sort of very dry cough. It was
            hard to tell where the horse was located but he thought the cough was from
            about the middle of the Southern Cross and Over the Top Yards area.663

13.19       On the morning of 19 August 2007, the competitors left the polocrosse grounds
            and travelled a short distance to the cross country course at Carroll’s Ranch.
            When the competitors arrived at the course, most of them “walked the course”.
            That involved the riders ambulating along the course for the purposes of
            familiarising themselves with the jumps and other obstacles they were required
            to negotiate as part of the competition phase.

13.20       Mark Tarrant, a school teacher and competitor at the event, started to walk the
            course at about 10.30 am. While he was near a jump known as the “Sunken
            Road” he noticed that one of the horses competing was coughing as it went
            through the jump. In oral evidence he described it as “cough as it landed ... a
            heaving or something like that”.664 The horse which he observed was
            bay/brown with a black mane and a black tail. Because competitors wear the
            same equipment, including a helmet, he was not sure about his description of
            the rider. He thought the competitor was male with a lean build.665

13.21       Jamie Birkett attended the cross country event to watch Chloe Cook complete.
            Just before Chloe was to compete between about 2.00 pm and 3.00 pm, Mr
            Birkett observed a young female riding her horse up the track from the area of
            the cross country course. He recalls that she was speaking loudly. The girl
            was about 14 to 16 years old, plump, dark hair and possibly with a ponytail. He
            could not recall what her horse looked like. He remembered the horse
            belonging to this rider coughed a few times as it approached and was breathing
            very heavily at the time.666

13.22       It is probable that one or more of the observations by Ms Small, Ms Bates,
            Ms Murphy, Mrs Chadwick, Ms Hine, Ms Oram, Ms Tompson, Mr Birkett and
            Mr Tarrant were of a horse or horses infected with equine influenza. None of
            the eyewitnesses knew the horse or its owner that they had heard and/or
            observed. Their accounts are contradictory if there was a single carrier of the

662
      T2183.
663
      WIT.MAIT.038.0002 – 0003.
664
      T2120 – T2121.
665
      WIT.MAIT.004.0003 – 0004.
666
      WIT.MAIT.038.0003 – 0004.


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             virus and they suffer from the inherent difficulties with accurate identification
             evidence of often fleeting glimpses.

The possible identity of the sick horse or horses

Norman Hindmarsh, Emma Hindmarsh and Lynda Brown

13.23        Carolyn Murphy and Christine Bates each identified the coughing horse to be in
             quite different locations. However, Jodie Hine, Sue Oram, Aimee Small and
             Kelly Tompson, each identified a similar area in the Southern Cross Yards
             which was occupied by the Hindmarsh group or Matthew Constance, Katelee
             McTaggart or Dr Josie Holmes.

13.24        Each member of the Hindmarsh group (Norman and Emma Hindmarsh and
             Lynda Brown) gave oral evidence before the Inquiry. They each confirmed that
             the horses within their group were not sick prior to the Carroll’s Ranch Event,
             and did not show any signs of sickness during the competition. Although
             documents recording interviews with Mr Hindmarsh and the New South Wales
             Department of Primary Industry (NSWDPI) showed a difference with his
             evidence to the Inquiry,667 the discrepancy was only minor and did not alter the
             substance of his evidence. Whichever date was correct, Mr Hindmarsh gave a
             consistent account that his horses became sick several days after and not
             during or before the Carroll’s Ranch Event.

13.25        The Hindmarsh group stayed for two days prior to the Carroll’s Ranch Event at
             a large equestrian centre in Lochinvar operated by Heath Ryan where many
             horses stayed overnight with them. Emma Hindmarsh took riding lessons at the
             centre from a teacher called Emma Mason. Emma Mason confirmed that the
             equestrian centre in Lochinvar did not become infected with equine influenza
             until late in September 2007.668

13.26        If the Hindmarsh group’s horses were infectious by the Carroll’s Ranch Event,
             then it is likely that some horses at the Lochinvar equestrian centre would also
             have become infected during their stay. Mr Birkett was asked in oral evidence if
             Emma Hindmarsh or Lynda Brown were the girl at the cross country with a
             coughing horse. He gave evidence, after observing them that he was unable to
             say that either was the girl.669

13.27        There is no reason to reject the direct evidence of the Hindmarsh witnesses that
             their horses did not become sick with equine influenza until after the Carroll’s
             Ranch Event. Furthermore, there is no apparent connection between the
             Hindmarsh horses normally resident in Tamworth and the persons concerned
             with the relevant consignments of imported horses nor the horse quarantine
             facilities many hundreds of kilometres distant in Sydney.




667
      A one or two day discrepancy in the date of first onset of the disease after the Carroll’s Ranch Event,
      see DAFF.0001.001.0276 and DAFF.0001.001.0298 – 0299.
668
      WIT.MAIT.061.0067_R.
669
      T2306.


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Matthew Constance

13.28       Michael Chamberlain was a competitor whose horse stayed in the Over the Top
            Yards. Mr Chamberlain resides in the same north-western area of New South
            Wales as Matthew Constance does. About a week and a half after the Carroll’s
            Ranch Event, Matthew Constance telephoned Michael Chamberlain for the first
            time. Mr Chamberlain gave evidence that during the telephone call Mr
            Constance said words to the effect:

                   “I travelled home to Brisbane on Sunday after the Carroll’s Event finished
                   and by the time I arrived back about midnight my horse was sick.”

13.29       Mr Chamberlain said that Mr Constance’s statement struck him as strange. He
            recognised that the Constance horse was sick quickly and a week before the
            Chamberlain horse had become sick.         Mr Chamberlain said that the
            conversation stuck in his memory.670

13.30       Emma Armstrong provided a statutory declaration to the Inquiry but did not give
            oral evidence. Ms Armstrong gave evidence of meeting and talking with
            Matthew Constance prior to the showjumping phase on 17 August 2007. She
            said that Matthew Constance was struggling with his jumps in the warm-up. Ms
            Armstrong observed that Mr Constance’s horse looked tired. She said that Mr
            Constance told her that his horse was “not itself”. Ms Armstrong observed that
            Mr Constance’s horse was eliminated because he could not make his jumps.671

13.31       Mr Constance provided a signed statutory declaration to the Inquiry and gave
            oral evidence. He gave evidence that prior to arriving at the Carroll’s Ranch
            Event, he stayed the evening of 15 and the day of 16 August at a property
            owned by Kevin McNab at Mt Tambourine, which had about 60 horses on it. Mr
            Constance gave evidence that the horses on Mr McNab’s property did not
            contract equine influenza until about nine weeks after the Carroll’s Ranch
            Event. He said that his horse was eliminated in the show jumping because it
            stopped twice and the technical delegate eliminated him from the competition.
            He also said that the layout of the course was particularly difficult and that there
            was a high number of falls and broken rails in the showjumping. Mr Constance
            first observed his horse to show symptoms of equine influenza on Wednesday,
            22 August 2007 when he returned from a friend’s property at Wynnum.672

13.32       In oral evidence, Mr Constance said that he used a blue rug to cover his horse
            at the Carroll’s Ranch Event.673 He gave evidence that his horse was jumping
            well in the warm-up.674 Mr Constance denied that his horse was struggling in
            the warm-up to the show jumping but volunteered that his horse stopped at one
            Oxer jump.675 Mr Constance denied that his horse looked tired but he agreed
            that his horse was not one hundred per cent.676 He denied saying to Emma

670
      T2108; WIT.MAIT.016.0006.
671
      WIT.MAIT.068.0002 – 0003.
672
      WIT.MAIT.002_R, 0003_R and 0006_R.
673
      T2145 – T2146.
674
      T2146.
675
      T2148.
676
      T2148.


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                                                                                        SUBS.INQ.001.0147




            Armstrong that his horse was not quite himself but admitted saying that the
            show jumping course was particularly difficulty.677 He explained that his horse
            was not one hundred per cent but he attributed that to the long trip that he had
            made from Queensland to compete in the event and that his horse had excelled
            in the dressage phase which had taken a lot out of him.678 Mr Constance
            explained that when a horse jumps over the sunken road jump, it is possible for
            the horse to exhale heavily and make a noise.679 Mr Constance reiterated that
            his horse was tired after the return to Minden in Queensland but reiterated that
            his horse was not coughing or sick in any way until Wednesday, 22 August.680

13.33       He explained that he telephoned Michael Chamberlain because he had spoken
            to him at the Carroll’s Ranch Event.681 Mr Constance denied telling Mr
            Chamberlain that his horse was sick when he arrived at about midnight in
            Brisbane on the night of the Sunday of the Maitland Event.682

13.34       After Mr Constance gave evidence, Mr Tarrant, who sat in the court and
            observed Mr Constance, gave evidence that he was not able to identify Mr
            Constance as the person who rode the horse which he observed cough at the
            sunken road jump during the cross country of the Carroll’s Ranch Event.683

13.35       Mr McNab provided a statutory declaration to the Inquiry confirming Mr
            Constance’s evidence about his attendance at Mt Tambourine on 15 August
            2007.684 Mr McNab also confirmed that equine influenza did not arrive at his
            property until about five to seven weeks after the Carroll’s Ranch Event.

13.36       If Mr Constance had introduced equine influenza into the Carroll’s Ranch Event,
            it is likely that the horses at Mr McNab’s property would also have become
            infected. The discrepancies between the evidence of Mr Constance and Ms
            Armstrong and Mr Chamberlain are not significant and may be explained by
            different interpretations placed upon the words spoken.

13.37       Queensland DPI records supplied to the Inquiry confirm that Mr Constance’s
            horses did not exhibit symptoms of equine influenza until 23 August 2007 and
            not 19 August 2007 which was the date that Mr Chamberlain understood Mr
            Constance told him over the telephone.685

13.38       Mr Constance gave evidence in a forthright manner and his demeanour did not
            suggest that his evidence ought to be rejected. Mr Chamberlain also presented
            as a truthful witness. However, he conceded that it was not easy for him and
            that he was unable to put the words of his conversation with Mr Constance in
            first person language.686 His qualified evidence supports the possibility that Mr


677
      T2148.
678
      T2148 – T2149.
679
      T2154.
680
      T2155 – T2157.
681
      T2158.
682
      T2158 – T2159.
683
      T2169.
684
      WIT.KAM.001.0001.
685
      QLD.0001.001.0018.
686
      T2108.


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            Chamberlain may have been mistaken about what he was told by Mr
            Constance.

Millie Beardmore

13.39       Because the early cases of equine influenza following the Carroll’s Ranch Event
            were geographically dispersed, they did not result in notification to the New
            South Wales Chief Veterinary Officer as required under legislation. The first
            notification occurred as a consequence of the rapid spread of the disease within
            CPEC environment of about 200 horses concentrated in a relatively small
            area.687 In the early days of the outbreak, it was though that horses at CPEC
            were the first to be infected in the general horse population. This placed
            attention upon Millie Beardmore because her two horses were the first in CPEC
            to show symptoms. Ms Beardmore gave written and oral evidence to the
            Inquiry. She explained that her horses had been in good health prior to the
            Carroll’s Ranch Event. One of the horses hurt its leg in a fence on Saturday at
            the Event which caused Ms Beardmore to go home early and not compete in
            the cross country phase.688 Ms Beardmore was a riding teacher at one of the
            riding schools that operated at CPEC. She gave evidence that she had not
            observed any horses with symptoms of equine influenza at CPEC prior to her
            horses first showing symptoms on 22 August 2007.

13.40       Ms Beardmore’s evidence was corroborated by several witnesses. Augusta
            Clarke, who operated a riding school at CPEC also gave evidence that to her
            knowledge, equine influenza first broke out at CPEC with Millie Beardmore’s
            horses on 22 August 2007. Dee Vodden, the Centre Manager of CPEC, David
            Caple, a senior ranger at CPEC and Catherine Thurley who was relieving Ms
            Vodden in the two weeks prior to the week of the outbreak gave similar
            evidence. Dr Derek Wong, a veterinarian with a practice at CPEC, said he was
            not aware of any horses that had symptoms at CPEC consistent with equine
            influenza prior to 23 August 2007. Dr Wong treated many of the horses at
            CPEC prior to the outbreak. If horses had respiratory symptoms prior to those
            of Millie Beardmore’s horses, it is highly likely that those symptoms would have
            been brought to the attention of Dr Wong. It was Dr Wong who notified the
            Department of Primary Industries (NSW) of the outbreak of a respiratory
            disease at CPEC on 24 August 2007.

13.41       Ms Beardmore presented as a witness of truth. Her evidence was corroborated
            by other independent evidence. She did not have any connection with persons
            associated with the quarantine system or those concerned with the relevant
            consignments of imported horses. It is probable that Ms Beardmore is horses
            became infected at the Carroll’s Ranch Event by another horse in the general
            horse population which had been infected with equine influenza.

Michael Goddard

13.42       Michael Goddard was identified by Ms Tompson as the rider of a grey horse.
            Ms Tompson thought that she saw Mr Goddard’s grey horse cough in the

687
      WIT.CPEC.001.0001.
688
      WIT.MAIT.024.0005 – 0007.


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                                                                                       SUBS.INQ.001.0149




           Southern Cross Yards on Saturday evening. The circumstances of Ms
           Tompson’s identification of the grey horse on Saturday evening were less than
           ideal. She observed the grey horse in the darkness of night illuminated only by
           a torch. Ms Tompson identified the location of the horse well away from the
           yard occupied by Mr Goddard’s grey horse. These circumstances all tend to
           diminish the reliability of Ms Tompson’s undoubtedly honest evidence.

13.43      Mr Goddard is a veterinary nurse employed by the Agnes Banks Equine Clinic.
           That clinic has no apparent connection with the quarantine system or any of the
           persons in connection with the relevant consignments of imported horses. Mr
           Goddard gave a statutory declaration to the Inquiry which did not reveal any
           matters to suggest that his horse brought equine influenza to the Carroll’s
           Ranch Event.

Jessica Farrell

13.44      Jessica Farrell’s horse, “Trig”, appears to have been the only horse with early
           symptoms of equine influenza that did not stay at the polocrosse ground on the
           evening of 18 August 2007. That fact could suggest that her horse introduced
           equine influenza to the Carroll’s Ranch Event. However, Ms Farrell gave oral
           and written evidence that her horse was not sick prior to or during the course of
           the Carroll’s Ranch Event. That evidence was confirmed by James Mooney
           who owned the property that “Trig” was agisted upon prior to and after the
           Carroll’s Ranch Event. Ms Farrell presented as an honest witness who did not
           have any other connection with the quarantine system or persons connected
           with the relevant consignments of horses. It would appear that Ms Farrell’s
           horse must have had contact with an infected horse of a kind sufficient to infect
           “Trig” during the Carroll’s Ranch Event. Although Ms Farrell gave detailed
           evidence of her horse’s contact with other horses during the Carroll’s Ranch
           Event, that evidence did not reveal the identity of any likely source of the
           infection.

Julie Allen, Josie Holmes, Emma Cudmore and Tiffany Williams

13.45      Various eye witnesses to the “coughing horse” identified areas in the Southern
           Cross or Over the Top Yards occupied by Nichola Richardson, Katelee
           McTaggart, Kathleen Chadderton, Julie Allen, Michael Chamberlain, Emma
           Cudmore, Cheryl Grant and Josie Holmes. Julie Allen and Dr Josie Holmes
           had horses with an onset of the disease so far removed in time from the
           Carroll’s Ranch Event, that the horses could not have brought an infection to
           the Event. Similarly, Emma Cudmore’s horse and Tiffany Williams’ horse did
           not contract equine influenza.

Cheryl Grant

13.46      Mrs Grant’s horse had an early infection of the disease following the Carroll’s
           Ranch Event. By a statutory declaration, she deposed to the absence of any
           symptoms of the disease prior to 22 August 2007. Her horses were in the
           Morpeth or Tamworth areas in the weeks prior to the Carroll’s Ranch Event.
           They had no apparent contact or connection with the quarantine system or
           persons connection with the relevant consignments of imported horses.


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                                                                                      SUBS.INQ.001.0150




Nicola Richardson

13.47      Nicola Richardson’s horse, “Knightrider”, did not show any symptoms of equine
           influenza until 23 August 2007. Ms Richardson gave a statutory declaration to
           the Inquiry which deposed that “Knightrider” was in normal health during and
           prior to the Carroll’s Ranch Event. Mrs Richardson resided near Scone. There
           was no other evidence to suggest any link between her and the quarantine
           system or those connected with the relevant consignments of imported horses.

Katelee McTaggart

13.48      Katelee McTaggart’s horse “Flash”, stayed at her property near Muswellbrook
           during the two weeks prior to the Carroll’s Ranch Event. The usual farrier for
           “Flash”, prior to the Carroll’s Ranch Event was Lyle Dennis. Mr Dennis did not
           work on “Flash” in the two weeks prior to the Carroll’s Ranch Event. Mr Dennis
           was interviewed by the Inquiry. He confirmed that there was no contact
           between himself and “Flash” for well over two weeks prior to the Carroll’s Ranch
           Event. Mr Dennis performed farrier work for the Arrowfield Stud. Mr Dennis
           also said he did not have any contact with the quarantine station or one of the
           farriers who went to it, Mr Brad Hinze, in July or August 2007. There was no
           other evidence to suggest any link between Ms McTaggart and the quarantine
           system or persons connected with the relevant consignments of imported
           horses.

Kathleen Chadderton

13.49      Kathleen Chadderton took three of her own horses to the Carroll’s Ranch Event
           and one of those horses had a heavy nasal discharge on 24 August 2007. In
           addition to her own three horses, Ms Chadderton took a further horse to the
           Carroll’s Ranch Event for a friend. Ms Chadderton operates a business called
           “Victory Sport Horses”, which is concerned with the training of performance
           horses, competing horses in events, training riders to compete in events and
           also selling horses. Ms Chadderton operates her business from Palm Grove on
           the Central Coast of New South Wales. Ms Chadderton placed three horses on
           18 August 2007 in the Southern Cross Yards but did not have a booking for
           those horses. Ultimately, one horse stayed overnight in the Southern Cross
           Yards and another two of her horses spent the evening in some wooden stalls
           at the polocrosse grounds.

13.50      At about 4.30 am on 19 August 2007 Ms Chadderton was awoken by Augusta
           Clarke, who told her that her horses were out and running free. It was strange
           and unusual because one of the horses was in the Southern Cross Yards while
           two were some distance away in the wooden yards. Ms Chadderton’s horses
           had never escaped at an event like this.

13.51      In the two weeks prior to the Carroll’s Ranch Event, Ms Chadderton observed
           her horses to be in ordinary health. In the week prior to the Carroll’s Ranch
           Event, Ms Chadderton had travelled to Queensland in her horse truck to deliver
           a mare and bring back a horse to her property. She gave evidence that she
           had no connection with the quarantine service or persons connected with the
           relevant consignment of imported horses.


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                                                                                            SUBS.INQ.001.0151




Michael Chamberlain

13.52          Michael Chamberlain gave oral and written evidence to the Inquiry. Mr
               Chamberlain said his horse was well before and during the Carroll’s Ranch
               Event and he presented as a witness of truth. Mr Chamberlain gave evidence
               that he did not have any dealings or contact with the quarantine service or
               persons connected with the relevant consignments of imported horses. Mr
               Chamberlain was at all relevant times in north-western New South Wales.

Daniella Dierks

13.53          On 14 August 2007, Dr James Whitfield, a veterinarian with the Randwick
               Equine Centre, visited the Mulawa Stud. Ms Daniella Dierks, a competitor at
               the Carroll’s Ranch Event and somebody who rented a stall in the Southern
               Cross Yards, worked at the Stud. Ms Dierks and Dr Whitfield said that Dr
               Whitfield sterilised his equipment prior to its use at the Stud on 14 August 2007.
               The horse which Ms Dierks rode at the Carroll’s Ranch Event had been at the
               Mulawa Stud for two weeks prior to the Event.

13.54          Ms Dierks resided on a property with her parents at 100 Arcadia Road, Arcadia.
               Ms Dierks’ parents are both dressage coaches and after Dr Whitfield attended
               at the Mulawa Stud, he then went to the property of Ms Dierks’ parents. Ms
               Dierks gave evidence that she was unaware Dr Whitfield did this and that it was
               not something that she had discussed with her parents or Dr Whitfield. She
               said that she did not associate herself with the horses on her parent’s property
               and that she lived with her parents but goes to work at Mulawa Stud.

13.55          The horses at Mulawa Stud did not contract equine influenza until
               16 September 2007. Ms Dierks’ horse did not become sick until 18 September
               2007. Ms Dierks gave evidence that her horse was not sick prior to or during
               the Carroll’s Ranch Event. She also gave evidence that she had no prior
               contact with the quarantine service or persons connected with the relevant
               consignments (other than Dr Whitfield) of imported horses. There was nothing
               about the demeanour of Ms Dierks to suggest that her evidence was not
               truthful.

Lucy Roberts

13.56          Lucy Roberts resides at the Coolmore property in the Hunter Valley in an area
               where cattle are grazed which is separate from the horse stud. Ms Roberts
               gave oral and written evidence. Ms Roberts gave evidence that her horse was
               not sick prior to or during the Carroll’s Ranch Event.

13.57          On 31 August 2007, nasal swabs were taken by the New South Wales
               Department of Primary Industry and they showed Ms Roberts’ horse to be
               negative for equine influenza. Ms Roberts gave evidence that there was no
               equine influenza on the Coolmore Stud until about October 2007. She gave
               evidence that in October 2007 horses generally at the Coolmore Stud first
               contracted equine influenza.689 Ms Roberts presented as a truthful witness.

689
      T2330.


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                                                                                             SUBS.INQ.001.0152




            There is no reason to disbelieve her evidence that her horse did not exhibit any
            symptoms before, during or immediately after the Carroll’s Ranch Event.

Conclusions with regard to the Carroll's Ranch Event

13.58       In the initial stages of the outbreak there was considerable effort by the local
            Disease Control Centre of the New South Wales Department of Primary
            Industry to identify the first infected animal at the Carroll’s Ranch Event, for the
            purposes of identifying the initial source of infection.690

13.59       Dr Rod Hoare, Dr Andrea Brittain, Dr Derek Major and Ms Vicki Burgess all
            investigated the probable identity of the infected horses which brought equine
            influenza to the Carroll’s Ranch Event. Their investigations were unable to
            identify that horse. The Inquiry had the benefit of their investigations and has
            itself reinterviewed competitors and other relevant witnesses. The competitors
            at the Carroll’s Ranch Event gave similar evidence as to the onset of the
            disease. They described the onset of symptoms at similar times after
            attendance at the Carroll’s Ranch Event and the initial symptoms they
            described were very similar.

13.60       Horses start shedding the disease about 24 hours prior to the commencement
            of showing symptoms.691 The probabilities are that the owner of the horse
            which brought the infection to the Carroll’s Ranch Event was aware of
            symptoms by no later than the evening of Sunday, 19 August 2007 and possibly
            earlier. None of the competitors at the Carroll’s Ranch Event gave evidence
            that their horse was sick at that time. It is therefore highly likely that the Inquiry
            has not received all of the relevant information about the onset of the disease in
            all horses that attended the Carroll’s Ranch Event.

13.61       The owners of the earliest infected horse or horses in the general horse
            population may have had some relationship with persons who dealt with the
            quarantine system or the relevant consignments. Those relationships may
            afford a strong motivation for the owner of the infected horse or horses at the
            Carroll’s Ranch Event to protect the identity of the persons associated with the
            release of the disease from quarantine. There may also be an apprehension of
            social or legal action against the person responsible for introducing the disease
            to the Carroll’s Ranch Event. These factors may well have led to the
            suppression of information which could have identified the horse that introduced
            the disease to the Carroll’s Ranch Event.




690
      WIT.DPI.001.0003 – 0004.
691
      DPI.0001.002.0005 – 0006.


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                                                                                     SUBS.INQ.001.0153




14        SCIENTIFIC TESTING

Tests by three laboratories on PEQ and PAQ samples

14.1        Dr Watson, a veterinary investigation leader at AAHL, gave evidence about the
            numerous tests conducted by AAHL on the samples of blood and nasal mucus
            taken whilst the imported horses were at the ECQS and SQS.

14.2        There were difficulties accessing the blood samples taken in PEQ in respect of
            the imported horses. When DAFF sought access to the USA PEQ samples
            they were advised that no sera was available. The Japanese authorities had
            retained PEQ sera but were not prepared to send the PEQ blood samples taken
            in Japan to Australia. AAHL was able to have part of the sera taken from the
            UK and Irish horses sent to it by the Veterinary Laboratories Agency (VLA) Lab
            at Weybridge, UK (who held those samples as a serum bank similar to the
            serum bank operated by AAHL).692

14.3        The Japanese authorities subsequently gave permission for Australian PAQ
            samples to be sent to Japan and tested with the Japanese PEQ samples. The
            testing was performed by the Japanese Racing Association (JRA) laboratory
            under the supervision of Professor Tomio Matsumura. A senior scientist from
            AAHL travelled to Japan and observed those tests. He considered those tests
            to have been conducted in a facility of comparable technology and process to
            the AAHL laboratory. He was satisfied that appropriate equipment and
            processes were used in the conduct of the testing. Professor Matsumura has
            an international reputation with regard to the laboratory diagnosis of viral
            diseases in horses.

14.4        By an error, the first samples taken from the Japanese horses after they had
            entered SQS were not taken to Japan for testing. That omission provided a
            longer span of time between PEQ and PAQ tests by the JRA for the horses
            from Japan in SQS than would otherwise have been the case.693

14.5        The Japanese tests of PEQ and PAQ samples were conducted in December
            2007.

14.6        The UK and Irish PEQ samples left the UK on 30 October 2007 bound for
            Melbourne and ultimately the AAHL laboratory at Geelong.694 The samples
            arrived in Melbourne on 1 November 2007 and were made the subject of a
            quarantine order.695 As no import permit was presented to AQIS at the time of
            importation, a quarantine order was placed on the consignment. A quarantine
            direction was issued to the brokers, Universal Air Cargo Pty Limited (UAC).696
            The required documentation was not presented to AQIS until 12 November
            2007. On that date the consignment was released from quarantine.697


692
      WIT.AAHL.001.0004.
693
      WIT.AAHL.001.0005.
694
      WIT.INQ.002.0015.
695
      WIT.INQ.002.0010.
696
      WIT.INQ.002.0001.
697
      WIT.INQ.002.0002.


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                                                                                         SUBS.INQ.001.0154




14.7        It would appear that the delay in release of the samples between 1 and 12
            November 2007 occurred because the responsible person at UAC was on
            annual leave and the person who was delegated the task of clearing the
            samples at quarantine and delivering them to AAHL did not do so. During the
            11 or 12 day period the samples were held in quarantine, they may have been
            “re-iced” once although there is no record when the actual event took place.698
            Once the consignment of bloods was cleared by AQIS it was delivered to AAHL
            on 13 November 2007. Prolonged storage at elevated temperatures and
            repeated freeze/thaw cycles may diminish the antibody level present in serum
            samples and make tests results from them less reliable.699 AAHL proceeded to
            test the UK and Irish PEQ samples with the Australian PAQ samples and these
            results were available in about December 2007.

14.8        As a means of obtaining further confidence in the UK and Irish results of AAHL,
            Dr Watson took sera from the UK and Irish PEQ samples together with the
            Australian PAQ samples in January 2008 to the United Kingdom for re-testing
            by the Animal Health Trust, in Newmarket, UK (“AHT”) from the VLA. The AHT
            was able to obtain further samples of the PEQ sera for the United Kingdom and
            Irish horses where they were still available and these were tested with the sera
            brought by Dr Watson. The AHT is an OIE reference laboratory for equine
            influenza. Dr Newton from the AHT is a world expert in equine influenza.

14.9        Dr Watson presented a table which summarised the results of these sera
            testing conducted by the AAHL, JRA and AHT laboratories.700

The type of tests

14.10       The serological quantitative antibody test known as haemagglutination inhibition
            (HI) was the test which formed the bulk of the serological testing conducted by
            the three laboratories on the samples.701 In the HI test serial doubling dilutions
            of sera are evaluated for their ability to inhibit haemagglutination using a
            standard set of reagents for each serum dilution.702 A four fold increase in titre
            level as measured by an HI test satisfies the definition of sero-conversion. An
            increased titre level of this magnitude is most likely caused by the presence of
            an active infection within the animal tested or it could be a response to a recent
            vaccination.703

Results for Japanese horses in Spotswood

14.11       The horses imported from Japan which entered SQS had PEQ blood samples
            taken on 17-18 and 24-25 July 2007. The Japanese horses entered SQS on 8
            August 2007 but did not have blood samples taken until 13 August 2007.

14.12       Seven of the nine horses from Japan had sero-converted according to the JRA
            tests between PEQ samples taken on 24/25 July 2007 and PAQ samples taken

698
      WIT.INQ.002.0002.
699
      WIT.AAHL.001.0004.
700
      WIT.AAHL.001.0244 – 0254.
701
      AHT.0001.001.0003.
702
      AHT.0001.001.0004.
703
      AHT.0001.001.0009.


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                                                                                      SUBS.INQ.001.0155




            on 24 August 2007.704 The two horses which did not show any sero-conversion
            were TH Dancer and Black Hawk.705

14.13       The tests conducted in PAQ can shed some light on when the seven horses
            may have been infectious between 24/25 July 2007 and 24 August 2007. Only
            one of the seven horses, Jungle Pocket, demonstrated a sero-conversion
            between 24/25 July 2007 and 24 August 2007 by the JRA tests and was
            confirmed by both AHT and AAHL to have sero-converted between 13 and 24
            August 2007.706 A second horse (Zenno Rob Roy) showed a sero-conversion
            between 13 and 24 August 2007 on the AAHL (but not AHT) results. If the
            AAHL results were correct, then Zenno Rob Roy and Jungle Pocket were in the
            same category.707

14.14       The other five Japanese horses that entered SQS (Orchard Oasis, Acoustics,
            Western World, Full of Laughter and Royal Successor) did not exhibit any
            change in titre level after 13 August 2007. Dr Newton interpreted those results
            to mean these five horses were unlikely to be infectious by 13 August 2007.708
            By contrast, Jungle Pocket and possibly Zenno Rob Roy continued to be
            infectious between 13 and 24 August 2007.

14.15       The change in titre levels for the Japanese horses could not be explained by
            vaccination occurring close to the time of the PEQ sampling on 24/25 July
            2007.709

Results for Japanese horses in Eastern Creek

14.16       Four horses imported from Japan entered ECQS on 8 August 2007 but did not
            have blood tests taken until 13 August 2007. One of the horses (Snitzel) sero-
            converted according to the JRA tests between PEQ samples taken on 24/25
            July 2007 and PAQ samples taken on 13 August 2007.710 Tests by AAHL (but
            not AHT) on the PAQ samples demonstrated sero-conversion by Snitzel
            between 13 August and 27 August 2007.711

14.17       There was apparent sero-conversion evident in Rock of Gibraltar between PAQ
            samples collected on 13 August and 27 August 2007.712 There was no
            evidence of sero-conversion by the other two Japanese horses in ECQS. The
            sero-conversions for Snitzel and Rock of Gibraltar would not be explained by
            recent vaccination because their most recent vaccinations were on 25 May and
            9 April 2007 respectively.713




704
      AHT.0001.001.0009.
705
      WIT.AAHL.001.0251; WIT.AAHL.001.0254.
706
      AHT.0001.001.0009.
707
      T4201/L35 - 42.
708
      AHT.0001.001.0009.
709
      AHT.0001.001.0009.
710
      AHT.0001.001.0010.
711
      AHT.0001.001.0010.
712
      AHT.0001.001.0010.
713
      CI.0001.046.0003.


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                                                                                         SUBS.INQ.001.0156




Results for the UK horses in Eastern Creek

14.18       Five of the twenty-two horses imported from the United Kingdom that entered
            ECQS demonstrated sero-conversions for one or both H3N8 antigens across
            the sera that included PEQ as well as PAQ samples. However, three of the five
            horses (Librettist, Wells High Class and Jorrit Van Stal Redia) had sero-
            conversions which were accompanied by sero-conversion to H7N7 antigen
            (Prague/56). The H7N7 sero-conversion could only be rationally induced by
            recent vaccination. The vaccine histories of the three horses showed they had
            been recently vaccinated on 14 July (Librettist) and 11 July (Wells High Class
            and Jorrit Van Stal Redia) 2007. The recent vaccination could reasonably
            explain the sero-conversion to both H7N7 and H3N8 antigens in these
            horses.714

14.19       Only two horses sero-converted to H3N8 in the absence of sero-conversion to
            H7N7 (Dorring Court and Dubai Destination) and these sero-conversions were
            in samples between 27 August and 7 September 2007 suggesting these were
            true infections acquired later in the outbreak.715

14.20       Country Reel exhibited a four fold increase in titre between consecutive
            samples. Dr Newton was cautious about whether this horse was actually
            infected.716 The horse had been vaccinated on 14 July 2007 which was the
            date it commenced PEQ. Dr Newton was of the view that titre levels increased
            more rapidly with an infection than had occurred with this horse. The increases
            in titre levels were probably associated with its recent vaccination.

Results for the USA horses in Spotswood

14.21       Horses imported from the USA entered SQS on 11 August 2007 and had blood
            tests taken on 13 August 2007. There were no sero-conversions by these
            horses in Spotswood.717

14.22       All eighteen horses had moderate to high HI antibody levels to H3N8 with the
            possible implication that there were no obvious sentinels that would develop
            overt signs of disease and shed large amounts of virus through coughing. This
            was probably a contrast with the situation at ECQS.718

Results for the USA horses in Eastern Creek

14.23       One of eight horses imported from the USA which entered ECQS on 3 and 7
            August 2007 demonstrated sero-conversion (Fox & Furkin). This result
            indicated sero-conversion between samples taken on 13 August and 20 August
            2007 with a relatively low level of antibody in the first PAQ sample, consistent
            with the vaccine history provided and consequential high susceptibility to
            infection. It is possible that Fox & Furkin had a relatively low residual immunity
            and acted to amplify the equine influenza virus in the early part of the outbreak.

714
      AHT.0001.001.0011 – 0012.
715
      AHT.0001.001.0012.
716
      T4177 – T4178.
717
      The AHT and AAHL tests were consistent.
718
      AHT.0001.001.0008 – 0009.


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                                                                                          SUBS.INQ.001.0157




14.24       Earlier tests performed by AAHL suggest sero-conversion to Sydney/07 antigen
            for samples taken between 27 August and 7 September 2007 for Fox & Furkin
            and Henny Hughes although these results were not confirmed by AHT, or those
            for Moulten/98 antigen conducted by AAHL.719 Fox & Furkin’s PEQ samples
            were not available and so the horse could have had an active infection when it
            entered PAQ. However, the low titre levels on 13 August and other evidence
            concerning the Japanese horses would appear to make it unlikely that Fox &
            Furkin brought an active infection into ECQS and was probably infected after
            entry into PAQ.

Results for Irish horses in Eastern Creek

14.25       Nine of the eighteen horses imported from Ireland which entered ECQS on 7
            August 2007 demonstrated sero-conversion for one (Ad Valorem, Danehill
            Dancer) or both (Antonius Pius, Aussie Rules, Encosta De Lago, Golden
            Snake, Holy Roman Emperor, Oratario, Sharmadal) H3N8 antigens. There
            were no sero-conversions evident between PEQ (11/17 July 2007) and PAQ (8
            August 2007) samples in any of the horses. The AHT results were not wholly
            consistent with those from tests conducted previously by AAHL which did
            indicate some sero-conversion between PEQ and PAQ. However, the results
            from AAHL did not appear wholly meaningful and there were doubts about the
            validity at that stage of the PEQ samples which had been held up in transit from
            VLA.

14.26       The earliest sero-conversion evident was in Encosta De Lago between samples
            collected on 13 and 20 August 2007. No other Irish horses demonstrated this
            early sero-conversion. The PEQ and immediate post PAQ samples from this
            horse were notable for their very low titre levels which would be consistent with
            high susceptibility to infection and high probability of shedding larger amounts of
            virus. This horse may have helped facilitate transmission to adjacent horses or
            via contaminated fomites. This would be consistent with Encosta De Lago
            acting as a sentinel and amplifier of infection having encountered the infection
            during PAQ rather than being the animal who introduced the infection. The fact
            that Encosta De Lago did not test positive on samples taken on or after 20
            August 2007 is consistent with this animal having been infected soon after
            arrival in PAQ and having cleared the infection before sampling began.720

Relationship between the Sydney/07, Japan/07 and Philadelphia/07 strains of
equine influenza virus

14.27       A phylogenetic tree for H3N8 was put in evidence through Dr Newton.721 It was
            based on analysing differences in the nucleotide sequences of the HA1 gene of
            the virus with viruses with identical HA1 sequences appearing vertically
            adjacent to each other with no horizontal distance between them. Horizontal
            distances in the tree represents accumulated nucleotide differences. In the
            phylogenetic tree presented by Dr Newton there are vertical lines on the right
            hand side of the tree which represent the various lineages of H3N8.

719
      AHT.0001.001.0012 – 0013.
720
      AHT.0001.001.0010 – 0011.
721
      AHT.0001.001.0080.


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                                                                                          SUBS.INQ.001.0158




14.28       The three viruses Sydney/07, Iberaki/07 and Pennsylvania/07 appear as a
            cluster of closely related viruses in the middle of the “variant American isolates”
            lineage. The three viruses Sydney/07, Iberaki/07 and Pensylvania/07 are
            identical at every amino acid residue of HA1 although there is one non-coding
            (ie the difference does not code for a change in amino acid) nucleotide
            difference between Philadelphia/07 and the other two viruses which had
            identical nucleotide sequence alignments.

14.29       It is not possible solely on the basis of phylogeny to state the precise order of
            their provenance. In considering Sydney/07 and Iberaki/07, these viruses
            demonstrated identical nucleotide as well as amino acid sequence alignments
            and therefore can be considered identical in terms of HA1, which is one of the
            most variable regions of the genome of influenza viruses.

14.30       These results are consistent with Sydney/07 and Iberaki/07 being two very
            closely related viruses that were isolated within a very narrow time window such
            that accumulated sequence changes did not have time to develop. The single,
            non-coding nucleotide sequence change from Sydney/07 and Iberaki/07 to
            Pensylvania/07 is consistent with, but not definitive proof, of a closely related
            virus circulating in North America being the source of the Japanese and
            Australian viruses. This assumes (probably reasonably) that there was no
            export of equine influenza from Japan or Australia into the USA to account for
            the small change seen in the Pensylvania/07 virus.

Relationship between the virus strains within Australia

14.31       AAHL conducted sequencing of completed genes from a range of isolates taken
            from the Australian outbreak. Comparison was undertaken of the HA1 segment
            of the viral genome for the virus isolated from samples taken at CPEC, ECQS
            and from Warwick, Queensland. The derived amino acid sequences examined
            were identical for the CPEC and ECQS isolates and differ at only one amino
            acid from Warwick. Six later isolates from a range of locations in New South
            Wales and Queensland were either identical to the CPEC isolate or differed by
            only a single amino acid.722 Dr Watson gave evidence that these results were
            consistent with there being only one strain of the virus in the Australian
            outbreak.723

Transmission of the virus into Australia and within the quarantine system

14.32       The only credible scientific explanation for the introduction of equine influenza
            into Australia is through the importation of horses. From the scientific testing,
            only the horses imported from Japan would appear to have had an active virus
            during PEQ, transportation and when they entered PAQ. Dr Newton concluded
            that the serological results and accompanying data strongly suggested that the
            most likely source of the Australian equine influenza infection in August 2007
            was through the importation of a consignment of infected horses from Japan
            rather than the USA.724 No other expert witness disagreed with this conclusion.

722
      WIT.AAHL.001.0003 – 0004.
723
      T3896.
724
      AHT.0001.001.0022 – 0023.


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                                                                                          SUBS.INQ.001.0159




14.33       Of importance to this conclusion is the evidence that there was an infection in
            both ECQS and SQS. Both infections were associated with the importation of a
            single consignment of horses from Japan which were split between the two
            quarantine facilities. Horses from Japan assigned to both quarantine stations
            demonstrated evidence of recent infection during pre-export quarantine. It is
            possible that there was also active infection present amongst the consignment
            at the time of air transport into Australia, thereby providing conditions for
            carriage of infection and onward transmission which in turn was ultimately
            dependent on the susceptibility of horses in close contact with the contaminated
            horses. Whilst SQS had an absence of susceptible horses, ECQS had
            susceptible horses in Encosta De Lago and Fox & Furkin, in close proximity to
            horses imported from Japan (Rock of Gibraltar and Stravinsky).

14.34       The results taken together with those from the part of the consignment of
            Japanese horses that transited into SQS indicate that Snitzel was a possible
            source of equine influenza virus whilst in quarantine at ECQS. However, given
            that there was the possibility of active infection amongst the group of 13 horses
            imported from Japan during PEQ and during the subsequent air transport, the
            possibility of physical carriage of the equine influenza virus into ECQS on any of
            the Japanese horses cannot be excluded. It appears likely from this evidence
            that at least one horse from Japan acted as the primary source of infection into
            the ECQS.725

14.35       Stravinsky did not have any elevated titre levels in PEQ or PAQ and five after
            days into quarantine at ECQS, Rock of Gibraltar still had the same titre level as
            he had in PEQ.726 It was only after 13 August that Rock of Gibraltar’s titre levels
            started to increase. Dr Newton’s evidence is consistent with the possibility that
            Rock of Gibraltar and Stravinsky had not been infected but had fomites on
            themselves and their equipment during air transport which came to infect
            Encosta De Lago upon arrival at ECQS.727 However, Encosta De Lago’s failure
            to show symptoms until 17 August is not consistent with such a scenario.
            Fomites can last for up to 48 hours outside of a host equine and the latency
            period of the disease is up to five days after infection.728 Assuming these
            maximum periods applied, Encosta De Lago should have shown clinical signs
            by 15 August if infected by fomites brought into the quarantine station on 8
            August which infected him by the latest on 10 August 2007.

14.36       If the transmission of the virus into ECQS was by an infected horse (rather than
            physical transmission of the disease) the sera results suggest that only Snitzel
            amongst the Japanese horses in ECQS was infected before PAQ and could
            have been actively infected at the time of entering ECQS.729 However, further
            explanation is needed for how the disease passed from Snitzel in row C to the
            area of ECQS in row E where Encosta De Lago and Rock of Gibraltar were
            located. Some elaborate scenarios for transmission from row C to row E of
            ECQS were not favoured by Dr Newton.730 Transmission of the virus to

725
      AHT.0001.001.0010.
726
      WIT.AAHL.001.0246.
727
      T4208.
728
      WIT.INQ.003.0015.
729
      T4203 – T4206.
730
      AHT.0001.001.0014.


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                                                                                         SUBS.INQ.001.0160




            Encosta De Lago could have been after arrival and during early PAQ by Rock of
            Gibraltar after he became infectious. The route by which Rock of Gibraltar
            became infected is not clear. Dr Newton considered that Rock of Gibraltar may
            have been infected during the flight. Dr Newton favoured Rock of Gibraltar as
            the most likely infector of Encosta De Lago.731 A transmission to Encosta De
            Lago by Rock of Gibraltar shedding virus was a more probable route of infection
            than a fomite to fomite transmission between Mr Bowd (who had contact with
            Snitzel) and the Coolmore farrier that worked on Encosta De Lago.732

14.37       Seven of the horses from Japan that entered SQS had elevated titre levels
            between PEQ and the PAQ tests on 24 August 2007. Five of those horses
            were no longer actively infectious after 13 August 2007 as the tests within PAQ
            for those horses showed constant titre levels after 13 August. It is possible that
            any of the seven horses from Japan which had shown a sero-conversion
            between PEQ and PAQ were still actively infectious on 8 August 2007 when
            they entered quarantine in Australia. As with the ECQS, it is possible that any
            one of them could have physically carried the virus into SQS even if they were
            not actively infected. Only Jungle Pocket and Zenno Rob Roy were still actively
            infectious after 13 August 2007. That fact suggests that they may have been
            infected at a later time than the other five Japanese horses that entered
            Spotswood but their infection could still have been while they were in PEQ. Dr
            Newton concluded that the results for Jungle Pocket and Zenno Rob Roy (and
            Snitzel) were consistent with the virus appearing to be present in PAQ and may
            well have been present and active during the air transport to Australia.733




731
      T4191.
732
      T4316 – T4317.
733
      T4201/L34, T4202/L9.


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                                                                                       SUBS.INQ.001.0161




15        EVENTS AT SPOTSWOOD QUARANTINE STATION

Overview

15.1        Wayne Gundry, manager of Spotswood Quarantine Station in Victoria gave
            evidence in relation to the operation of Spotswood and the consignment of
            horses from Japan undertaking PAQ during August 2007.

15.2        Spotswood Quarantine Station is located on approximately 12 acres, about 10
            kilometres west of the Melbourne central business district. Spotswood has
            facilities to quarantine cats, dogs, cattle, horses and birds.

15.3        Mr Gundry had been the manager of the Spotswood Quarantine Station since
            February 1989, and was assisted by Mr Angelo Ravaneschi, assistant manager,
            who had worked at Spotswood for approximately 25 years.

15.4        The Victorian region did not have a ‘Chief Quarantine Officer of Animals’
            position equivalent to Dr Widders’ position in NSW.734 Nor did the region have
            the equivalent position of Regional Manager of Live Animal Imports also held by
            Dr Widders. AQIS management above Gundry included Assistant Regional
            Manager Mr Dennis Way (Cargo Management) whose responsibilities included
            air cargo and post arrival quarantine of animals at Spotswood,735 and above
            him, Regional Manger for the Victorian region, Ms Annette Drury.

15.5        In the 2006/2007 financial year, 229 horses undertook post arrival quarantine at
            Spotswood. The majority of horses imported into Spotswood were horses
            returning from Hong Kong imported by New Zealand Bloodstock.736 IRT, CBIHT
            and Livestock Air Corporation also imported three or four smaller shipments
            each in a 12 month period.737 All the thoroughbred shuttle stallions undertaking
            PAQ at Spotswood over the previous six to nine years had come exclusively
            from Japan.738

Procedures at Spotswood Quarantine Station

15.6        Prior to the outbreak of equine influenza, Mr Gundry was aware of the
            Operations Manual and Live Horse Work Instruction, although in his evidence,
            he stated that he did not believe that either of the documents had been
            finalised. Mr Gundry recalled that he saw both these documents when they
            were circulated for comment in draft form in 2004.

15.7        Mr Gundry kept a hard copy of the Operations Manual in the office at
            Spotswood. Although he believed it was in a draft format, he thought the
            document was a comprehensive guide to the operating procedures that should
            be followed at Spotswood.739


734
      T3218.
735
      WIT.SPOT.001.0001 at para 9; T3255.
736
      T3169; WIT.SPOT.0001.0001 at para 13.
737
      WIT.SPOT.0001.0001 at para 13.
738
      T3205.
739
      T3189.


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                                                                                          SUBS.INQ.001.0162




15.8        Mr Gundry did not believe that the Live Horse Work Instruction document was
            an operational document that applied to Spotswood prior to the outbreak of
            equine influenza as Spotswood had no role in the clearance of live horses.740

Locally produced documents

15.9        Some of the locally produced documents in use at Spotswood immediately prior
            to the equine influenza outbreak were:

            (a)         Quarantine Operational Notice 1999/108: policy for access to horses
                        during quarantine

                        Mr Gundry considered the Operational Notice 1999/108 dated 6
                        December 1999741 was a policy document that was still operative and
                        which guided the procedures at Spotswood.

            (b)         Post Arrival Quarantine – Sydney 2000 Olympic Games

                        The policy documents with regard to quarantine measures for the
                        Sydney Olympics742 were part of Mr Gundry’s information pool rather
                        than documents used in day-to-day procedures. Mr Gundry believed the
                        documents represented best practice at that time and therefore he had
                        decided to implement some of the procedures included in those
                        documents.743

            (c)         Quarantine of Horses – Instructions for: Grooms and Quarantine of
                        Horses – Instructions for: Veterinarians and Farriers

                        The Quarantine of Horses documents 744 were printed in A3 format and
                        displayed as visual reminders of what the requirements were whilst on
                        the quarantine station. Mr Gundry thought that the documents may have
                        been created between 1998 and 2000 in the lead up to the Olympics745
                        and had been developed by reference to resources prepared for the
                        Olympics.

                        The veterinarian and farrier form was displayed on a pin board in the
                        main horse stables where the vets would do their paperwork and the
                        temperature charts and health record sheets were kept.746 The grooms’
                        form was displayed beside the veterinarian’s document in the main
                        horse stables, in the office area and also in the change room. In his
                        evidence, Mr Gundry stated that the instruction documents were not
                        generally brought to the grooms’ attention during the induction process




740
      T3189.
741
      AQIS.0002.016.0955.
742
      AQIS.0002.016.0959 - 0963.
743
      T3153-3154.
744
      AQIS.0002.016.0965 and AQIS.0002.016.0964.
745
      T3226.
746
      T3154.


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                                                                                                   SUBS.INQ.001.0163




                        as most of the grooms attended Spotswood regularly and were already
                        familiar with the documents.747

                        Mr Gundry’s evidence was that the documents accurately reflected the
                        procedures in place prior to the outbreak.748 The record sheets referred
                        to the veterinarian’s form were generated by AQIS and kept on a table in
                        the change room at the entrance to the main stables.749 These daily
                        monitoring sheets recorded the date, AM temperature, PM temperature
                        and any comments about the horses’ condition or treatments given.

            (d)         Authorisation for Groom to enter the Spotswood AQIS Quarantine
                        Station

                        The grooms accompanying the horses were required to sign the
                        ‘Authorisation for Groom to Enter’ document750 as set out in the
                        Operations Manual. The form contained similar conditions as the
                        document at Form 7 of the Operations Manual751 and included an
                        authorisation by the importing agent which required them to certify that:

                               I have fully explained AQIS requirements to the person named
                               above. I have instructed the person to fully comply with AQIS
                               conditions without exception. I understand that AQIS will audit
                               compliance with the conditions listed above. Detection of non-
                               compliance with the above conditions will result in increase
                               auditing or eviction of the groom from the AQIS quarantine
                               station. I will be responsible for any costs incurred relating to
                               increased auditing of grooms.

                        Mr Gundry believed that he had initially developed this authorisation
                        form (as well as the veterinarians authorisation form described below)
                        based on the conditions and processes in place during the Olympics.
                        Mr Gundry believed that this document was then incorporated into the
                        2004 draft Operations Manual.

            (e)         Authorisation for Veterinarian or Farrer to enter the Spotswood AQIS
                        Quarantine Station

                        Veterinarians and farriers were also required to sign an authorisation
                        form on entry to the quarantine station.752 This document was not signed
                        on every occasion a veterinarian attended, particularly where the same
                        veterinarian attended frequently.753 The form included the same
                        conditions as those listed in Form 8 of the Operations Manual.754

            (f)         Movement of Animals under Quarantine/Isolation Restrictions

747
      T3165 – 3166.
748
      T3226.
749
      T3226.
750
      AQIS.0002.014.0025 and AQIS.0002.016.0952.
751
      AQIS.0001.001.0080 at 0125-0126.
752
      DAFF.0001.215.0040 and AQIS.0002.016.0966.
753
      T3172 – T3173.
754
      AQIS.0001.001.0080 at 0127.


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                                                                                           SUBS.INQ.001.0164




                        Within a few days prior to the arrival of the transport vehicles,
                        Spotswood would receive a ‘movement declaration’ from the transport
                        company.755 The form was introduced by Mr Gundry and Mr Ravaneschi
                        in early 2007 in response to some trucks turning up at Spotswood which
                        had not been thoroughly cleaned out, and still contained old dirt and
                        faeces. The document was formulated with the assistance of AQIS
                        veterinarian Mr Nick Branson who recommended that Mr Gundry adapt
                        part of the export health certificate documentation so as to create the
                        certificate in its current format.756 The purpose of the document was to
                        ensure that the trucks were cleaned before the animals under quarantine
                        were loaded into the trucks at the airport.757

            (g)         Horse imports for Spotswood Quarantine Station import clearance and
                        post-arrival procedures

                        This document briefly summarises the steps involved in the import
                        clearance process and the documentation involved at each step.758 The
                        document was created by Mr Gundry in March 2007 and sent to Chris
                        Medwin, Operations Co-ordinator (Exports) in Victoria, who also
                        managed the veterinarians at the Melbourne Airport. In his evidence,
                        Mr Gundry indicated that he had had concerns about the state in which
                        the import documentation had been arriving at Spotswood from the
                        Airport and so the document was created to clarify his expectations in
                        relation to that documentation.759

            (h)         Visitors sign in book

                        All visitors, including grooms, were required to sign in and out of the
                        Spotswood Quarantine facility as required by the Operations Manual. A
                        copy of the book was not produced to the Inquiry although in his
                        evidence, Gundry explained that the book was kept in the gatehouse at
                        the main entry gate.760

Access to the quarantine station

15.10       Prior to the outbreak of equine influenza, there were no security guards present
            at the station. The front gate to the facility was locked 24 hours a day.761 All
            visitors to the quarantine station were required to sign the visitor’s book which
            was kept in the gatehouse at the main entry gate.762

15.11       Entry and exit by the grooms was based on an honour system.763 Grooms were
            provided with a key to the facility and were also expected to sign the visitors’
            book on entry to, and exit from, Spotswood. Veterinarians and farriers were not
755
      AQIS.0002.014.0041.
756
      T3216.
757
      T3200 – T3201.
758
      AQIS.0002.016.0953.
759
      T3150.
760
      T3175.
761
      T3138.
762
      T3175.
763
      T3175.


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                                                                                        SUBS.INQ.001.0165




            given a key.764 Visitors were not allowed access to the Quarantine Station
            outside business hours, including veterinarians, except in an emergency.
            Mr Ravaneschi lived on site at Spotswood and therefore any arrangements for
            out of hours access by veterinarians was arranged through him.

15.12       There was no permanent accommodation facility for grooms at Spotswood as
            most of the regular grooms lived locally. Over a period of 12 months, grooms
            would be accommodated on site on only two or three occasions at which time
            the importing agents would hire a caravan which was placed just outside the
            shower block in the main stable complex.765

Facilities related to horses

15.13       In his evidence, Mr Gundry gave a brief description of the Spotswood
            quarantine facility. Spotswood had 33 enclosed horse boxes in two rows with a
            central passage way. Each box led onto an outdoor sand yard. There was a
            passageway between the boxes that enabled the horses in the boxes to be
            accessed by grooms and anyone else attending upon them.766 Within the main
            stable building was a toilet, shower and feed storage area. Prior to the equine
            influenza outbreak, the vets and grooms were using this shower block to
            shower out before leaving the quarantine station.

15.14       There was also an open cattle shed with 24 yards within which portable pens
            could be set up, so that horses could be held in those pens at night. The entry
            to the shed was from the southern end although there was an entrance via a
            portable showering hut which was located at the northern entrance. During the
            day, any horses in the temporary pens had access to four ‘day paddocks’ at the
            southern end of the facility.767 The stallions were generally not let out in the
            paddocks.

15.15       Prior to the outbreak of equine influenza, a block of cat pens had been built in
            the old horse stables,768 between the main stable building and the cattle shed.
            Accordingly, most of the gateways and doorways leading to other parts of the
            quarantine station had been locked to ensure that people visiting the cats in the
            new pens did not go beyond the permitted areas.769

Procedures in place at Spotswood Quarantine Station

Induction of Grooms

15.16       The groom induction process generally took place before the horses had arrived
            at Spotswood. The grooms attend the quarantine station the day before the
            horses arrived to lay out the boxes and bedding. The induction process would
            occur at this stage. During the induction process, Mr Gundry or Mr Ravaneschi
            would explained the procedures to the grooms who then signed the groom

764
      T3254.
765
      T3173.
766
      SPOT.0001.001.0001.
767
      See plans of the facility at SPOT.0001.001.0002 and SPOT.0001.001.0003.
768
      Labelled ‘Brick Building’ on the site plan at SPOT.0001.001.0003.
769
      T3171.


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                                                                                          SUBS.INQ.001.0166




            authorisation form and were given a key. As with the authorisation form for
            veterinarians and farriers, this document was not signed on every occasion a
            groom attended Spotswood as many of the grooms attended regularly and were
            expected to be familiar with the requirements.770

Arrival procedures

15.17       There were no published ‘horse windows’ at Spotswood as there was
            significantly less horse traffic compared to Eastern Creek. Accordingly,
            importing agents would simply contact Mr Gundry to make arrangements for an
            appropriate arrival date. On arrival at Spotswood, the grooms would lead the
            horses to their stalls, supervised by Mr Gundry or Mr Ravaneschi. There was
            generally no pre-arranged stall plan; rather importers were allocated a section
            of the stables. The stallions at Spotswood were kept a stall apart from each
            other if there was adequate space which made the horses easier to manage.771

15.18       Any equipment brought in the transport vehicles was taken into Spotswood and
            held until the completion of the quarantine period.

15.19       The transport vehicles were cleaned using a fire hose and then disinfected with
            Virkon, either by Mr Gundry or Mr Ravaneschi. In his evidence, Mr Gundry
            explained that although SOP2 of the Operations Manual only required AQIS
            supervision of the cleaning process772, he believed that having an AQIS officer
            clean the transport vehicle was a more thorough way of ensuring the vehicle
            was satisfactorily cleaned and disinfected, particularly given the high biosecurity
            risk.773

Biosecurity procedures on arrival

15.20       Grooms, veterinarians, farriers and all other visitors who had contact with the
            horses were required to shower out and wear dedicated clothing when
            attending to the horses as set out in ‘SOP 4 Personal Decontamination’ of the
            Operations Manual.774 Prior to the equine influenza outbreak, visitors used the
            shower in the main stables block.775

15.21       As at August 2007, truck drivers were excepted from this requirement, and in
            fact had never been required to shower out.776 Although the truck drivers wore
            overalls at the airport and AQIS staff cleaned the transport vehicles, Mr Gundry
            stated in his evidence that the failure to ensure that truck drivers were also
            required to shower out was one of the biggest downfalls of the process at
            Spotswood.777




770
      T3172.
771
      T3165.
772
      SOP2.
773
      T3156.
774
      WIT.SPT.0001.0001 at para 14; T3171, T3166.
775
      T3171 – 3172.
776
      T3202 and T3231.
777
      T3202 (see also T3231 - 3232)


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                                                                                        SUBS.INQ.001.0167




Monitoring of grooms, private veterinarians and farriers

15.22       Farriers rarely came to Spotswood (perhaps 2 occasions in a 12 month
            period778), however when a farrier did visit, Mr Gundry or Mr Ravaneschi would
            supervise them the entire period they were on the station. A new veterinarian
            would also be supervised, although Mr Gundry and Mr Ravaneschi were more
            flexible with regular veterinarians who were expected to be more familiar with
            the quarantine procedures.779 Entry and exit by the grooms was based on an
            honour system and the grooms were not supervised whilst on the station.

Monitoring of horses’ health

15.23       Horse health record sheets were generated to record details of the horses’
            temperature, clinical signs and any treatment given by the veterinarian as
            required by the Operations Manual.780 The health records were kept on the
            change room at the entrance to the main stables. A Government vet would
            review the health record sheets on those occasions when they attended
            Spotswood, generally on the horses’ arrival and again just prior to release.
            Spotswood staff would also look at those temperature charts on at least two or
                                                         781
            three occasions during the 14 day PAQ period.

Consignment of horses on 8 August 2007

15.24       Details of PEQ, vaccination and arrival at the airport of the Japanese horses are
            outlined elsewhere in these submissions. This section summarises what
            occurred at Spotswood following the arrival of the horses.

15.25       A signed disinfection certificate for the vehicle driven by Mr Hore, the SHT
            driver was produced to the Inquiry. The document, dated 8 August 2007, and
            sent to Spotswood by Mr Bennett782, certifies that the vehicle was cleaned and
            disinfected with Virkon at the dilution rate 1:100 prior to collecting the horses
            from the airport.783 The document is in a similar form to the ‘Movement of
            Animals under Quarantine/Isolation Restrictions’ prepared by Mr Gundry.784

15.26       The three grooms (Ms Pengelly, Mr Papandreou and Mr Best) had attended
            Spotswood in the morning, prior to the arrival of the horses to set up the stalls
            and bedding. It is understood from Gundry’s evidence that the grooms were
            most likely inducted at this stage.785

15.27       Mr Best and Mr Papandreou accompanied the horses in the floats from the
            airport. On arrival at Spotswood, Mr Ravaneschi supervised the unloading of
            the Japanese horses and then cleaned and disinfected the transport vehicles.
            The three stallions were placed in the stalls numbered 2 (Black Hawk), 4
            (Jungle Pocket) and 6 (Zenno Rob Roy) in the main stables. The six mares
778
      WIT.SPOT.001.0001 at para 19; T3169 - 3170, T3231.
779
      T3177, T3231.
780
      AQIS.0001.001.0080 at para 9.4.
781
      T6226 - 6227.
782
      CBHT.0001.001.0133.
783
      CBHT.0001.001.0134.
784
      AQIS.0002.016.0968.
785
      T3164.


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                                                                                          SUBS.INQ.001.0168




            were placed in the temporary pens in the cattle shed (although they had access
            to the paddocks during the day).786 Mr Hore, the truck driver assisted the
            grooms to unload the mares from the truck and lead them into their stables.787
            Ms Pengelly looked after the Japanese mares during PAQ and met the horses
            when they arrived at Spotswood on 8 August 2007. Mr Papandreou looked
            after the three stallions throughout the PAQ period.788

15.28       The transport vehicles were cleaned and disinfected with Virkon by
            Mr Ravaneschi789 and the drivers were then able to remove their overalls.790
            Neither driver showered out, nor was asked to do so by AQIS officers.

15.29       There is little evidence before the Inquiry relating to the transport, arrival and
            PAQ of the 18 stallions which arrived at Spotswood from the USA on 11 August
            2007. Pauline Cushing, an IRT groom accompanied the stallions on the flight
            from New York. She did not travel to Spotswood from the airport as she was
            scheduled to attend Eastern Creek to replace Tetsuhito.791

Veterinarian attending during PAQ

15.30       During PAQ, Dr Meredith Flash of Flemington Equine Clinic attended the
            Japanese and US horses at Spotswood.792 Following the equine influenza
            outbreak, a document was provided to AQIS, and produced to the Inquiry,
            outlining her movements during the PAQ period.793 Tax invoices detailing the
            dates of her attendances, clinical signs and treatments given were also
            produced to the Inquiry.794

15.31       Dr Flash first attended Spotswood on 8 August 2007 to examine Jungle Pocket,
            which had an elevated temperature after arrival from Japan. Mr Ravaneschi
            was advised of Dr Flash’s attendance and the abnormal temperature in a
            facsimile from Mr Bennett.795 In a tax invoice prepared by Flemington Equine
            Clinic, a description of the attendance that day indicates that Jungle Pocket
            showed the following clinical signs on examination:

                   Temp: 39.5, HR [heart rate]: 52 RR [respiration rate] 30. Harsh lung
                   sounds both side gut - no abnormalities, mild dehydration. Blood for
                   Quarantine.

15.32       The tax invoice indicates that Jungle Pocket was treated with Gentamycin,
            Bomacillin and Butasyl, and that a blood sample was taken for quarantine.796



786
      T 3142.
787
      WIT.SHT.002.0001 at para 4; T4378.
788
      See comments on stall plan at DAFF.0001.012.0298.
789
      T3155 - T3156, T3165, T3233.
790
      WIT.SHT.002.0001 at para 4; WIT.SHT.001.0001 at para 3; T4401.
791
      WIT.IRT.003.0001.
792
      Details of veterinarian’s movements at DAFF.0001.217.0011 – 0014.
793
      DAFF.0001.217.0011.
794
      CBHT.0001.001.0183 – 0195.
795
      CBHT.0001.001.0133.
796
      CBHT.0001.001.0183.


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                                                                                         SUBS.INQ.001.0169




15.33       On 9, 10, 11 and 12 August 2007, Flash again attended Jungle Pocket at
            Spotswood and treated the stallion with Gentamycin and Bomacillin.

15.34       On 11 August 2007, Dr Flash also treated two US horses, Ponder and DM
            Dillinger, which were suffering from elevated temperature and ‘depressed
            mentation’ on arrival that day. Those same horses, along with a third horse,
            Mattjesty, were again treated on 13, 14, 15 and 16 August.

15.35       On 13 August 2007 Dr Flash attended Spotswood to draw Government bloods
            from the 18 stallions from the USA, the 3 Japanese stallions and the 6
            Japanese mares. The blood samples were sent to the Australian Animal Health
            Laboratory at Geelong for storage.

15.36       On 22 August 2007, Dr Flash attended Spotswood to examine an IRT stallion
            from USA, Metropolitan, then returned on 23 August 2007 to take a nasal swab
            from that horse.

15.37       On 24 August 2007, Dr Flash attended Spotswood to take blood and nasal
            swab samples from all the horses at Spotswood.

15.38       In his statutory declaration, Mr Gundry stated that one of the mares from Japan
            was treated for travel sickness.797 There is nothing in Dr Flash’s itinerary to
            indicate that this is the case. However, a tax invoice for TH Dancer798 indicates
            that a health check was conducted on 24 August 2007, and an email from
            Gundry to Ironside dated 24 August 2007 suggests the mare had some nasal
            discharge and was placed on antibiotic powder treatment.799

15.39       It is understood that no farriers attended to the horses during the PAQ period.

15.40       With respect to the consignment in August 2007, Mr Gundry was not aware of
            any breaches of the procedures, and to his knowledge, all persons who had
            contact with the horses (apart from the truck drivers) observed the shower out
            procedure.800

15.41       There is no evidence to suggest any of the entrants to Spotswood are
            associated with the outbreak.




797
      WIT.SPOT.0001.0001 at para 31.
798
      CBHT.0001.001.0188.
799
      DAFF.0001.217.6692.
800
      T3202.


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16       OVERVIEW OF COUNSEL ASSISTING’S SUBMISSIONS

The circumstances that contributed to the outbreak

16.1       It is first necessary to consider how the outbreak occurred and then to consider
           the circumstances which contributed to it.

How the outbreak occurred

16.2       In August 2007 there was an intake of fifty two horses into ECQS and twenty
           seven horses into SQS. Thirteen of those horses were from Japan. Those
           thirteen horses arrived by air in Melbourne on 8 August 2007. Four were
           carried by air to Sydney on the same day and transported to ECQS. The
           remaining nine horses went to SQS.

16.3       Subsequent analyses of blood sera taken from those horses in PEQ and PAQ
           establishes that one of the four Japanese horses in ECQS (Snitzel) sero-
           converted (ie was infected with equine influenza) between 24 July and 13
           August. That analysis also establishes that seven of the nine Japanese horses
           in SQS sero-converted between 24 July and 24 August. Those analyses
           indicate that some of the horses imported by air from Japan were infected with
           equine influenza at some stage in PEQ or during their transportation by air to
           Australia and at the time they entered PAQ. Those eight horses include Snitzel,
           Jungle Pocket and Zenno Rob Roy which all undertook PEQ at the Shaddai
           Stallion Station on the island of Hokkaido near the towns of Abira and Atsuma.

16.4       None of the other horses in ECQS is shown to have been infected during PEQ
           or when it entered PAQ. Two of those other horses became infected in PAQ
           and before 20 August. Those horses were Fox & Firkin (which sero-converted
           on samples taken between 13 and 20 August) and Encosta De Lago (which
           sero-converted on samples taken between 13 and 20 August).

16.5       The first reported cases of equine influenza outside ECQS were in two horses
           in the CPEC. Subsequent analysis shows that the viruses isolated in ECQS
           and in CPEC (Sydney/07 and Centennial Park/07) are identical. They are also
           almost identical to the Japanese strain Ibaraki/07 isolated and reported in mid
           August 2007 and to the American strain, Philadelphia/07 (or Pensylvania/07)
           isolated and reported in late August 2007.

16.6       There is no evidence of any contamination of horses in the general horse
           population in Victoria or which would support a finding that the virus was carried
           out of SQS to horses in New South Wales. The only plausible ways in which
           this might have occurred (by contamination via grooms or vets attending the
           horses in SQS or by the transport vehicles which carried the Japanese horses
           from Tullamarine to SQS) have been excluded by evidence that those persons
           either did not have contact with horses outside SQS or only had contact with
           horses in Victoria or (in the case of one of the drivers) horses carried into New
           South Wales which in each case did not become infected with the virus before
           the outbreak.




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16.7       The serological results and analyses and the evidence in relation to SQS point
           to the most likely source of the Australian outbreak being the importation of a
           consignment of infected horses from Japan rather than from the United States
           of America. The only explanation for the presence of horses infected with
           equine influenza in ECQS and SQS at the same time is that a number of horses
           in the consignment of thirteen horses from Japan were infected.

16.8       That conclusion is consistent with the fact that those horses undertook PEQ at
           premises on the island of Hokkaido between 17 July and 6 August 2007 and
           that there were subsequently a number of notifications to the OIE of outbreaks
           of equine influenza on that island from as early as 14 August.

16.9       It is not possible to draw any conclusion as to the source of the infection of
           those horses in Japan and when it occurred. The horses could have become
           infected because they were exposed to the virus during PEQ or during their
           transportation by road to Chitose airport or in their carriage to Australia.

16.10      The first horses outside ECQS to show signs of equine influenza were horses
           which had attended a horse competition near Maitland organised by the Ranch
           Riding Club and held over three days commencing on Friday 17 August. Those
           horses included the two horses in CPEC which first showed signs of the virus
           on 22 August.

16.11      The evidence in relation to the Maitland event and particularly as to the extent
           of equine influenza spread among horses which attended that event is only
           really consistent with an infected horse or horses having attended the event and
           infected the other horses present. The infected horse or horses have not been
           identified although there is evidence (from a number of witnesses) of a
           coughing horse or horses being present at the event.

16.12      There have been no other reports of equine influenza in the general horse
           population in New South Wales or elsewhere in Australia before the Maitland
           event. As has already been noted, the virus isolated in Centennial Park was the
           same as that isolated within ECQS. The question then is how did that virus,
           which was infecting a horse or horses from Japan at the time they arrived in
           Sydney on 8 August, escape into the general horse population.

16.13      The possible scenarios as to how the virus escaped into the general horse
           population are as follows –

           (a)          From the airport by airborne spread;

           (b)          From the airport or in the transport of the horses to ECQS by
                        contaminated persons, equipment or transport vehicles later coming into
                        contact with a horse in the general horse population which then became
                        infected;

           (c)          From ECQS by airborne spread;




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           (d)          From ECQS by contaminated persons or equipment or dogs (kennelled
                        in ECQS) coming into contact with a horse in the general horse
                        population which then became infected.

16.14      Contamination by airborne spread from the airport can be rejected as a likely
           cause. First, the Japanese horses were not exhibiting clinical signs of infection
           at the time they arrived. If any of them was shedding virus it was not doing so
           in any significant or noticeable volumes. Secondly, the weather conditions at
           the airport in the afternoon of 8 August included an ambient temperature of
           22.5oC, a relative humidity of 22% and a fairly clear sky. Those sunny
           conditions would not have permitted the survival of the virus for any significant
           period of time. Thirdly, the part of Sydney’s Kingsford Smith Airport where the
           horses were unloaded from the aircraft and then loaded into transport vehicles
           is inside the perimeter of the airport and some distance from roadways and
           industrial and residential areas. The evidence does not indicate that there were
           any horses in that area likely to be infected by airborne spread. All of these
           factors taken together make it most unlikely that airborne spread from the
           airport was the source of the outbreak.

16.15      In addition, the absence of any reported cases of equine influenza in the
           general horse population before 21 August makes it unlikely that any
           contamination of a naïve horse in that population which later attended the
           Maitland event occurred on 8 or 9 August. Such a horse would have become
           infected by 13 August and would have remained infected for a period of up to
           ten days. If the horse was to have competed in the Maitland event it would
           have had to undertake preparation and training and probably would have had
           contact with other horses during the period that it was infected. The fact of
           infection would have made it most unlikely that the horse could have
           undertaken the necessary preparation and training without the disease being
           noticed. At the same time the horse would probably have had contact with
           other horses which themselves would have become infected and that infection
           would have been noticed.

16.16      Contamination from the airport via contaminated persons, equipment or
           transport vehicles can also be excluded for the same reason. In addition the
           evidence indicates that none of the persons and equipment which were or was
           likely to have had contact with the infected horses subsequently had contact
           with any horses in the general horse population which were infected before 24
           August. Those persons include Dr Yan Hee Song, the transport drivers, Edwin
           Clarke of Livestock Transport Group and Craig Atkinson of Coolmore, Tom
           Magnier and Jim Carey of Coolmore, John Sunderland and Stuart McKay of
           Darley Stud, Martin Story and Brad Bowd of Arrowfield, Julian Cornter of
           International Racehorse Transport, the Japanese vet and grooms (Dr Tsunoda
           and Messrs Noomote and Kudo) and the grooms, Messrs Keane of Coolmore
           Stud and McDonald of IRT. Specifically, the evidence of the movements of the
           truck drivers does not establish that any horse transported in those vehicles in
           the immediate period after 8 August was infected at any time before the
           Maitland event.

16.17      It may be that some of the evidence addressing these matters is incomplete or
           not correct and that contamination occurred via one of these means. Two


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           matters suggest that this is not the case. First, the inquiries and examinations
           undertaken have not identified any respects in which the evidence is incomplete
           or inaccurate. Secondly the infection cycle of the virus and the absence of any
           reports of infected horses before the Maitland event makes it unlikely that a
           horse could have become infected on 8 or 9 August because that fact is not
           likely to have remained unnoticed and unreported.

16.18      Contamination via windborne spread from ECQS can also be excluded as a
           likely source of the escape of the virus from ECQS. The first horse in ECQS
           which exhibited noticeable clinical signs was Encosta De Lago on 17 August.
           Before that time it is unlikely that any horse was shedding sufficient amounts of
           the virus to result in airborne spread and infection of horses outside the
           quarantine stations. The fact that only a small number of the fifty two horses in
           the quarantine station eventually became infected is not consistent with a horse
           outside the quarantine station being infected by windborne spread (when those
           inside were not).

16.19      That leaves one possible scenario which is that a person or equipment or dog
           contaminated with the virus in ECQS left ECQS and in some way contaminated
           a horse in the general horse population.

16.20      One can exclude from this scenario the possibility that the contamination
           occurred via dogs which were themselves infected in ECQS. There have been
           some reported instances of dogs being infected that have occurred where the
           dogs have had direct or indirect contact with previously naïve horses during the
           acute stages of their infection. However, the dogs at ECQS were kept separate
           from the horses and the infected horses shed only small amounts of the virus
           when compared to fully susceptible horses. In addition there have been no
           reported instances of dogs infected with equine influenza excreting sufficient
           virus to reinfect horses. Some evidence suggests that the virus infecting the
           dog becomes genetically altered so as to make reinfection of horses even less
           likely.

16.21      There then remains as the most likely scenario that the virus escaped from
           Eastern Creek on the person, clothing or equipment of a groom vet, farrier or
           some other person who had contact with the horses and who then left the
           quarantine station without adequately or at all cleaning or disinfecting
           themselves, their clothing and equipment. The timing of the Maitland event and
           the emergence of clinical signs within Eastern Creek strongly suggest that
           escape of the virus is most likely to have occurred in the period after 10 August
           2007.

16.22      The evidence does not enable a more specific finding to be made as to the
           most likely mechanism by which the virus escaped from the quarantine station.
           However, it is possible by reason of the likely timing of any escape to identify
           the vets and farriers who may have unintentionally carried the virus out of the
           station. However it is not possible to identify any grooms or other persons who
           in fact did so.

16.23      In the period from 10 August various of the horses were attended to by their
           grooms, two farriers and four vets. Their movements in and out of the


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           quarantine station and their activities whilst in the equine enclosure were not
           supervised or monitored by anyone from AQIS or by any of the other persons
           residing in the equine closure during the period of the intake.

16.24      The evidence enables the following findings to be made in relation to these
           persons:

           (a)          A number of the grooms (especially those from Coolmore and
                        Arrowfield) had physical contact with a horse or horses which were likely
                        to be shedding the virus on and after 10 August.

           (b)          Some of the grooms on occasions left the quarantine station without
                        showering out and changing their clothes. That finding should be made
                        not withstanding that no groom who gave evidence (other than Cushing
                        and Maguire) accepted that he or she had done so. The making of a
                        finding in those terms does not involve a finding that any particular
                        groom left the quarantine station without showering and changing after
                        having had contact with a specific horse which at that time was shedding
                        the virus.

           (c)          On 13 August the farrier Scott Barlow attended horses in the quarantine
                        station and did not clean or disinfect his farrier’s tools and apron before
                        leaving ECQS;

           (d)          On 14 August the farrier Brad Hinze attended the Coolmore horses in
                        the quarantine station (including Rock of Gibraltar) and left the
                        quarantine station without showering or changing his clothes or cleaning
                        and disinfecting his farrier’s tools and apron;

           (e)          Various private vets attended horses in the quarantine station on and
                        after 10 August. They included Dr Crowley (last visit 10 August), Dr
                        Bruyn (14 August), Dr Whitfeld (14 August) and Dr Argyle (twice on each
                        of 10 and 11 August). None of those vets showered out before leaving
                        the station. Each of Doctors Bruyn, Whitfeld and Argyle said he wore
                        overalls and gum boots which were removed before he left the station
                        and that he washed his hands. Doctors Bruyn and Whitfield also
                        washed their faces.

16.25      The evidence of each of these witnesses or groups of witnesses has been
           tested. None of the grooms admitted to any contact with a horse outside the
           quarantine station. The movements of the vets and farriers were also carefully
           examined. Although some had contact with horses on the day they attended
           the quarantine station and in the days immediately thereafter (eg Barlow on 13
           August and the following days; Hinze on 14 August and the following days; Dr
           Bruyn on 14 August; Dr Whitfeld on 14 August and Dr Argyle on 10 and 11
           August), the evidence does not suggest that any of the horses attended to
           outside Eastern Creek was infected before the Maitland event.

16.26      The only other person who had contact with the horses on and after 10 August
           and before 20 August was Dr Widders on 13 August (when he took blood from
           the Japanese horses). The evidence does not identify any other AQIS


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           personnel or non-AQIS personnel who is likely to have had access to the
           horses in this period. Dr Widders said he had no contact with any horses
           outside the quarantine station.

16.27      In those circumstances the finding which should be made as to how the
           outbreak occurred can only be expressed in general terms. That finding is that
           the virus escaped from horses infected within ECQS and that it did so via
           contaminated persons or equipment leaving ECQS and coming into contact with
           a horse in the general horse population. The contaminated persons or
           equipment are most likely to have been associated with caring for the horses
           whilst in quarantine.

Circumstances which contributed to the outbreak

16.28      If there were in place at Eastern Creek and being properly implemented in
           August 2007 even the most rudimentary biosecurity measures it is most unlikely
           that there would have been any escape of equine influenza from the quarantine
           station. Such measure would have included at a minimum that people having
           contact with the horses in the equine enclosure be required to shower and
           change their clothes before exiting the equine enclosure and to leave
           contaminated clothing and equipment in the quarantine station.

16.29      That such a measure was not being implemented within the quarantine station
           in August 2007 is a serious failure by those within DAFF and AQIS who were
           responsible for the management of quarantine risks and in particular the
           management of post entry quarantine arrangements. The persons who
           ultimately must take responsibility for that failure include the Secretary of DAFF
           as the Director of Animal and Plant Quarantine and the person who, under the
           Minister, is charged with the execution of the Quarantine Act, the Executive
           Director of AQIS and the Executive Manager of the Quarantine and Plant
           programs within AQIS.

16.30      That such a measure was not being implemented within the quarantine station
           in August 2007 was the consequence of a number of acts and omissions on the
           part of various employees and officers of AQIS occurring at different levels of
           that organisation and over a period of time from at least 2003.

16.31      The examination in the course of the Inquiry of the other aspects of the process
           for the importation of live horses - which starts with the imposition of import
           conditions and the vaccination of the horses and which includes PEQ, the
           transport of the horses by road to an airport in the country of export, their air
           carriage to Australia and their unloading at an airport in Australia and
           subsequent road transport to the quarantine station at ECQS or SQS - has
           revealed a number of other deficiencies and inadequacies in the biosecurity
           measures in place and the way in which those measures are formulated,
           reviewed, implemented and their implementation checked. Those various
           deficiencies and inadequacies operated, in some cases separately and certainly
           together, to increase the likelihood that a horse infected with equine influenza
           would be imported into Australia with the consequent risk that the virus could
           escape from PAQ as in fact occurred in August 2007.



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16.32      We propose to address first the position in relation to procedures or the lack of
           procedures at ECQS and then to address the other deficiencies and
           inadequacies which have been revealed by the evidence. These other
           deficiencies and inadequacies are addressed as part of the overview, dealing
           with the need for any strengthened biosecurity measures for quarantine
           management of imported horses.

16.33      As at August 2007 there were no operating procedures or work instructions that
           had been prepared within AQIS which were understood by those officers at
           ECQS responsible for the quarantine of live horses as setting out the
           biosecurity measures which had to be implemented within the quarantine
           station. In this respect the position in the government owned quarantine station
           was in stark contrast with that which obtained at the privately owned quarantine
           station at Sandown which was required by AQIS to have in place fully
           documented and regularly audited procedures. There is no satisfactory
           explanation as to why that should have been the case.

16.34      The circumstances which contributed to the absence of any documented
           procedures being in place for Eastern Creek are described in much detail in the
           narratives which accompany this outline. They include the following –

           (a)          The Live Horse Work Instruction issued in May 2004 was not intended or
                        understood by the officers within the Live Animal Imports program to be
                        exhaustive or final in respect of the quarantine procedures to be
                        implemented at the quarantine stations;

           (b)          The draft Operations Manual for Horses which was published in March
                        2004 was at the time intended to become a document which would
                        exhaustively deal with those procedures. That draft was never finalised
                        and was never regarded as containing instructions which had to be
                        followed;

           (c)          As at August 2007 the Executive Manager of the Quarantine programs
                        (which included Live Animal Imports and Post-Entry Animal Quarantine)
                        believed that the Live Horse Work Instruction was a document published
                        in final form which set out the procedures that should be followed within
                        the quarantine stations unless there was a specific reason for a
                        quarantine officer to vary those procedures;

           (d)          As at August 2007 the manager of the Live Animal Imports program,
                        which was responsible for promulgating nationally applicable work
                        instructions and operating procedures and auditing (ie checking) to see
                        that those procedures were being implemented, believed that the Live
                        Horse Work Instructions laid down the relevant procedures for the
                        quarantine stations and that they were being implemented. However
                        that program had never undertaken any audit or check to see that this
                        was in fact the position. Although it was required to do so it had
                        apparently not done so because it lacked the financial resources to
                        perform that task in priority to other tasks it had;




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           (e)          At the same time at the New South Wales regional management level,
                        the officer responsible for implementing any work instructions and
                        operating procedures promulgated by the national program was aware
                        of the Live Horse Work Instruction but did not regard it as applicable or
                        as sufficient and satisfactory, believed that he had brought these matters
                        to the attention of the national program manager and did not know
                        whether the officers in the quarantine station were aware of that
                        document (and it follows, whether they were implementing it). He took
                        no steps to implement the instructions although he was required to
                        implement nationally promulgated instructions in the region;

           (f)          The assistant New South Wales Regional Manager responsible for the
                        management of the Live Animal Import and Post-Entry Animal
                        Quarantine programs in New South Wales as at August 2007, was
                        aware of the existence of the Live Horse Work Instruction, had never
                        looked at it and did not know if it was being implemented in the region.
                        Nor did she regard it as part of her function or that of her immediate
                        superior, the New South Wales Regional Manager, to see that it was
                        being implemented;

           (g)          The Live Horse Work Instruction itself nominates the Regional Manager
                        as the person who shall ensure that quarantine officers involved in the
                        import of live horses are aware of the instruction and have access to it.
                        As at August 2007 that Regional Manager was not aware of the
                        existence of the Live Horse Work Instruction and was not aware that he
                        had any responsibility to see that it was being implemented in New
                        South Wales. He did not have any responsibility to liaise with the
                        national program to report or confirm that it was being implemented;

           (h)          As at August 2007 none of the AQIS officers at ECQS having any
                        responsibility for the management of the quarantine of horses (the
                        Manager, the Supervisor of Animal Quarantine and the senior
                        Quarantine Officer having some responsibility for horses) understood
                        that the Live Horse Work Instruction or draft Operations Manual for
                        Horses set out instructions or procedures which had to be complied
                        within ECQS;

           (i)          As at August 2007 none of the same AQIS officers at ECQS regarded
                        the AQIS intranet as the place where relevant and applicable work
                        instructions and operating procedures could be located easily. That was
                        contrary to the position of the manager of the relevant national program
                        who regarded the AQIS intranet as the means by which such
                        instructions were published and made known to regional staff.

           (j)          None of the officers at ECQS received any training or instruction from
                        the relevant national program or the Regional Office as to the existence
                        of any work instructions governing the clearance and quarantine of live
                        horses or as to their implementation.

           (k)          The fact that the manager and staff at ECQS were unaware of any
                        documented procedures which they were required to follow was brought


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                                                                                              SUBS.INQ.001.0178




                        to the attention of the manager of the Live Animal Import and Post-Entry
                        Animal Quarantine programs in April 2008. Notwithstanding that fact the
                        manager did nothing to investigate how that circumstance may have
                        come about or to put any measures in place to avoid a recurrence of it.
                        Nor did he take any steps to bring the matter to the attention of the New
                        South Wales regional management who were responsible for seeing that
                        any procedures published by the national programs were being
                        implemented.

16.35      This outline of the position bespeaks an organisation which lacked clear lines of
           effective communication between those responsible for formulating procedures
           and those responsible for implementing them and one in which there was no
           sufficient training and education in relation to procedures to be followed and no
           checking to see that procedures were being implemented.

16.36      As well as this absence of any clear and documented procedures, there were
           other factors which contributed to the lack of any effective supervision of
           persons entering and leaving the quarantine station. The principal factors
           among those other factors were:

           (a)          The quarantine station was under staffed. The quarantine station was
                        not manned 24 hours a day and was closed during the weekends.
                        Grooms, vets, caterers and cleaners had access cards to the main gate
                        and/or keys to the gate to the equine facility. Visitors including farriers
                        and others entered and left the quarantine station and horse enclosure
                        without the knowledge of AQIS officers particularly out of hours and on
                        the weekends. There was only one officer at the quarantine station who
                        had been allocated any particular duties in relation to the horses. She
                        was also responsible for assisting the quarantine management of cats
                        and dogs and that took most of her time (there were already insufficient
                        quarantine staff to manage the cats and dogs). That officer had been
                        instructed in late 2006 not to spend any time in the equine enclosure
                        unless it was necessary for her to do so. She was told to attend to her
                        other duties (ie cats and dogs) and that there were “certain budgetary
                        restraints” on her doing otherwise;

           (b)          The facilities at Eastern Creek Quarantine Station in August 2007 were
                        not conducive to the effective implementation of even the most
                        rudimentary biosecurity measures.         There was no showering or
                        changing facility at the point of entry to and exit from the equine
                        enclosure or at the point of entry to and exit from the quarantine station.
                        Nor was there any effective system for recording and monitoring the
                        entry and exit of persons from the quarantine station or from the equine
                        enclosure on a 24 hour basis;

           (c)          The quarantine station was not funded to enable it to discharge properly
                        its quarantine management functions. The budgets for the post-entry
                        animal quarantine program were prepared annually on the assumption
                        that the existing human and other resources in place were sufficient to
                        discharge those functions. That assumption was clearly not sound.



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The need for any strengthened procedures for quarantine management of
imported horses

16.37      As is mentioned above, examination of the other aspects of the process for
           importation of live horses has revealed a number of other deficiencies and
           inadequacies in the biosecurity measures in place and the way in which they
           are formulated, reviewed, implemented and their implementation checked. It is
           convenient to address these matters under the following headings:

           (a)          Import conditions and PEQ;

           (b)          Arrival at an Australian airport;

           (c)          Cleaning of road transport vehicles at PAQ;

           (d)          PAQ;

           (e)          The role of Biosecurity Australia;

           (f)          The Quarantine Act.

Import conditions and PEQ

16.38      The import conditions are formulated by Biosecurity Australia (as policy advices
           which are adopted by AQIS). They deal with vaccination, PEQ and some
           activities to the point of loading onto an aircraft or vessel for carriage to
           Australia. They also deal with some aspects of PAQ.

16.39      In relation to vaccination, the import conditions do not specify any particular
           vaccine or vaccines containing particular strains or representative strains. The
           OIE panel recommendation is that vaccines containing currently circulating
           strains be used (and specifically the North American and United Kingdom
           isolates of the variant American sub-lineage). Some currently available
           vaccines are known to be less effective than others and to contain strains which
           are no longer circulating. Consideration must be given to specifying
           particular vaccines (if available) and at least to identifying vaccines which
           cannot be used.

16.40      The conditions current as at August 2007 did not require that PEQ premises be
           inspected and approved by AQIS or Biosecurity Australia or some other
           qualified body before they were eligible to be used. Nor did they require that
           such premises have fully documented procedures which are capable of being
           audited. Nor were there any arrangements for their implementation to be
           checked by any Australian authority. The inspection and approval of PEQ
           premises would enable a greater assurance on the part of AQIS that all
           relevant biosecurity risks have been adequately identified and addressed
           by procedures which are documented and capable of being audited.
           There should then be provision for the regular audit of approved PEQ
           premises to enable some assurance that those procedures are being
           implemented.



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16.41      The conditions current as at August 2007 did not require that horses be
           tested for equine influenza whilst in PEQ. This should occur. The
           amendments to the conditions in December 2007 require that horses be tested
           twice in PEQ 7 to 10 days apart with the last test within four days of departure.

16.42      In addition, blood samples should be taken from the horses whilst in PEQ
           and some part of that sample should be frozen, stored and transported to
           Australia with the horse. In the recent outbreak difficulties have been
           experienced in obtaining access to blood samples taken in PEQ for the purpose
           of identifying horses which may have sero-converted and managing any
           outbreak of equine influenza within the quarantine station.

16.43      The current conditions do not address exhaustively the movement of the horses
           from their PEQ premises to the point where they are loaded onto an aircraft for
           carriage to Australia. There are in this period risks of contamination from
           people, vehicles, equipment and other horses which have not been subject to
           the PEQ regime. AQIS or Biosecurity Australia or some other qualified
           body should view and understand the activities from PEQ to the time of
           departure so as to identify any biosecurity risks which should be
           addressed by import conditions or other requirements.

16.44      Currently the health and any other certificates required by the import conditions
           are checked on the arrival of the horse in Australia. The certificates in
           relation to vaccination, equine influenza testing and satisfaction of the
           conditions applying during the period of PEQ should be inspected for
           compliance with the import conditions before the horse is loaded for
           carriage to Australia. This could be done by way of facsimile or email
           communication with AQIS officers in Australia or by authorised certifiers present
           at the place of departure. Such a procedure would give some assurance that
           horses which have not satisfied their import conditions to that point do not enter
           Australia.

Arrival at an Australian airport

16.45      Currently there are four different AQIS national programs which are engaged in
           the clearance of live horses on their arrival in Australia and transportation to a
           quarantine station. They are the Live Animal Imports Program (responsible for
           clearance of the horses and audit of associated paperwork), the Airports
           Program (responsible for clearance of the crew and passengers and their
           personal baggage whether carried or checked), the Import Clearance program
           (responsible for clearance of cargo eg tack and other equipment and the horse
           airstalls) and the Post-Entry Animal Quarantine program (responsible for
           managing the horses and transport vehicles when they arrive at the quarantine
           station).

16.46      The single sequence of activity which commences on the arrival of the aircraft
           and concludes with the departure of the horses for the quarantine station and
           the cleaning of any transfer facility and airstalls involves a number of third
           parties in handling or having contact with the horses. They include grooms and
           vet who may have travelled with the horses by air, importing agents, grooms
           and vets meeting the horses at the airport, transport drivers, representatives of


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           studs and owners and waste disposal, cleaning, security and other
           subcontractors.

16.47      Because of the number of people involved and the number of different AQIS
           officers responsible for undertaking different tasks, sometimes in relation to the
           same people at the same or different times, it is critical that there should be one
           person who is familiar with the overall process and whose responsibility it
           is to supervise the performance of the various clearance procedures and
           biosecurity tasks. In addition it is critical that the AQIS officers involved
           have clear statutory authority to give instructions to non-AQIS personnel
           in relation to their own conduct and the movement of the horses and any
           equipment and other property. This is dealt with below in relation to the
           Quarantine Act.

16.48      The standard operating procedures which currently apply to the clearance and
           quarantine of live horses were issued in December 2007. They deal with the
           clearance of the horses at the airport, their transport to the quarantine station
           and the management of their quarantine. Those procedures were prepared
           following the August 2007 outbreak to meet perceived deficiencies and
           inadequacies in procedures believed to be in place at that time. The revised
           procedures were not produced after any formal or informal analysis by
           Biosecurity Australia or some other qualified body of the various activities in that
           process with a view to identifying the biosecurity risks which arose and how
           they should be addressed. Notwithstanding that some officers of Biosecurity
           Australia had involvement in the formulation of the procedures insofar as they
           relate to the airport and the road transport to the quarantine station, the revised
           operating procedures should be the subject of such an analysis and
           review.

16.49      The airports where horses currently can be landed are Kingsford Smith Airport,
           Sydney and Tullamarine Airport, Victoria. In Sydney there is a Livestock
           Transfer Facility in which the horses are unloaded and transferred to the waiting
           transport vehicles. At Tullamarine there is no such facility. At each airport
           there should be a facility for the unloading and transfer of the horses
           which enables appropriate biosecurity measures and procedures to be
           carried out effectively and safely from the perspective of the horses and
           those handling them.

16.50      People who have contact with the horses at the airport who are not travelling
           with them to the quarantine station should be required to shower and change
           their clothes. Ideally there should be a showering and changing facility
           provided at the airport to enable this to occur there rather than at the
           quarantine station (as currently happens at least in Sydney).

Cleaning of road transport vehicles at PAQ

16.51      The evidence indicates that not all parts of the transport vehicles are currently
           disinfected and cleaned at the quarantine station after the horses have been
           unloaded. Sufficient staff should be available at the quarantine station to
           both supervise the unloading of the horses and to supervise the cleaning
           of the transport vehicles.


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PAQ

16.52      The standard operating procedures issued in December 2007 were not
           prepared after any inspection and analysis by Biosecurity Australia or some
           other qualified body of the quarantine station and the processes and activities
           which occur in it. Such an inspection and analysis should be undertaken
           with a view to identifying any relevant biosecurity risks and reviewing the
           operating procedures to obtain an assurance that it sufficiently addresses
           each of those risks. If it does not, Biosecurity Australia or the other body
           undertaking that review should advise what changes should be made to those
           operating procedures.

16.53      Similarly to the extent that the import conditions address biosecurity risks within
           the quarantine station, those import conditions should be reviewed by
           Biosecurity Australia (as the body which formulated the conditions) after
           it has undertaken an inspection and analysis of the quarantine stations
           and the activities undertaken there.

16.54      The facilities at Eastern Creek and Spotswood quarantine stations should
           be reviewed by experts in the design and operation of facilities for
           biosecurity containment. There is a need to review the adequacy of those
           facilities including the need for a point of entry and exit at which persons
           authorised to enter the horse enclosure may be monitored and shower in and
           out and comply with other biosecurity requirements. Such a review should
           address the need for suitable means of electronic surveillance including close
           circuit television, the need for a facility to store chemicals, drugs, instruments
           and equipment for use by persons attending the horses in quarantine and the
           desirability of having any horse stalls and yards which are separated from the
           main stalls and yards in the horse enclosure to enable isolation of horses
           suffering from contagious or infectious diseases. It should also address
           whether there is a need to have separate areas within the quarantine station to
           hold horses imported from different regions and held as part of the one
           quarantine intake.

16.55      The adequacy of the staffing of the quarantine stations with respect to the
           quarantine of live horses should be reviewed having regard to the
           activities and procedures contained in or required by any operating
           procedure as finally adopted.

16.56      The budgets for the quarantine stations should then be prepared on a
           basis which is sufficient to fully fund the staffing of those quarantine
           stations so as to enable those requirements to be satisfied without
           adversely affecting in any way the performance of any other activities and
           functions at the quarantine station.

16.57      The Standard Operating Procedure issued in December 2007 regulate the
           movements of vets, farriers and others entering and leaving the quarantine
           station. In order to ensure that the quarantine responsibility is a shared one,
           consideration should be given to imposing as a condition of entry of any
           non-AQIS personnel to the equine enclosure within a quarantine station
           that the person has an obligation to report breaches or suspected


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           breaches (by that or any other person) of quarantine procedures and
           providing that the person might be excluded from future entry to such premises
           in the event of breach of such procedures by that person or in the event of a
           failure of that person to report a suspected breach by any other person.

The role of Biosecurity Australia

16.58      Biosecurity Australia’s role includes undertaking import risk analysis, providing
           biosecurity policy advice and recommendations as a result of those analyses
           and providing day to day advice to AQIS on biosecurity issues.

16.59      Biosecurity Australia should be asked to undertake a non-regulated but
           formal import risk analysis relating to the importation of live horses.

16.60      Australia’s quarantine policies in relation to the importation of live horses have
           developed over time. Since before 1990 the conditions and requirements have
           been varied to take account of outbreaks of particular diseases or revised
           assessments of the risks attaching to those diseases. There has never been
           any formal risk analysis undertaken by Biosecurity Australia which in one
           document identifies the risks associated with importation and describes the
           ways in which they are to be addressed by the imposition of import conditions
           so as to achieve the outcome that the “level of quarantine risk” is sufficiently low
           to allow importation to proceed. There are a number of reasons why
           Biosecurity Australia should undertake such a formal risk analysis. First it
           would require a rigorous review of the current import conditions and their
           adequacies in the light of current scientific and other information. Secondly, it
           would result in there being in one place an analysis of the disease risks
           associated with importation and how they are addressed by the import
           conditions. Thirdly, it would provide a reference point recording current policy
           which could then be the subject of regular review.

16.61      As between AQIS and Biosecurity Australia there is uncertainty as to the role
           which Biosecurity Australia has in relation to AQIS’ operational and procedural
           matters. To date the import conditions formulated by Biosecurity Australia deal
           to some extent with PEQ and PAQ although Biosecurity Australia has never
           undertaken inspections and inquiries to satisfy itself as to what happens in PEQ
           and in the period before the horses are loaded for carriage and also to satisfy
           itself as to what happens in PAQ. In order to properly formulate those policies
           and address the risks involved in those activities Biosecurity Australia should
           undertake inspections and reviews of the whole importation process from
           PEQ to PAQ.

16.62      The position is the same in relation to the operating procedures and work
           instructions formulated by AQIS and covering the period from the arrival of the
           horses in Australia to their release from PAQ. Biosecurity Australia should
           be asked to review those operating procedures and advise whether any
           further or revised measures should be undertaken.

16.63      Finally, there is as between AQIS and Biosecurity Australia an absence of any
           protocol or procedure which regulates the circumstances in which Biosecurity
           Australia should initiate the giving of advice to AQIS without any request for it to


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           do so and to review existing policies and import risk analyses. There should
           be in place procedures which require Biosecurity Australia at regular
           intervals to review existing import risk analyses, existing import policies
           and conditions and existing AQIS operating procedures.

The Quarantine Act

16.64      The Quarantine Act contains various provisions as to when animals (which are
           within the definition of goods) are “subject to quarantine” and as to the
           circumstances in which animals may be “ordered into quarantine”. It also gives
           quarantine officers various powers in relation to animals which have been
           “ordered into quarantine” or which are “subject to quarantine”. Some of the
           provisions overlap and depend upon the quarantine officer being satisfied of a
           particular matter or matters.

16.65      The provisions of the Quarantine Act should be reviewed to ensure that
           quarantine officers have all of the powers they require in order to ensure
           that adequate biosecurity measures are followed in accordance with the
           import policies and operating procedures in relation to the importation of
           live horses which are in place.




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                                                  Table of Contents



1          BACKGROUND TO THE INQUIRY ........................................................... 1
    The equine influenza outbreak in Australia .................................................................. 1

    An outbreak of equine influenza in Japan .................................................................... 3

    The social and economic effects of the outbreak ......................................................... 4

    The establishment of this Inquiry and the Terms of Reference .................................... 6

2          THE EQUINE INFLUENZA VIRUS ............................................................ 8
    The different sub-types of the virus and lineage of the H3N8 sub-type ........................ 8

    Animals and species infected by the virus ................................................................... 9

    The clinical signs of equine influenza .......................................................................... 9

    Long term effects on horses ...................................................................................... 10

    Incubation and virus excretion ................................................................................... 10

    Pathogenesis of the virus .......................................................................................... 11

    Survival of the virus ................................................................................................... 11

    Diagnosis of equine influenza .................................................................................... 12

    Vaccination................................................................................................................ 15

3          RECENT OUTBREAKS OF EQUINE INFLUENZA AND CURRENTLY
           CIRCULATING STRAINS ........................................................................ 17
    Overview ................................................................................................................... 17

    South Africa (1986) ................................................................................................... 17

    South Africa (2003) ................................................................................................... 17

    India (1987) ............................................................................................................... 18

    Hong Kong (1992) ..................................................................................................... 18

    Monitoring of currently circulating strains ................................................................... 18

    Equine influenza in the United Kingdom (2007) ......................................................... 19

    Equine influenza in Ireland (2007) ............................................................................. 19



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    Equine influenza in the United States (2007) ............................................................. 19

    Equine influenza in Japan (2007) .............................................................................. 20

4          AUSTRALIA’S INTERNATIONAL OBLIGATIONS AND QUARANTINE
           POLICY .................................................................................................... 21
5          THE STRUCTURE OF AND SENIOR PERSONNEL OF THE
           DEPARTMENT OF AGRICULTURE, FISHERIES AND FORESTRY ..... 23
6          HORSE IMPORT POLICIES .................................................................... 26
    Overview ................................................................................................................... 26

    Import conditions relevant to equine influenza as at August 2007 ............................. 27

    Revised import conditions implemented after the outbreak ........................................ 30

    The absence of any formal risk analysis relating to the importation of live horses ..... 32

    The relationship between AQIS and Biosecurity Australia in relation to the formulation
    of policy for importation of horses .............................................................................. 34

    Deficiencies in the policies and import conditions as currently formulated ................. 35

    Vaccination................................................................................................................ 35

    PAQ .......................................................................................................................... 36

7          THE QUARANTINE ACT ......................................................................... 38
    Overview ................................................................................................................... 38

    Importation of live animals ......................................................................................... 38

    Airports where horses may be landed ....................................................................... 39

    Appointed quarantine stations ................................................................................... 39

    Quarantine measures and powers ............................................................................. 39

    Compliance agreements............................................................................................ 41

    Recovery of quarantine expenses ............................................................................. 41

8          AQIS WORK INSTRUCTIONS AND PROCEDURES ............................. 43
    Prior to 2003.............................................................................................................. 43

    Development of the Live Horse Work Instruction and the Operations Manual ........... 43

    Live Horse Work Instruction....................................................................................... 54

    Import Clearance ....................................................................................................... 55

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    Procedures at all quarantine stations......................................................................... 56

    Operations manual .................................................................................................... 58

    Groom induction checklist and induction record......................................................... 60

    Authorisation for groom to enter Eastern Creek Post Entry Quarantine Station ......... 60

    Operating procedure for horses ................................................................................. 61

    AQIS expectations of horse grooms at ECQS ........................................................... 62

    Visitors book.............................................................................................................. 62

    Horse procedures document ..................................................................................... 62

    Checklist of cleanliness - horses ............................................................................... 62

    Importers’ horse health records ................................................................................. 63

    Development of other procedures.............................................................................. 63

    Groom Induction Checklist & Induction Record.......................................................... 63

    Authorisation for groom to enter Eastern Creek Post Entry Quarantine Station ......... 63

    Operating procedure for horses ................................................................................. 64

    AQIS expectations of horse grooms at ECQS ........................................................... 65

    Sandown HACCP Manual ......................................................................................... 65

    IRT Guidelines........................................................................................................... 67

9          THE IMPORTATION OF HORSES INTO AUSTRALIA ........................... 69
    Importers and the issue of import permits .................................................................. 69

    PEQ .......................................................................................................................... 70

    Foreign PEQ facilities ................................................................................................ 79

    ECQS ........................................................................................................................ 81

10         EVENTS AT ECQS FROM JUNE 2006 TO MARCH 2007 ...................... 87
    Events from March to August 2007............................................................................ 88

    Events regarding Live Horse Work Instructions and Operations manual.................... 88

    Access to the quarantine station................................................................................ 93

    Arrival procedures ..................................................................................................... 94


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   Induction of grooms ................................................................................................... 94

   Monitoring of horses’ health....................................................................................... 95

   Monitoring of grooms ................................................................................................. 96

   Private vets and farriers............................................................................................. 96

   Other visitors ............................................................................................................. 97

11        THE SIX CONSIGNMENTS COMPRISING THE AUGUST 2007 INTAKE ..
          ................................................................................................................. 98
   Overview ................................................................................................................... 98

   Consignment 1 (3 horses from United States) ........................................................... 98

   Consignment 2 (12 horses from United Kingdom) ................................................... 101

   Consignment 3 (10 horses from the United Kingdom and 6 horses from Ireland) .... 103

   Consignment 4 (5 horses from United States) ......................................................... 109

   Consignment 5 (12 horses from Ireland).................................................................. 112

   Consignment 6 (13 horses from Japan) ................................................................... 116

12        ATTENDANCE BY VETERINARIANS AND FARRIERS AND
          ACTIVITIES OF GROOMS .................................................................... 124
   Coolmore - Veterinarians......................................................................................... 124

   Darley and Arrowfield .............................................................................................. 124

   Other horses ........................................................................................................... 125

   AQIS veterinary inspection ...................................................................................... 126

   Attendances by farriers............................................................................................ 127

   Scot Barlow ............................................................................................................. 127

   Bradley Hinze – 14 August 2007 ............................................................................. 129

   Activities of grooms during PAQ .............................................................................. 132

   IRT/CBHIT............................................................................................................... 132

   Arrowfield ................................................................................................................ 133

   Coolmore................................................................................................................. 134

   Darley...................................................................................................................... 135

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   Clinical signs of respiratory illness emerge at ECQS ............................................... 136

13       THE MAITLAND EVENT........................................................................ 140
   The Carroll’s Ranch Event ....................................................................................... 140

   The circumstances of the outbreak of equine influenza at the Maitland Event ......... 140

   An infected horse at the Carroll's Ranch Event........................................................ 140

   The possible identity of the sick horse or horses ..................................................... 145

   Norman Hindmarsh, Emma Hindmarsh and Lynda Brown....................................... 145

   Matthew Constance ................................................................................................. 146

   Millie Beardmore ..................................................................................................... 148

   Michael Goddard ..................................................................................................... 148

   Jessica Farrell ......................................................................................................... 149

   Julie Allen, Josie Holmes, Emma Cudmore and Tiffany Williams ............................ 149

   Cheryl Grant ............................................................................................................ 149

   Nicola Richardson ................................................................................................... 150

   Katelee McTaggart .................................................................................................. 150

   Kathleen Chadderton............................................................................................... 150

   Michael Chamberlain ............................................................................................... 151

   Daniella Dierks ........................................................................................................ 151

   Lucy Roberts ........................................................................................................... 151

   Conclusions with regard to the Carroll's Ranch Event ............................................. 152

14       SCIENTIFIC TESTING ........................................................................... 153
   Tests by three laboratories on PEQ and PAQ samples ........................................... 153

   The type of tests ...................................................................................................... 154

   Results for Japanese horses in Spotswood ............................................................. 154

   Results for Japanese horses in Eastern Creek ........................................................ 155

   Results for the UK horses in Eastern Creek ............................................................ 156

   Results for the USA horses in Spotswood ............................................................... 156


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   Results for the USA horses in Eastern Creek .......................................................... 156

   Results for Irish horses in Eastern Creek................................................................. 157

   Relationship between the Sydney/07, Japan/07 and Philadelphia/07 strains of equine
   influenza virus ......................................................................................................... 157

   Relationship between the virus strains within Australia ............................................ 158

   Transmission of the virus into Australia and within the quarantine system ............... 158

15        EVENTS AT SPOTSWOOD QUARANTINE STATION ......................... 161
   Overview ................................................................................................................. 161

   Procedures at Spotswood Quarantine Station ......................................................... 161

   Locally produced documents ................................................................................... 162

   Access to the quarantine station.............................................................................. 164

   Facilities related to horses ....................................................................................... 165

   Procedures in place at Spotswood Quarantine Station ............................................ 165

   Induction of Grooms ................................................................................................ 165

   Arrival procedures ................................................................................................... 166

   Biosecurity procedures on arrival ............................................................................ 166

   Monitoring of grooms, private veterinarians and farriers .......................................... 167

   Monitoring of horses’ health..................................................................................... 167

   Consignment of horses on 8 August 2007 ............................................................... 167

   Veterinarian attending during PAQ .......................................................................... 168

16        OVERVIEW OF COUNSEL ASSISTING’S SUBMISSIONS .................. 170
   The circumstances that contributed to the outbreak ................................................ 170

   How the outbreak occurred ..................................................................................... 170

   Circumstances which contributed to the outbreak.................................................... 175

   The need for any strengthened procedures for quarantine management of imported
   horses ..................................................................................................................... 179

   Import conditions and PEQ ...................................................................................... 179

   Arrival at an Australian airport ................................................................................. 180

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   Cleaning of road transport vehicles at PAQ ............................................................. 181

   PAQ ........................................................................................................................ 182

   The role of Biosecurity Australia .............................................................................. 183

   The Quarantine Act ................................................................................................. 184




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