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Pasadena Police - two OH-58s make contact

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Old 16th Mar 2018, 08:16
  #121 (permalink)  
 
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Crab, you think there may be a memo iterating a necessity to be positioned on the pad?
if there was one before the accident then it must have been ignored but I bet there is something in their local order book now

As humans we are often not very good at acknowledging our own failings and don't deal well with having them paraded in front of others - hence the modern safety management systems that encourage us to confess our errors but then try to erase the blame.
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Old 16th Mar 2018, 09:14
  #122 (permalink)  
 
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Megan - the human psychology is for another debate.
Given, aviators are not the best at dispensing it at times but please let's not cloud the issue here.
Please understand that there is a process to go through and the process should be based on the latest information we have when addressing a safety related incident such as this, which is "Just Culture" (Look it up sometime).

Just culture is not a NO blame game. We all learn from it but we must use the tools avaialble to find the ROOT cause of the problem.

In this instance, it is that a human being miscalculated / misinterpreted their position in space. We cannot then dissect it further by determining if the pilot missed breakfast or had an argument with their partner before leaving for work, or was abused whilst a child. We 'the aviation fraternity' are not in the business of psychological profiling or councilling. If we were, dozens of current pilots would be out of work, I would suggest!.

Once the cause is found, we can then apply just culture to determine the punitive actions. This is where the humanity comes in to compensate for the human factors that caused the problem in the first place.

BUT understand this, the pilot involved must be left in absolutely no doubt that it was they and they alone that caused this accident. Looking for someone else to contaminate (the person who ranged the first helo - is muddying the water). If the 2nd helo was from another police unit, coming for a visit; would they have done the same thing?

Try and move away from: "Society is to blame", often it boils down to an individual who drops the ball for a second. Plain and simple.

Debrief the pilot.
Admonish the pilot.
Educate the pilot.
Fly the pilot.

Bring them down.....................and then rebuild them.
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Old 16th Mar 2018, 10:27
  #123 (permalink)  
 
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Originally Posted by [email protected]
just to keep you happy Nubian - my answer is yes, of course we could still have been having this discussion.
Ok then....

I think the points that I and others have made about it being the landing pilot's responsibility not to land on another aircraft - REGARDLESS of where that aircraft is parked - is paramount.
You think I disagree? Point is this was an accident waiting to happen due to that the Pasadena Police failed to identify the high risk that was present, with no room for pilot error. And as we have determined, pilots f..k up!


With the new HLS layout, it is less likely to happen again - that's why the NTSB recommended the changes but its also even less likely to happen again because it has happened once and plenty of lessons were learned from it.
First time solo students wouldn't be at risk there now....

BTW - which pilots are happy with a 2 ft tip clearance?
You haven't read the report have you?! Do you only comment on the comments?

I've cut this from the report for you:

Pad 1 was 49x49 feet; the center of pad 1 to its outside edge was 25 feet. The edge of pad 1 to center of pad 2 was 12 feet. Thirty-seven feet separated the center of pad 1 from pad 2
Again, the OH58's rotor diameter is 35',6'' (radius 17,8X 2 helicopters) will give you a little less than 2 feet if both helicopters running.

They have no doubt been operating like this, otherwise I'm quite sure the landing pilot would not try to land on ''her'' markings in the first place.
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Old 16th Mar 2018, 10:32
  #124 (permalink)  
 
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Originally Posted by Thomas coupling
Megan - the human psychology is for another debate.
Given, aviators are not the best at dispensing it at times but please let's not cloud the issue here.
Please understand that there is a process to go through and the process should be based on the latest information we have when addressing a safety related incident such as this, which is "Just Culture" (Look it up sometime).

Just culture is not a NO blame game. We all learn from it but we must use the tools avaialble to find the ROOT cause of the problem.

In this instance, it is that a human being miscalculated / misinterpreted their position in space. We cannot then dissect it further by determining if the pilot missed breakfast or had an argument with their partner before leaving for work, or was abused whilst a child. We 'the aviation fraternity' are not in the business of psychological profiling or councilling. If we were, dozens of current pilots would be out of work, I would suggest!.

Once the cause is found, we can then apply just culture to determine the punitive actions. This is where the humanity comes in to compensate for the human factors that caused the problem in the first place.

BUT understand this, the pilot involved must be left in absolutely no doubt that it was they and they alone that caused this accident. Looking for someone else to contaminate (the person who ranged the first helo - is muddying the water). If the 2nd helo was from another police unit, coming for a visit; would they have done the same thing?

Try and move away from: "Society is to blame", often it boils down to an individual who drops the ball for a second. Plain and simple.

Debrief the pilot.
Admonish the pilot.
Educate the pilot.
Fly the pilot.

Bring them down.....................and then rebuild them.

TC,

Nobody has said it is a no blame game when people make mistake. Just culture is just that! You do a deliberate/intended act which is a violation and there is no excuse, but if it was an unintended one based on misjudgement/honest mistake it is a whole different cup of tea.
The result (i.e.. crash) could be the exactly the same scenario.

Just saying she did wrong without finding the root cause is too simple, as you would not know how to fix the problem, and here is where I challenge Crab as to what was the root cause. He suggest as I quoted (exactly!) earlier to remove her license (what he considered the root cause).
If you and Crab seriously mean that the dumb-ass pilot would only need to be:
Debrief the pilot.
Admonish the pilot.
Educate the pilot.
Fly the pilot.
and the problem would be solved, I'll agree that would count for this pilot as she would sure as **** never want to do this over! But it is obvious that she was not operating there alone, so in your way of dealing with the case it would be a great chance for it to happen again, but to another complacent pilot (a few years down the line). You have treated the symptom, not the root cause.

If I'll use a comparison like som of the others do: If you have stomach pain due to cancer, you don't treat the pain with painkillers do you??
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Old 16th Mar 2018, 11:01
  #125 (permalink)  
 
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So what exactly are you saying the root cause is then, Nubian?

Given that "my" way of dealing with it would sort "this" particualr incident out, how would "you" deal with it in your quest to identify the root cause?

Let me give you a starter for ten:

IF you think for one minute that altering or highlighting the landing spots, is a part of the ROOT cause - forget it.

This is a red herring - tidying up the site.
A first time visitor will apply sound airmanship and SA and determine 'independent' of any ground markings - on where to land their helo. Making a landing spot compulsory, based on markings SHOULD not prevent the pilot from surveying the site before committing to land.

Now that this 'option' is out of the way, please tell me what the root cause (now) is?
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Old 16th Mar 2018, 12:25
  #126 (permalink)  
 
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Once the cause is found, we can then apply just culture to determine the punitive actions
Excuse me!!!!! The antithesis of all the courses and reading I've done, but punitive is alive and well in many company's, oil and aviation, it's a counter productive process to anything outside of being deliberately nefarious .
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Old 16th Mar 2018, 12:35
  #127 (permalink)  
 
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https://www.caa.co.uk/uploadedFiles/...%20Culture.pdf


Errors and unsafe acts will not be punished if the error was unintentional. However, those who act recklessly or take deliberate and unjustifiable risks will still be subject to disciplinary action.
https://www.vocabulary.com/dictionary/punitive

If by applying just culture, the individuals actions were found to be reckless or unjustifiable risk taking, I would take punitive action.

It seems the courses and reading you've done - were a waste of time Megan.
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Old 16th Mar 2018, 12:59
  #128 (permalink)  
 
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Nubian - You don't actually seem to have a point to make but at least get your facts right - the report says
The distance between the outside of Pad 1 to the outside of Pad 2 was 33 feet, as measured by a total station provided by the Pasadena Police Department.
note that says OUTSIDE to OUTSIDE so your 2 ft clearance is utter tosh.

And what on earth does
First time solo students wouldn't be at risk there now....
have to do with anything here????

I have stated over and over what I believe the root cause to be - how it is dealt with is up to the regulators.

You seem to need to find a reason for her mistake to explain why she made it - if it is because she was having personal problems, what exactly would you do about dealing with that.
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Old 16th Mar 2018, 12:59
  #129 (permalink)  
 
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Originally Posted by Thomas coupling
So what exactly are you saying the root cause is then, Nubian?

Given that "my" way of dealing with it would sort "this" particualr incident out, how would "you" deal with it in your quest to identify the root cause?

Let me give you a starter for ten:

IF you think for one minute that altering or highlighting the landing spots, is a part of the ROOT cause - forget it.

This is a red herring - tidying up the site.
A first time visitor will apply sound airmanship and SA and determine 'independent' of any ground markings - on where to land their helo. Making a landing spot compulsory, based on markings SHOULD not prevent the pilot from surveying the site before committing to land.

Now that this 'option' is out of the way, please tell me what the root cause (now) is?
TC,

I don't think you'll ever get my point so I leave it here. We have 2 very different views to what was the primary cause behind this, and what would prevent it.
I trust the Pasadena Police acted on the root cause based on the NTSB's findings.

Cheers
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Old 16th Mar 2018, 13:01
  #130 (permalink)  
 
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The NTSB didn't identify any root cause.....
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Old 16th Mar 2018, 13:17
  #131 (permalink)  
 
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The best way to make sure this never happens again?

Replace them with drones!
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Old 16th Mar 2018, 13:25
  #132 (permalink)  
 
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Originally Posted by [email protected]
if you believe that having the aircraft parked in the wrong place caused this accident then you must believe that.

It was clearly a strong contributory factor - it shouldn't have been parked there unless there was good reason - the close proximity of the fuel pumps (24') might have been a reason that some pilots preferred the aircraft 'off' the spot - there is a clear discrepancy between what the 2 pilots said about that process.
It was parked there because the pilot and crew rolled it straight out of the hangar to the left of the markings, turned around, and walked away.

If they had spotted it correctly, the accident wouldn't have happened. Whether you view this as the primary cause or not is your discretion, but I think it the key event.
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Old 16th Mar 2018, 14:20
  #133 (permalink)  
 
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Originally Posted by [email protected]
Nubian - You don't actually seem to have a point to make but at least get your facts right - the report says note that says OUTSIDE to OUTSIDE so your 2 ft clearance is utter tosh.

And what on earth does have to do with anything here????

I have stated over and over what I believe the root cause to be - how it is dealt with is up to the regulators.

You seem to need to find a reason for her mistake to explain why she made it - if it is because she was having personal problems, what exactly would you do about dealing with that.

Utter tosh, huh?! The 33 feet is the distance between ''box1'' and ''box2'' and the box which is just about the footprint of the landing gear of the helicopter. Now, you do the math with 2 helicopters with 35 feet MR diameter!! I don't know what you think is acceptable clearance, but that is too f..king close in my book, and should never been approved for use in the first place.

You don't need to try to question my numbers on this one, as I am sitting looking at the official wreckage dimension sheet from the base.

If you don't understand the information in the cutout which I provided, it is your loss, sorry!
I know it will be unbelievable for you, but you can find this yourself if you wish.

As for the last slice..... before all went south.

From the NTSB docket:

At the time, the pilot did not realize that the parked helicopter was not in the “box.” The pilot’s state of mind was that the other helicopter was in the box; pay attention to your box when you land and you will be fine.

As with TC, I'll leave you with your opinion now. I have used enough energy on this case.


Cheers,




R22butter,

Yeah, it's bound to happen! There is only a matter of time before the first fatality from a falling drone or out of control drone causing a fatal accident. There has been several incidents already.
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Old 16th Mar 2018, 15:00
  #134 (permalink)  
 
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You don't need to try to question my numbers on this one, as I am sitting looking at the official wreckage dimension sheet from the base.
Oh I really think I do

Lets just look at what the NTSB report actually says
WRECKAGE AND IMPACT INFORMATION

On-scene documentation was conducted. The accident had been recorded on video. The recorded video showed that N96BM was moved out of the hangar toward Pad 1. The helicopter was parked to the west and outside of the painted square that denoted Pad 1, which placed N96BM in-between Pad 1 and Pad 2 facing south.

The distance between the outside of Pad 1 to the outside of Pad 2 was 33 feet, as measured by a total station provided by the Pasadena Police Department.

After the impact, both helicopters came to rest upright, with minimal displacement/movement of each helicopter. N911FA came to rest facing toward the northeast, and mostly inside of Pad 2; a portion of the aft skid came to rest outside of the Pad 2 box. N96BM remained to the west of Pad 1.

The transmission and main rotor blades separated from N96BM, and came to rest adjacent to the helicopter. The main rotor blades of N911FA separated from the transmission, and came to rest about 10 feet forward and to the left of the helicopter; directly behind N96BM. The transmission for N911FA remained attached to and inside the helicopter in its relative normal position. One main rotor blade from each helicopter, where they initially contacted each other, came to rest near the hangar, forward of N96BM, and near a chain link fence, behind N96BM.

During the on-site examination, the distance between the two parking pads as well as the distance between Pad 1 and the fuel farm was noted. Measurement of the separation distance between Pad 1 and Pad 2 was measured as 33 feet. The distance between Pad 1 and the fuel farm was measured as 24 feet. According to AC 150/5930-2C Heliport Design section 214 titled Helicopter Parking, parking pads size depends on the number and specific size of the helicopter that will be accommodated at the facility. The minimum distance between parking pads should be one-third the diameter of the main rotor blades. Additionally, under subsection e. fueling (2) it stated not to locate fueling equipment in the TLOF (touchdown and liftoff area), FATO (final approach and takeoff area), or safety area, maintaining a distance of one-half rotor diameter clearance from objects, and if that was not practical at the existing field to install long fuel hoses.
The square pad is approximately the same width as the skids (either 6 ft 4 in or 6 ft 8 in depending on which skid type is fitted) and the distances are quite clearly stated (first sentence in bold) from the outside edge of the square pad to the outside edge of the next one (33 Ft).

So you don't have to be a rocket scientist to acknowledge that the centre to centre distance is 33 ft PLUS the width of the painted square.

Even if we say the squares are only 6 ft across, that means the centre to centre distance is 39 ft.

The rotor diameter of the OH 58 is 35 ft 4 in so with both helicopters correctly positioned in the centre of their squares, there is an 3 - 4 ft clearance between the tips.

The report then says
The minimum distance between parking pads should be one-third the diameter of the main rotor blades
that is clearly nonsense as that would mean the pads could be 12 ft apart!!!

It seems more than reasonable to surmise that what they meant was that the clearance between 2 helicopters rotors on adjacent pads should be a minimum of 12 ft.

So, if the squares are 7 ft across and the distance between the outside edges of the pads is 33 ft you get a centre to centre distance of 40 ft - giving 5 ft clearance. Its not the 12 ft specified but neither is it 2 ft.

It isn't easy to say with more accuracy but the squares appear to be as wide, if not slightly wider than the width of the skids so they must be at least 6 ft wide and probably 7 ft. If they are wider than that - which is entirely possible, the clearance gets bigger - a 10 ft square would give 8 ft clearance.

OK Nubian - enough flannel - show how you get to 2 ft clearance based on what is actually in the report as opposed to what you think is in the report.

And are you honestly telling me that you believe they operated with a 2 ft rotor to rotor clearance for many years without anyone ever questioning it????

Last edited by [email protected]; 16th Mar 2018 at 16:52.
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Old 17th Mar 2018, 09:00
  #135 (permalink)  
 
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Originally Posted by [email protected]
Oh I really think I do

Lets just look at what the NTSB report actually says

The square pad is approximately the same width as the skids (either 6 ft 4 in or 6 ft 8 in depending on which skid type is fitted) and the distances are quite clearly stated (first sentence in bold) from the outside edge of the square pad to the outside edge of the next one (33 Ft).

So you don't have to be a rocket scientist to acknowledge that the centre to centre distance is 33 ft PLUS the width of the painted square.

Even if we say the squares are only 6 ft across, that means the centre to centre distance is 39 ft.

The rotor diameter of the OH 58 is 35 ft 4 in so with both helicopters correctly positioned in the centre of their squares, there is an 3 - 4 ft clearance between the tips.

The report then says that is clearly nonsense as that would mean the pads could be 12 ft apart!!!

It seems more than reasonable to surmise that what they meant was that the clearance between 2 helicopters rotors on adjacent pads should be a minimum of 12 ft.

So, if the squares are 7 ft across and the distance between the outside edges of the pads is 33 ft you get a centre to centre distance of 40 ft - giving 5 ft clearance. Its not the 12 ft specified but neither is it 2 ft.

It isn't easy to say with more accuracy but the squares appear to be as wide, if not slightly wider than the width of the skids so they must be at least 6 ft wide and probably 7 ft. If they are wider than that - which is entirely possible, the clearance gets bigger - a 10 ft square would give 8 ft clearance.

OK Nubian - enough flannel - show how you get to 2 ft clearance based on what is actually in the report as opposed to what you think is in the report.

And are you honestly telling me that you believe they operated with a 2 ft rotor to rotor clearance for many years without anyone ever questioning it????
Ok, one more post and I'll be quick.

Yes, I have misread and concluded the reference of 37 feet was from center to center. Having re-read this, I see they refer from one center to the egde of the other box. So, it will be a few feet more clearance.

My apology!

Now, pad2 was located slightly in front of pad1 and if now the clearance between the pads center-center are as you say 43feet (which may very well be) the lateral clearance 90 degree out the right side of pad1 to the helicopter coming into land (slightly from behind pad2) will not be 43 feet.

After all, the way the base was utilised with 2 pads that close, was a result of an expansion from one to more helicopters, and the Police was exempt from following the AC for heliport design as they were a public service outfit and the pad was built before the AC came out. This is the 3rd AC since 1994 on the subject, but the base was built in 1972.

This however, does not change my view on the cause of events and what ultimately caused the crash.

This does not mean that I think the landing pilot free from charges as it looks like you think. Not at all! She was the last ''slice'' that could have stopped this from happening, but didn't.

I just recognise that the Pasadena Police made the changes as they saw fit the best and that would reduce the chance for this ever happen again.

Cheers
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Old 17th Mar 2018, 09:14
  #136 (permalink)  
 
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Fundamentally, the report is not well written and a diagram would have helped enormously as would a more precise description of the dimensions.

Looking at the pad on Google Earth and using the history function, there are photos of the different aircraft (that the pad was designed for) but also one with a -58 on pad 1 - with a simple measurement of the rotor, you can see that even with the diagonal offset of pad 1 to 2, there is more than adequate clearance with 2 helos there - but clearly not the mandated minimum of 1/3 rotor.

It is possible that the measurement of 33 ft is edge to edge, ignoring the diagonal offset which would give a bigger safety margin but not by much.

The PD seemed to have ignored the reduced safety margin from introducing new helos and not even bothered to repaint the pads - perhaps the main contributory reason for the accident was an underlying laissez-faire attitude to safety - the classic 'we've done it this way for years and never had a problem'!

At least it is all sorted now and the fickle finger of youtube fame can 'having writ, move on'.
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Old 17th Mar 2018, 22:42
  #137 (permalink)  
 
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Someone mentioned, further up the thread, that they would have to go back to 300's. maybe the pads would be a good size to operate 300's from, and as said above, nothing got changed when they got the 58's. even one 300 and a 58 would be fine.
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Old 17th Mar 2018, 22:45
  #138 (permalink)  
 
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The incident was in 2012!
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Old 18th Mar 2018, 19:45
  #139 (permalink)  
 
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Originally Posted by heli-cal
Whilst they still have airworthy helicopters, perhaps they'll consider recruiting pilots capable of flying them.
N911FA

The 49-year old pilot of N911FA held a commercial pilot certificate with a rating for rotorcraft-helicopter issued on January 17, 1991. The pilot held a second-class medical issued on June 6, 2012, with the limitation that the pilot must have available glasses for near vision. The pilot's estimated total time was 16,200 total hours with an estimated 8,000 hours in the accident make and model. The pilot had been assigned to the Pasadena PD Air Operations division since 1989; 22 years as a pilot and one year as a Tactical Flight Officer (TFO).

N96BM

The 40-year old pilot of N96BM held a commercial pilot certificate with a rating for rotorcraft-helicopter issued in August of 2010. The pilot held a second class medical issued on March 22, 2012, with no waivers or limitations. The pilot's estimated total time was 13,065 hours with an estimated 725 hours in the accident make and model. The pilot had been assigned to the Pasadena PD Air Operations Division since 2005; 2 years as a pilot and 5 years as a TFO.
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Old 19th Mar 2018, 05:51
  #140 (permalink)  
 
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ICAO ANNEX 14 V2 states the minimum clearance should be 1/2 W ( W = widths of largest aircraft in play).

Therefore, tip to tip clearance should be at least 17.5 feet (18 feet) rounded up. Properly laid out, with each helicopter skid on the "inboard" lateral line of the landing box the clearance of 1/2 W between tips should be assured.

In Annex 14 there are no "thirds" calculations.

Could it be that the US regs are not compliant with ICAO requirements?

ALL HELICOPTERS PILOTS should know this ICAO separation standard. 1/2 of your own rotor ( at least) width is a lot bigger than a few feet so if the manoeuvre feels unduly tight then it cannot be compliant.

Whilst not wanting to be overly judgemental, ending a flight by descending my rotor disc through the spinning rotor of a landed helicopter would be 100% my fault regardless of what markings are on the ground. Rule number 1 - Don't bump into anything!
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