C R M



 

Briefing

 
 

 
Victor : Any word on that storm lifting over Salt Lake, Clarence?
Oever : No not likely, Victor. I just reviewed the area report for 1600 hours through 2400.
Victor : Uh, huh ...
Oever : There's a front stalled over the Dakotas, backed all the way to Utah.
Victor : Yeah, well, if she decides to push over to the great lakes, it could get plenty slippery.
Oever : Uh, huh.
Victor : What about the southern route, around Tulsa?
Oever : I double checked the terminal forecast and winds aloft and I had cloudy ceilings all the way.
Victor : Where do they top out?
Oever : Well . . . there's some light scattered cover to 20,000 icing around 15. . .
Worker3 : Wahhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh.. (falling off ladder from washing plane's windows)
Victor : Boy looks like the original plan ought to be the best bet.
Oever : Denver it is.
Murdock : Sorry Clarence. Latest weather report shows everything is sopped in from Salt Lake to Lincoln.
Oever : Oh, Hi Roger! Glad to have you aboard! Victor, this is Roger Murdock, Victor Basta.
Victor : How do you do Roger?
Murdock : Nice to meet you!
Oever : Roger, I was telling Victor that I reviewed the area report for 1600 hours through 2400 there's a front stalled over the Dakotas. . .

 

 

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Careful when you open the cockpit door

Read more about it here.

 

 

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Pilot monitoring

 

 

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Making Monitoring Matter

 

Reading Checklists

Most of the normal checklists are read aloud in a challenge/response format. One pilot reads the item, and the other pilot calls out the verification. On the ground it’s usually the first officer who reads. In the air, it’s whichever pilot is not physically flying. For instance, using C and R for challenge and response, a LANDING checklist would go roughly as follows (this is a generic example):

C: “Landing gear?”
R: “Down, three green lights”

C: “Flaps and slats?”
R: “Thirty-Five, Thirty-five, Set”

C: “Spoilers?”
R: “Armed”

C: “Autobrakes?”
R: “Three”

The pilot who is reading then says, “Landing checklist is complete.”

Sometimes both pilots are required to call out verification of an especially important item. Challenge/Response becomes Challenge/Response/Response. Trying it again:

C: “Landing gear?”
R: “Down, three green”
R: “Down, three green”

C: “Flaps and slats?”
R: “Thirty-Five, Thirty-five, Set”
R: “Thirty-Five, Thirty-five, Set”

C: “Spoilers?”
R: “Armed”

C: “Autobrakes?”
R: “Three”

At other times, the pilot reading the checklist calls out both the item and the verification. It depends.

 

Read more on Ask the Pilot

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Rethinking the Briefing

Alaska Airlines revamps approach and departure briefings to focus on flight-specific threats.

by Rich Loudon and David Moriarty | August 24, 2017

On Aug. 14, 2013, an Airbus A300-600 freighter experienced a controlled flight into terrain (CFIT) fatal accident during a localizer non-precision approach to Runway 18 at Birmingham (Alabama, U.S.) Shuttlesworth International Airport (“False Expectations,” ASW, Feb. 2015). The National Transportation Safety Board ultimately concluded that pilot error, specifically “the flight crew’s continuation of an unstabilized approach and their failure to monitor the aircraft’s altitude during the approach,” was the probable cause of the crash, which killed both crewmembers and destroyed the airplane.

The cockpit voice recorder revealed a haunting revelation about the content of the crew’s arrival briefing — it was perfect. Or was it? There was certainly a lot of talking by the pilot flying (PF) as he dutifully “ticked all the required boxes,” but no discussion regarding the relevant threats or countermeasures that could have averted disaster. The fatigued crew chose to fly a seldom performed, non-precision approach at night to a short runway with limited lighting; the weather forecast suggested an unpredictable cloud ceiling. This is one more example of an all-too-common thread in recent industry accidents: the loss of flight path and situational awareness due to onset of high crew workload as a result of rapidly changing conditions.

We have spoken to numerous U.S. and international air carriers about the content of their departure and arrival briefings and have found most to be strikingly similar. The commonality is a decades-old briefing method that has neither adapted to next generation flight decks nor incorporated breakthroughs in our understanding of human cognition. Today’s typical standard operating procedure (SOP) briefing is simply too long (due to years of adding more and more items determined to be ”too important not to discuss”). Additionally, briefings have become one-size-fits-all solutions serving as repositories for redundant verbal crew crosschecks of highly automated, highly reliable systems. Finally,  too often they are one-sided conversations that lack involvement from the crewmember that recent industry accident trends indicate will play a primary role in maintaining safety margins: the pilot monitoring (PM).

[...]

It is time to rethink the way we brief — not only to address these issues but also to create a methodology that incorporates recent breakthroughs in cognitive theory regarding decision making in the very environments that are proving to be so challenging for pilots. After a year of research and development, we came up with four goals for our briefings:

Read more about it on the Flight Safety Foundation

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Pilot fatigue

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Do personality differences in the cockpit impair performance?

Why did the first officer on Air India IX-812 fail to take over the controls from the captain after asking for a go-around 3 times? While multiple factors led to the accident, the crew interaction and personalities definitely played their part as well. I will get back to this later.

Most of my days on the job are characterised by good crew interaction where synergy seems to flourish in the cockpit, but some days are just more of a struggle to get through.

 This leads to the question: Do different personalities in the cockpit impair our performance?

• do first officers at times tailor their behaviour to meet the captain’s expectations?

• do some captains feel too challenged by the first officer’s behaviour?

• can different personalities disrupt the synergy in the crew interaction?

 From the psychological point of view, there are different opinions on the matter of whether we actually can be put in specific boxes of personalities. There seems, however, to be a consensus that we all have five personality traits in common.

 A personality trait is a habitual pattern of behaviour, thoughts, and emotions.

We possess all five traits, but they vary in degree from person to person. They are relatively stable throughout our lives and are valid across gender, culture etc. Based on the trait theory from psychology, these are known as The Big Five:

Openness: Imagination, insight, adventurousness, creativity, openness to new things. People low on this trait are often more traditional, dislike change and resist new things.

Conscientiousness: Organized and mindful of details, with good impulse control and goal-directed behaviour, well-prepared. People who dislike structure and schedules usually score low on this trait.

Extraversion: Excitement, socialising, talkativeness, self-expression. A person with a low score prefer solitude, and feel exhausted by socialising.

Agreeableness: Trustworthiness, altruism, kindness, affection. Those low on this trait tend to be more competitive and even manipulative.

Neuroticism: Sadness, moodiness, emotional instability. People with low scores are emotionally stable, deal well with stress, are relaxed and do not worry much.

[...]

During the investigation, the colleagues of the captain and first officer were asked to describe their characters. The captain was known as friendly and helpful, but also as an assertive type who always wanted to be right. The first officer was known to be meticulous in his adherence to procedures. A man of few words. This could suggest that the captain was of the more extroverted type, and the first officer of the more introverted type. This might have led to personality discrepancies being a part of the error chain.

One of the conclusions were: "Many aspects of how these two pilots communicated to perform routine tasks, suggested that the pilots were not working in harmony.”

 

Read more about it on Aerotime

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Single pilot operation



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A Jetstar flight nearly crashed because the pilot was text messaging on his phone


Submitted by News Desk 2 on Thu, 04/19/2012 - 15:28

 

Jetstar Flight JQ57 nearly crashed on landing at Singapore's Changi Airport because the pilot was text messaging and forgot to set the landing gear on the Airbus A320 during the May 27th, 2010 flight according to the results of an investigation into the incident.

According to the report by the Australian Transport Safety Bureau, the flight which departed Darwin Australia was on its landing approach when the captain's phone began receiving messages. The first officer was in control of the plane, the pilot flying (PF), and tried to notify the captain that something was not right, the captain failed to respond, instead replying to messages he had received.

 

Read more about it here.


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Captain Arrested; Suspected of Being Under the Influence of Alcohol

 

 

January 4, 2013 by Brian Cohen

A captain of American Eagle — the regional airline of American Airlines — was reportedly removed from the aircraft at Minneapolis-Saint Paul International Airport before piloting a Bombardier CRJ-700 aircraft to LaGuardia Airport in New York and arrested after supposedly failing a sobriety test.

The unidentified pilot — currently suspended from flying until an inquiry pertaining to the incident is completed — was suspected of being under the influence after witnesses reportedly noted the scent of alcohol. The blood alcohol level recorded by a preliminary alcohol breath test supposedly surpassed the legal limit to pilot a commercial aircraft, although the exact reading is unknown.

Visit NBCNews.com for breaking news, world news, and news about the economy

Read the article on Flyer Talk

 

Flight, a movie on the same topic


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Deadly Tenerife

 


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Lanzarote 737 overran as first officer struggled to cope

 

 

 

By:   David Kaminski-Morrow London
01:00 20 Feb 2012 
Source:

 

 

Spanish investigators have found that an overbearing captain helped create the circumstances for an unstable approach, which led an Air Europa Boeing 737-800 to overrun at Lanzarote.

The aircraft overflew the Runway 21 threshold at 55m (180ft) at 175kt (324km/h), with the flaps deployed at just 25° owing to automated flap-loading limitations.

It travelled halfway along the runway - which was wet - before touching down some 1,300m beyond the threshold. While the brakes were applied immediately, thrust reversers were not activated for 13s, by which time the 737 was barely 200m from the end of the runway.

The aircraft, which had arrived from Glasgow, overran at 94m and crossed a 60m stopway before coming to a halt just a metre from the jet-blast barrier, next to the perimeter fence.

Spanish investigation agency CIAIAC discovered that the 737 was originally to land on Runway 03, and the flying first officer had programmed this descent into the flight management computer.

 

air europa boeing 737-800, adrian jack/airteamimages.com

 © Adrian Jack/AirTeamImages.com 

Investigators have found that an overbearing captain helped create the circumstances for an unstable approach, which led an Air Europa Boeing 737-800 to overrun at Lanzarote on 31 October 2008

 

But the captain opted instead for a Runway 21 approach, without consulting the first officer, forcing him to prepare a different landing procedure without much time. The aircraft, at the time, was at 14,600ft (4,453m) and 56km (30.5nm) from the runway.

While the first officer tried, with difficulty, to reprogramme the flight computer, the captain prompted him to keep descending. "[The first officer's] lack of assertiveness to tell the captain that he did not agree with what he was being forced to do is undoubtedly a contributing factor to the genesis of the incident," said CIAIAC.

It said the captain "made every decision" but "at no time" asked the first officer's opinion. Despite being aware of the "worsening" situation, and "undoubtedly" noticing the inability of the first officer to cope after the runway switch, the captain did not touch the controls or the autopilot.

"During the approachthe first officer was at times overwhelmed by work, while the captain limited himself to telling the first officer that he had to descend more, without actually intervening directly," said CIAIAC's report on the 31 October 2008 event.

While the captain had 8,388h on type (more than 10 times that of the first officer), CIAIAC said he decided to continue the approach "in spite of the presence of a multitude of indications that suggested or required that the manoeuvre be stopped".

These indications included the aircraft's high energy state as well as repeated alerts from the enhanced ground-proximity warning system, over a 28s period, as it descended below 900ft.

Although the aircraft sustained minor tyre damage in the incident, none of the 80 occupants was injured.

 

Read here and you can read more about it there.

 

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Learning from mistakes

View more videos at: http://nbcdfw.com.

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Mayday - Kid in the cockpit

 

Read on Aeroflot Flight 593 on Wikipedia

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Passengers in the cockpit

 


Read more about these incidents on the Aviation Herald andhttp://www.news.com.au/travel/news/vietnam-airlines-pilots-punished-over-model-in-cockpit/story-e6frfq80-1226641133555#ixzz2Taqx9KXe

 

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Flight 232 at Sioux City

 

Find out more about it here

United Airlines Flight 232 was a scheduled flight from Stapleton International Airport in Denver, Colorado, to O'Hare International Airport in Chicago, with continuing service to Philadelphia International Airport.[2] On July 19, 1989, the DC-10 (Registration N1819U) operating the route crash-landed in Sioux City, Iowa, after suffering catastrophic failure of its tail-mounted engine, which led to the loss of all flight controls. 111 people died in the accident while 184 survived.[note 1][1] Despite the deaths, the accident is considered a prime example of successful crew resource management due to the manner in which the flight crew handled the emergency,[3] and the high number of survivors considering that the airplane was landed without conventional control.[1] The flight crew became well-known as a result of their actions that day, in particular the captain, Alfred C. Haynes, and a DC-10 instructor on board who offered his assistance, Dennis E. Fitch.

The manner in which the engine failed resulted in high-speed shrapnel being hurled from the engine; this shrapnel penetrated the hydraulic lines of all three independent hydraulic systems on board the aircraft, which rapidly lost their hydraulic fluid. As the flight controls on the DC-10 are hydraulically powered, the flight crew lost their ability to operate nearly all of them. Despite these losses, the crew were able to attain and then maintain limited control by using the only systems still workable: the two remaining engines. By utilizing each engine independently, the crew made rough steering adjustments, and by using the engines together they were able to roughly adjust altitude. The crew guided the crippled jet to Sioux Gateway Airport and lined it up for landing on one of the runways. However, without flight controls, they were unable to slow down for landing, and were forced to attempt landing at much too high a speed and rate of descent. On touchdown, the aircraft broke apart, caught fire, and rolled over. The largest section came to rest in a cornfield next to the runway. Despite the ferocity of the accident, approximately two-thirds of those on board survived due to multiple factors. The cause of the engine failure was traced back to a manufacturing defect in the fan disk, which had microscopic cracks due to impurities. The cracking was present during maintenance inspections and should have been detected by maintenance personnel, revealing shortcomings in the maintenance processes.[1]

The accident had a strong influence on the industry. DC-10s were modified to prevent catastrophic loss of hydraulic fluid should a similar failure occur again.[1] These modifications were also included in the DC-10's direct successor, the MD-11. Research has been conducted to see if computers might be able to control aircraft using the engines alone, improving on what humans can do unaided. The accident is cited as an example of why "lap infants"—children without a seat of their own—should have their own seat and be properly restrained on all flights.[4] This campaign has been led by United 232's chief flight attendant, one of the notable survivors of the accident. Several other notable people survived, and the news photography in the direct aftermath led to an iconic image being produced; that image was transformed into sculpture and now serves as flight 232's memorial.[5]

Despite the assumed extreme unlikelihood of such catastrophic failures occurring, other aircraft have lost all conventional control. Of these, United 232 was the most successful by far, as the others crashed with the loss of all or nearly all persons on board. United 232's level of success was not exceeded until 2003, when a cargo jet lost all flight controls after being struck by a surface to air missile but was nevertheless able to land safely.


 

 

 

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2 Pilots stood down  after dispute in the cockpit

 

 

 

 

 

Qantas has stood down two pilots who had a heated argument in the cockpit of a Boeing 747 jumbo.

Qantas has stood down two pilots who had a heated argument in the cockpit of a Boeing 747 jumbo.

QANTAS has stood down two pilots who had a heated argument in the cockpit of a Boeing 747 jumbo on the tarmac at Dallas' international airport.

Just weeks after Qantas stood down a captain for returning a positive alcohol reading, it has emerged that another captain and a second officer on a 747-400 had an argument over the take-off calculations they should be punching into the passenger jet's computer system.

Qantas has launched an investigation into the dispute between the pilots, who have been told they cannot fly. The incident occurred last Tuesday night (US time) as a major thunderstorm was rolling across Dallas, causing severe congestion at the airport.

<i>Illustration: Cathy Wilcox</i>

Illustration: Cathy Wilcox

Because the pilots were already close to exceeding their 20-hour duty limits due to delays caused by the thunderstorms, Qantas' flight operations managers decided to keep the plane on the ground overnight at Dallas-Fort Worth International Airport.

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The managers were later informed of the argument between the pilots and stood them down. It meant the airline had to bring in replacement pilots to fly QF8 back to Sydney via Brisbane the next day.

The 747-400 jumbo, which can carry about 320 passengers on the ultra-long-haul route across the Pacific, had been due to arrive in Brisbane at 5am on Thursday but did not touch down until 18 hours later.

A Qantas spokesman confirmed yesterday that a captain and a second officer had been withheld from service while an investigation was under way.

But he said the flight was late arriving in Brisbane because of the delays caused by the thunderstorms, not the altercation between the two pilots.

"Qantas flight QF8 from Dallas-Fort Worth to Brisbane on 14 August was delayed overnight as a result of severe thunderstorms in the Dallas area,'' he said.

The 13,816-kilometre route is one of the longest non-stop routes in the world and the longest flown by 747 jumbos.

 


Read more: http://www.watoday.com.au/travel/travel-incidents/pilots-stood-down-after-dispute-in-cockpit-20120820-24inx.html#ixzz24Vgf9r7D

Read more about it  here 

 

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Kenya 737 crash probe highlights disparity between pilots

Pairing of a dominant captain and a reserved first officer on the crashed Kenya Airways Boeing 737-800 in Cameroon appears to have contributed to their poor co-ordination and failure to correct the aircraft's fatal trajectory.

The 52-year old captain had 8,682hr of which 824hr were on the 737-700/800, says the Cameroon Civil Aviation Authority in its final technical report into the crash outside Douala.

Progress reports during captaincy training mentioned his satisfactory aircraft handling but described an "overbearing tendency" towards colleagues, a "touch of arrogance" and "insufficient flight discipline".

Since his securing captaincy on the 737, it adds, Kenya Airways instructors had mentioned "several recurrent shortcomings" in areas such as respect for standard operating procedures, crew resource management and cockpit scanning - although remedial recommendations had been made in each case.

Read more here and here

 

 

 

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NTSB confirms pilot fault in Northwest overflight

Friday March 19, 2010

Resource Center

US National Transportation Safety Board determined that last October's Northwest Airlines overflight incident occurred "because the pilots became distracted by a conversation unrelated to the operation of the aircraft."

The incident, in which NWA Flight 188 overflew its destination airport of Minneapolis-St. Paul by more than 100 mi. and had no contact with controllers for approximately 77 min., achieved worldwide notoriety, although the aircraft returned to the airport and landed safely (ATWOnline, Nov. 5, 2009). NTSB also said that air traffic controllers "did not follow procedures to ensure NWA 188 was on the correct frequency, which delayed the identification of the aircraft as NORDO [no radio communications]."

The NTSB investigation confirmed what generally was believed to be the case at the time--that the pilots were discussing a new crew scheduling system and "each was using his personal laptop computer contrary to company policy," NTSB stated.

It appears that earlier in the flight, the first officer mistakenly dialed in an incorrect frequency while the captain was absent from the cockpit. Upon the captain's return, the pilots began discussing the bidding process and opened their laptops, which NTSB said may have blocked their primary flight and navigation displays but not the "upper screen of the electronic centralized aircraft monitor. . .where ACARS MSG blinks." The pilots missed numerous ACARS messages "and at least nine messages" regarding their position on the multifunction control and display unit and the PFDs as they neared MSP.

NTSB found "that a lack of national requirements for recording ATC instructions when using automated flight tracking systems, such as directing an aircraft to switch frequencies or to indicate that an aircraft has checked in on an assigned frequency, was a factor in the controllers' delay in performing necessary actions and notifications required by lost communications procedures."

by Perry Flint

 

 

 

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The High and the mighty

 

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The history of CRM

 

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Ditching Over the Gulf of Mexico

January 28, 2011

Kelly McHugh: Ditching Over the Gulf of Mexico
 

File Size 18.1 MB / Running Time 19:49

By Glenn Pew, Video Editor

 

Podcast Index | How to Listen | Subscribe Via RSS

 

Kelly McHugh was flying a Piper Jetprop P46T at 26,000 feet over the Gulf of Mexico on December 4, 2010, when the engine started to lose power. He was more than an hour from shore with three other men aboard, and, one way or another, they were all about to get wet. AVweb's Glenn Pew spoke with McHugh to hear the story of the ditching.

 

Want to save this podcast and listen later? Click here for the MP3 file.

 

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Because of a light bulb - Origin of the CRM?

Eastern Air Lines Flight 401 was a Lockheed L-1011 Tristar 1 jet that crashed into the Florida Everglades on the night of December 29, 1972, causing 101 fatalities (77 initial crash survivors, two died shortly afterward). The crash was a result of the flight crew's failure to recognize a deactivation of the autopilot during their attempt to troubleshoot a malfunction of the landing gear position indicator system. It is believed that fatigue and poor CRM contributed to the accident. As a result, the flight gradually lost altitude while the flight crew was preoccupied and eventually crashed. It was the first crash of a wide-body aircraft and, at the time, the deadliest in the United States.[1]

After the crash, Flight 401 was also known for reported paranormal activities, supposedly stemming from the salvage of aircraft parts; Eastern Airlines later removed the Flight 401 parts.[1] The effects of this crash on the airline industry continue today and resulted in the development of Crew (or Cockpit) Resource Management (CRM)[citation needed], a technique that requires air crews to divide the work in the cockpit amongst available crew ensuring that someone continues focusing on flying the plane while troubleshooting continues. United Airlines Flight 232[citation needed] is one of the most well known examples of effective CRM.

Read more here.

 

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Lanzarote 737 overran as first officer struggled to cope

air europa boeing 737-800, adrian jack/airteamimages.comSpanish investigators have found that an overbearing captain helped create the circumstances for an unstable approach, which led an Air Europa Boeing 737-800 to overrun at Lanzarote.

The aircraft overflew the Runway 21 threshold at 55m (180ft) at 175kt (324km/h), with the flaps deployed at just 25° owing to automated flap-loading limitations.

It travelled halfway along the runway - which was wet - before touching down some 1,300m beyond the threshold. While the brakes were applied immediately, thrust reversers were not activated for 13s, by which time the 737 was barely 200m from the end of the runway.

The aircraft, which had arrived from Glasgow, overran at 94m and crossed a 60m stopway before coming to a halt just a metre from the jet-blast barrier, next to the perimeter fence.

Spanish investigation agency CIAIAC discovered that the 737 was originally to land on Runway 03, and the flying first officer had programmed this descent into the flight management computer.

 

 © Adrian Jack/AirTeamImages.com 

Investigators have found that an overbearing captain helped create the circumstances for an unstable approach, which led an Air Europa Boeing 737-800 to overrun at Lanzarote on 31 October 2008

Read more here

 

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They have a gift

 

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A team or a crew?

 

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