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A new report on a Canadian Boeing 737 accident. A must read for first officers

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A new report on a Canadian Boeing 737 accident. A must read for first officers

Old 26th Mar 2014, 12:43
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A new report on a Canadian Boeing 737 accident. A must read for first officers

I have read many accident reports in my career. This new report which can be seen on Rumours and News forum on a Canadian Boeing 737 crash while attempting an ILS, is surely the most comprehensive I have ever read. It is lengthy but quite enthralling story of how an unstable approach started from top of descent and ended still unstable as the aircraft hit terrain during a go-around, with the first officer constantly warning the captain of impending danger and being ignored. Basically the aircraft was full scale off localiser and below glide slope in the last minute of the ILS in low cloud.

Transportation Safety Board of Canada - Aviation Investigation Report A11H0002

I have included here a pertinent section of the accident report and which prompted me to place it on Pprune. It applies to all Australian operators that have multi-crew aircraft. And more so, where the first officer is inexperienced and lacking previous real world flying. Interpret that as you wish...

Quote: "How far should the first officer allow the aircraft to deviate before taking over control from the captain?

There is a history of incidents and accidents in which the FO was the PNF and warned of a deteriorating situation, but did not take control when the captain continued an unsafe course of action (section 1.17.8.5). In all of these occurrences, the company had some form of two-communication rule, but the defence failed because the FO did not intervene and take control of the aircraft. Some likely reasons for this failure are difficulty in identifying subtle incapacitation, ambiguity in the wording of the procedure, or inhibitions on the part of FOs to take the drastic measure of taking control from a captain.

At the time of the First Air accident, there was no training or guidance within the company on how an FO would escalate a concern to the point that a go-around or change of control could be commanded. In the absence of policies and procedures, such as PACE (probing, alerting, challenging, and emergency warning), enabling the FO to escalate his concern as well as providing the authority to take control of the aircraft from the captain, the FO was limited to an advisory role. The FO was clearly aware of the increasing risk. The approach had continued beyond 2 points at which a go-around was required: first, when there is full localizer deflection, and second, in an unstable approach below 1000 feet. At both of these points, the FO attempted to communicate the need to go around to the captain. While not as definitively and clearly expressed as they could have been, these attempts are indicators that the FO was continuing his efforts to change the captain’s course of action.

The FO had previously flown as captain on another aircraft type with the company. However, he was new to the B737, and although obviously uncomfortable with the navigational situation, deferred to the captain.

There was no policy specifically authorizing an FO to escalate his role from advisory to taking control, and this FO likely felt inhibited from doing so. The FO made many attempts to communicate his concerns and suggest a go-around, but did not take control of the aircraft from the captain.

This accident and the other 3 occurrences cited (section 1.17.8.5) are indicators that failure of FOs to take control in deteriorating situations will occasionally result in catastrophic consequences in the global fleet of transport aircraft. Without policies and procedures clearly authorizing escalation of intervention to the point of taking aircraft control, some FOs may feel inhibited from doing so." Unquote.

While the depth of the report may bore some less than enthusiastic airline pilots the discussion by the investigators on exactly how does a co-pilot take over physical control from the captain intent on pressing on regardless of risk, is worth close study. This subject is rarely covered in airline SOP.
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Old 26th Mar 2014, 14:11
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hoorah

Thank you for taking the time to make a good post! Such a nice change from newbie advice and the best headset! Cheers.
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Old 26th Mar 2014, 23:44
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Check out page 4, send shivers down my spine.
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Old 27th Mar 2014, 01:28
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This is why, at an airline level NTS is not only included in cyclics now but actually assessed.

As per. http://www.casa.gov.au/wcmswr/_asset...os_annex_c.pdf
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Old 27th Mar 2014, 05:42
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Cheers Centaurus, thank you for providing the link to the TSBC report. It is truly an exemplar and manages well to raise some important issues in a calm, concise manner. No tub thumping, just fact and analysis, which provide first class entry into some very complex issues; food for thought, you bet. There's something for everyone in the package and there are some interesting 'side-bars' in the report. The complexity of operating in the high latitudes for one; remote areas and Arctic weather for another two. One of the more oblique elements (as in not directly related) was the operational support/despatch/flight following system used, which functioned smoothly, fully supporting 'their' aircraft. Many may feel operational control is intrusive and should end when the doors shut; but a good support network with 'base' covering your tail, operating in that region would be a great asset.

Section 1.7 Meteorological information was impressive, the quantity and quality of met updates available and provided to the crew were indicative of a weather service on the ball, functioning like a well oiled clock. A quality service, that's a very remote destination with light traffic, subject to the whims of the Northern Arctic wind and weather.

Bravo Canucks. Well done indeed. (Big smile and round of applause).

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Old 27th Mar 2014, 08:03
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A very detailed accident report. Full marks to the Canadians.

Thanks to Centaurus for bringing this to the forum. With Airlines looking towards MPL schemes for a supply of future pilots, this report makes essential reading.

It might just make the difference in saving 100's of lives as well as your own.

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Old 28th Mar 2014, 01:18
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Centaurus,

I just finished reading the report when I saw your post. Although I am involved in a helicopter rescue organisation there are still some very good human factors lessons to be learned by any aircraft operator. We do emphasis with our crews the responsibility of all crew to speak up if they have concerns regarding an evolving situation and have established communication protocols as part of our specifically EMS designed CRM program. I have already forwarded this report on to my Safety Manager.
Great stuff
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Old 28th Mar 2014, 09:19
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Around thirty years ago a process was introduced into Qantas to address this problem. In the orders it was stated that in this scenario the FO should say ' Captain you must listen to me' - then state what should happen. If this phrase was used it had to be the subject of an incident report. The message is clear to all concerned and hence it is rarely if ever required.
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Old 28th Mar 2014, 11:49
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That's a very interesting report. Thanks Centaurus for highlighting it!

I find it interesting that there's such an emphasis on how first officers might take control from captains.

In this case the first officer seemed, outwardly, quite vague about the danger that the aircraft was in. There was no obvious need for the first officer to take control from the Captain - at least, unless the Captain ignored a direct and blunt suggestion! But this suggestion never occurred.

I tend to wonder in this kind of report why the crew seemed so reluctant to call a spade, a spade. What's in the human dynamic that prevented it?
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Old 28th Mar 2014, 20:42
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Post # 25 by PEI 3721 is worth a read; it mentions a couple of areas of interest, worthy of a revisit, research and ponder. Just thinking out loud here and trying to get a positive fix, not on went wrong, but why.

Once the turn onto the ILS is made, the last thing needed is any sort of doubt about 'Who's on first' and 'What's on second', early in the piece there is time, not a lot, but time and space are available to determine 'what's wrong with this picture'. I expect most have been in the position, a little high a little hot, vectors, radio, turbulence, ice, cramped for wriggle room etc. and being a little 'untidy' on the intercept, all easily sorted; but, what if the 'expected' picture goes pear shaped. These guys had two separate 'mental pictures' ~ expectations, to unscramble, with doubt, disbelief in the mix. Something was wrong, but it seems they were unsure of exactly WTF was wrong, now that's scary. The doubt, disbelief, the urge (if you like) to sort it out, within a sane time frame, would be strong; before giving it away. Remember the Dash 8 CFIT, the one that had the undercarriage problem, the attention of both crew focussed inside.

It's so very easy to say they should have gone around and I agree; being unable to know what to trust is reason enough; however, they did not. The elements which preceded the attempted late, rather than early overshoot are of interest, starting at just before the turn onto final. More reading and head scratching required methinks.
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Old 29th Mar 2014, 02:45
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Around thirty years ago a process was introduced into Qantas to address this problem. In the orders it was stated that in this scenario the FO should say ' Captain you must listen to me' - then state what should happen. If this phrase was used it had to be the subject of an incident report. The message is clear to all concerned and hence it is rarely if ever required.
... which was great and everybody understood it.

In their infinite wisdom a few years ago they removed the "You must listen Captain" phrase and replaced it with RAISE - an useless acronym that nobody ever remembers what it stands for.
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Old 29th Mar 2014, 10:59
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A succinct report. The accident report was compiled logically, articulately and concisely. I enjoyed every page. A report of this quality is 'never to long'.
The Canucks have excelled in their investigative abilities to become world leaders. Things weren't always that way, but they have had a number of accidents at the big end of town and as a result their processes have developed to the point of being wold class. Never mind, the way things are going in Australia we will end up with our own learning curve when some serious tin is destroyed in the not so distant future. Pity a country has to learn this way.

In this crash there are some disturbing similarities (F/O inaction) with Garuda, 2007, Yogyakarta. On that occasion the F/O could have taken control of the aircraft on probably a dozen occasions but he didn't.

Again Centaurus, good post and good timing mate. One can only wish that the Australian Government, at the behest of the good Senators, would read that report and then ram it down the throat of that fool Dolan and show him how things should be done
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Old 29th Mar 2014, 22:50
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While the depth of the report may bore some less than enthusiastic airline pilots the discussion by the investigators on exactly how does a co-pilot take over physical control from the captain intent on pressing on regardless of risk, is worth close study. This subject is rarely covered in airline SOP.
The FO never made a hard statement about the approach until .2 seconds before the missed approach attempt. All the statements leading up to that point seemed like expressions of opinion which the captain over rode, in his opinion the approach would be recovered and landing assured.

Before taking over (and much earlier in the approach) the FO needed to say "GO-ROUND" and if the captain didn't listen then a harsher statement including the intent to take over should he not listen.

I don't think this is an example of teaching FOs to take-over from the PF during an approach, this is an example of using clear concise language to achieve an outcome. If you state an opinion the other guy will most likely follow his idea of the situation. If you just tell him its unsafe GO-ROUND he has no choice really other than to do such. As it stated in the report what the FO really meant to say early on was "we are unstable go-round", instead he made it sound like an opinion rather than fact, and, never used the phrase go-round.

Wrestling for control at low altitude when communication is unclear is even more dangerous.
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Old 29th Mar 2014, 23:29
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P377:
One can only wish that the Australian Government, at the behest of the good Senators, would read that report and then ram it down the throat of that fool Dolan and show him how things should be done
Couldn't agree more Para, although at this point in time it would seem to be a wane hope..

Indeed there is much to be learnt from such a succinct report and it would seem that the Canucks not only talk the talk but also walk the walk ... Reference Safety Action Required 4.2 of the report:
4.2.1. Unstable approaches

In this accident, the aircraft arrived high and fast on final approach, was not configured for landing on a timely basis, had not intercepted the localizer and was diverging to the right. This approach was not considered stabilized in accordance with the company's stabilized approach criteria, and the situation required a go-around. Instead, the approach was continued. When the crew initiated a go-around, it was too late to avoid the impact with terrain. Unstable approaches continue to be a high risk to safe flight operations in Canada and worldwide.

Flight Safety Foundation research concluded Footnote 172 that 3.5% to % of approaches are unstable. Of these, 97% are continued to a landing, with only 3% resulting in a go-around. To put these figures in context, there were, in 2012, 24.4 million flights worldwide in a fleet of civilian, commercial, western-built jet airplanes heavier than 60 000 pounds. This means that between 854 000 and 976 000 of those flights terminated with an unstable approach, and approximately 828 000 to 945 000 continued to a landing. The potential negative consequences of continuing an unstable approach to a landing include controlled flight into terrain (CFIT), runway overruns, landing short of the runway, and tail-strike accidents.
Occurrences in which an unstable approach was a contributing factor demonstrate that the severity can range from no injuries or damage to multiple fatalities and aircraft destruction. In Resolute Bay, the continuation of an unstable approach led to a CFIT accident and the loss of 12 lives. Without improvements in stable approach policy compliance, most unstable approaches will continue to a landing, increasing the risk of CFIT and approach and landing accidents.

In this investigation, the Board examined in detail the defences available to air carriers to mitigate the risks associated with unstable approaches and their consequences. These mainly administrative defences include:
  • A company stabilized-approach policy, including no-fault go-around policy;
  • Operationalized stable approach criteria and standard operating procedures (SOPs), including crew phraseology;
  • Effective crew resource management (CRM), including empowering of first officers to take control in an unsafe situation;
  • Use of flight data monitoring (FDM) programs to monitor SOP compliance with stabilized approach criteria;
  • Use of line-oriented safety audits (LOSA) or other means, such as proficiency and line checks, to assess CRM practices and identify crew adaptations of SOPs;
  • Non-punitive reporting systems (to report occurrences or unsafe practices);
  • Use of terrain awareness and warning systems (TAWS).
While First Air had some of these defences in place, including a stabilized approach policy and criteria, a no-fault go-around policy, safety management system (SMS) hazard and occurrence reporting, the two-communication rule and an older-generation ground proximity warning system (GPWS), these defences were not robust enough to prevent the continuation of the unstable approach or collision with terrain. Other TSB investigations have shown that non-adherence to company SOPs related to stabilized approaches is not unique to First Air.

In addition, the use of newer-generation TAWS with forward-looking terrain avoidance features will enhance a flight crew's situational awareness and provide increased time for crew reaction. However, if the risk in the system is to be reduced significantly, the industry must take other steps and not rely on purely technological solutions.
The first step is for operators to have practical and explicit policies, criteria, and SOPs for stabilized approach that are enshrined in the company operating culture.

The second step is for companies to have contemporary initial and recurrent CRM training programs delivered by qualified trainers and to monitor and reinforce effective CRM skills in day-to-day flight operations. Effective CRM is a defence against risks present in all phases of flight, including unstable approaches.

The third step involves monitoring of SOP compliance through programs such as flight data monitoring (FDM) and line-oriented safety audits (LOSA). In Canada, TC requires large commercial carriers to have SMS, cockpit voice recorders (CVRs), and flight data recorders (FDRs). However, these carriers are not required to have an FDM program. Even so, many of these operators routinely download their flight data to conduct FDM of normal operations. Air carriers with flight data monitoring programs have used flight data to identify problems such as unstabilized approaches and rushed approaches, exceedance of flap limit speeds, excessive bank angles after take-off, engine over-temperature events, exceedance of recommended speed thresholds, GPWS/TAWS warnings, onset of stall conditions, excessive rates of rotation, glide path excursions, and vertical acceleration.

FDM has been implemented in many countries, and it is widely recognized as a cost-effective tool for improving safety. In the United States and Europe—thanks to ICAO—many carriers have had the program for years. Some helicopter operators have it already, and the Federal Aviation Administration (FAA) has recommended it.

Worldwide, FDM has proven to benefit safety by giving operators the tools to look carefully at individual flights and, ultimately, at the operation of their fleets over time. This review of objective data, especially as an integral and non-punitive component of a company safety management system, has proven beneficial in proactive identification and correction of safety deficiencies and in prevention of accidents.

Current defences against continuing unstable approaches have proven less than adequate. In Canada, while many CAR 705 operators have voluntarily implemented FDM programs, there is no requirement to do so. First Air was not conducting FDM at the time of this accident. Furthermore, FDM programs must specifically look at why unstable approaches are occurring, how crews handle them, whether or not crews comply with company stabilized-approach criteria and procedures, and why crews continue an unstable approach to a landing. Unless further action is taken to reduce the incidence of unstable approaches that continue to a landing, the risk of approach and landing accidents will persist.

Therefore, the Board recommends (A14-01) that:

Transport Canada require CARs Subpart 705 operators to monitor and reduce the incidence of unstable approaches that continue to a landing. A14-01
The TSBC through their employee interactive blog (vs the Beaker blog) put out the following blog piece:
One unstable approach too many
March 28th, 2014 Posted by: Brian MacDonald

According to international air industry figures, 3.5 to 4 percent of all aircraft approaches to landing are unstable; and of those, 97 percent actually continue to a landing. Most of the time, everything works out just fine. But sometimes there are consequences: a runway overrun, a tail strike, or in the case of Resolute Bay, Nunavut, on August 20, 2011, a fatal crash. It’s time to put a spotlight on this issue to see what needs to be done to address this ongoing problem.


Any pilot will tell you that landing is one of the most critical phases of flight, in part because the aircraft is maneuvering at a much slower speed, and much closer to the ground. A stabilized approach helps to ensure that the plane is ready for landing and that the pilots are prepared for the demanding task of landing an aircraft. Many air transport operators incorporate stabilized approach policies and procedures within their operations. This is intended to be an administrative defense against several negative outcomes, such as runway overruns and controlled flight into terrain (CFIT). A stable approach involves controlling, and stabilizing, several key criteria before the aircraft reaches a predefined point – usually several miles back from the airport, at 1000 feet above the ground. These criteria include:
A. Course – The aircraft is on the prescribed track to land. This avoids any excessive bank angles during the final moments before landing;
B. Speed – Should be within a few nautical miles per hour of appropriate speed for approach conditions of weight and weather. This provides the slowest speed for landing, but with built in safety margins;
C. Rate of descent - Should be set to maintain the glide path. This avoids excessive changes and allows an optimum closure rate to the runway surface,
D. Power setting – Should be set to maintain optimum airspeed and rate of descent previously mentioned. This prevents excessive changes to airspeed and rate of descent and ensures the engines are in a power range that allows for rapid acceleration should a go-around be required; and
E. Aircraft configuration – The landing gear should be down and final flap selection completed. This avoids configuration changes in the final moments of the approach which could in turn adversely affect speed, rate of descent and power setting


An approach is considered stabilized if all criteria in company procedures are met before or when reaching the predefined minimum stabilization height. An approach that does not meet the criteria at this point, or becomes unstable below this point, requires an immediate go-around— which means climbing to a safe altitude to determine the next course of action. On that fateful day in August 2011, the First Air pilots initiated a go-around, but it was too late.


Flight crews are required to stabilize approaches to runways for a number of reasons. Landings will be more consistent and predictable. Flight crews also have more time—and more attention—to monitor key elements such as communications and systems operation, thereby boosting their situational awareness. And at the heart of all of this is safety. Establishing and stabilizing the key variables in advance means fewer last-minute adjustments, which helps minimize workload during this critical phase. So when flight crews reach the pre-determined point where they must decide whether to proceed with the landing or carry out a go-around, they have more space—and time—to do so.


But this didn’t happen on August 20, 2011. The investigation into this accident highlights that there are too many unstable approaches that continue to a landing—some resulting in tragedy. Because current defences have proven less than adequate, and unless further action is taken, the risk of landing accidents will persist. That is why the Board issued a recommendation that:


Transport Canada require airline operators to monitor and reduce the incidence of unstable approaches that continue to a landing.


If air operators take a hard look at addressing unstabilized approaches, this will hopefully mean safer landings for everyone. - See more at: One unstable approach too many - The TSB Recorder - The TSB Recorder
And perhaps to highlight the issue of unstabilised approaches the TSBC have released another report of interest and as noted here aviationsafety.net (FSF): Embraer 145 runway excursion caused by unstabilized approach and improper braking technique during heavy rain


Happy Sundy learning...
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Old 30th Mar 2014, 07:38
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Flight Data Monitoring which Qantas has had for over thirty years is a must have.
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Old 30th Mar 2014, 08:13
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Sarcs, the Asiana crash in San Fran would be a candidate for an example of unstable approach gone wrong. Admittedly there are always more than one causal factor, however this accident would sit in that low percentage rate of unstable approaches that went horribly wrong when all of Professor Reasons other cheese holes lined up.

Again, the Yanks, Canucks and Singaporeans have turned accident investigation into a fine art.
And to be honest, Australia's ATSB was of a high calibre until Dolan took the reigns. People like Alan stray and others don't just grow on trees. Who knows, maybe one day we will see a return to a quality ATSB, we've been there before.
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Old 30th Mar 2014, 08:58
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If you state an opinion the other guy will most likely follow his idea of the situation. If you just tell him its unsafe GO-ROUND he has no choice really other than to do such.

Don't you believe it. If a captain is intent on pressing on to land when circumstances are clear that it is going to a very close thing, previous accidents of this nature have revealed via the CVR that he becomes oblivious to the calls by the first officer.
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Old 30th Mar 2014, 21:47
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In their infinite wisdom a few years ago they removed the "You must listen Captain" phrase and replaced it with RAISE - an useless acronym that nobody ever remembers what it stands for.
Ummm. It still exists as an option. FAM 21.2.2.2 or thereabouts. iI's just not the only option. I would have thought that a good thing?
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Old 30th Mar 2014, 21:52
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The whole point of 'You must listen' is that it is official, in the orders and must be reported. This gives it weight and makes it effective.
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Old 30th Mar 2014, 22:48
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All interesting reading.
Would I not be wrong in saying going around after a self stuffed up App is something we all would have trouble initiating? I mean we are all human (with all our failings) & no one likes to admit failure of any kind & peer pressure is alive & well in all of us no matter what culture.
We still have to work with each other & there would always be a certain amount of awkwardness in the cockpit if you flew again latter down the track with a guy where you had to take over the controls due his inabilities some time ago. The male ego, the thought of yr mates thinking he stuffed up & the management also having perhaps an unsavory opinion, all very real I suspect & happens not just in aviation.
A very late decision to go-around would be the last straw when it all got very obvious that it was hopeless so until then it's save face all the way down.

To sum it up nobody likes to repeat any exercise for whatever reason if they stuffed up in the first place.


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