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Spanair accident at Madrid

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Old 20th Sep 2008, 07:40
  #1881 (permalink)  
 
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Are you concluding then with no facts that is what happened?
No - read my post(s) - heavily caveated.

They must know with FDR and CVR readouts what happened.
No - not to the standard required of an accident report / investigation. They know what the data says... not know what and crucially why, something happened (or not). That takes a lot of analysis and even trick cyclists

Keeping that information secret serves no purpose in the interest of safety.
What purpose does it serve?
Uninformed chattering, wild conclusions, accusations etc. In the press and as shown in the last 94 pages here It always has been that way (see BA38) - why should this accident be different

NoD
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Old 20th Sep 2008, 08:06
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NigelonDraft

I for one do not like the "steady" leak of info here, I think legitimately from the Spanish media, in turn from the judicial inquiry (?) NB it is only that - a judicial inquiry for prosection purposes (if appropriate). It is not seemingly an "accident investigation" i.e. to draw lessons for prevention of future accidents.
The thread on safety and judges develops further into this matter.
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Old 20th Sep 2008, 08:35
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As I surface this morning I was wondering how many attempts to take off with no flaps/slats had been attempted with more than 2 crew members on the flight deck (in the "olden days" when we had flight engineers)? I seem to recall one at Nairobi on B747 in the 1970s. So this type of omission is not unheard of even with an extra pair of eyes on the flightdeck.
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Old 20th Sep 2008, 08:59
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RAT inop

There is something that is still not very clear to me (caviat: frequent SLF here and humble Cessna PF)

I understand that RAT inop is MEL, but surely making RAT inop to 'isolate' the problem by pulling the CB, as was done in MAD, can t be MEL as it disconnects the TOWS, which is a NOGO item. Failing maintenance SOP or training? Or unclear translation of manuals?

I was reassured by thye statement of a pprune member here (pilot) that he would have run to the cockpit door if the TOWS didn t come on when he noticed as a passenger that the flaps were not deployed at take-off. It helps to get rid of some inhibitions you have as PAX. (I won t do it in an A300!)
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Old 20th Sep 2008, 12:08
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borgha,
I understand that RAT inop is MEL, but surely making RAT inop to 'isolate' the problem by pulling the CB, as was done in MAD, can t be MEL as it disconnects the TOWS, which is a NOGO item. Failing maintenance SOP or training?
The RAT problem was a symptom of the groundshift failure.It didnt cause it.Nobody knows what caused it.The main contender is the relay mentioned by wings1011.ie the engineer deliberately puts the aircraft into flight mode to check the strobe lights on the ground and then doesnt reset it..cb is missed by pilots during pre-flight.This is apparently what happened at Lanzarote.But surely the daily check would have been done at BCN in the case of the Spanair.Was this relay pulled at BCN and never subsequently reset?This is unlikely for 2 reasons:
a)it implies a TOCW check was never done for that day
b)why didnt the RAT problem show up at BCN(the effect of ambient temp on the probe to reach its overheat tripoff temp???)

The MEL would have directed the crew to use manual thrust for takeoff.If they had used the AT for takeoff,what thrust setting would they get?GA not TO...aircraft is in flt mode.GA thrust vs TO thrust for takeoff..what is the difference between the two for the stated conditions?probably negligible.

This has been mentioned before but...there are still pilots who believe that the TOCW nuisance check is a replacement for the functional check pre-flight.Thats got to be cleared up.

Checklists..covered in detail and the consensus is that a killer item review last thing is the answer.Just like FA's mentallly reviewing evac duties as the plane takes the runway.We hope theyre doing that just as we hope the pilots are checking the config items.Thats the theory.Line up is a busy time though and often you get cleared immediate takeoff.Ive seen airlines with SOP's that call for the FO to read out the compass headings and call out threshold elevation..thats with the ac lined up and brakes set.Practical in the real world?plus there are automatic tasks to be performed as you line up..about four for each pilot.What is the answer?I dont know to be honest but suggest this:a re-focusing on the fundamentals of airmanship(is your plane safe for flight) and less concentration on SOP rote duties(have you forgotten to put wx radar on or the strobes?)Some of the young co-pilots are so brainwashed into execution of the SOP's that theres no spare brain capacity to look at the big picture,the fundamentals.Distract the skipper and youve got a time-bomb waiting to go off..I see it all the time..pilots rushing to perform the FL100 duties at the expense of an ATC call.Which is more important I ask you?
Give me a co-pilot who as we line-up says"hey,we forgot the checklist" than one who busies himself with the lights,cabin call,transponder at the expense of all elseSlow down and take care of the fundamentals.
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Old 20th Sep 2008, 13:57
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i think you'll find that the opposite is the case. the md80 does in fact have flap actuators and slat actuators. if they hydraulic system is depressurised they will gravity extend
A normal hydraulic cylinder actuator would move as you describe, but I believe these actuators were threaded....like these:

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Old 20th Sep 2008, 14:12
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For those familiar with the MD workings: Is it even possible at all to have a flaps handle down (to 11º) and have the flaps not come out? I don't know, ... hydraulic malfunction, or even the handle mechanical path just becoming detached from the control drum, etc, etc????

I know that flaps possition can quite conclusively be detected by looking at the gauges and indicators, but I guess I'm asking if it is "likely" or possible at all to lower a flaps handle "casually" to 11º on a MD-82 without giving it a second look (not looking at failure/deployment indicators/lights) and still have the flaps not extend.

I know it's a long shot to suspect an "inop flaps" flight at the exact same time an "inop TOWS" developed, but I just wanted to know if it was possible at all ... if actually the MD-82's flaps always have to necessarily come out when the lever is lowered or they can ever fail to come out without a halelluyah of a warning (i.e. much more than a blinking light in the corner of the eye).
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Old 20th Sep 2008, 15:46
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"Was this relay pulled at BCN and never subsequently reset?This is unlikely for 2 reasons:
a)it implies a TOCW check was never done for that day"

.........Check could have been done before c/b tripped.
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Old 20th Sep 2008, 15:51
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Commercial airline safety....

After having read all the posts in this thread, it appears obvious to me that human factors are involved - to what extent only the official report will show.

I have flown for 42 years (16 years on the DC-9/MD80 series aircraft) and know - like all pilots - that mistakes are made and will be made in the future irrespective of SOP's etc.
Of course it does not mean that improvements in procedures etc. should not be implemented.

But the fact is that commercial aviation is EXTREMELY SAFE - all pilots know this, but the news media often seem to promote the opposite view - unfortunately.

Look at these facts:

Total fatalities in aircraft accidents worldwide 2007: 692. (IATA)

Road fatalities USA 2007: 41059 (Denver Post)
Road fatalities EU 2007: 29516 (EU)
Road fatalities India 2007: approx. 100 000 (source: several websites)

Journalists, please start putting these matters in a proper and fair perspective!

And SLFs, dont worry, sit down and relax - you are in safe hands!

Last edited by grebllaw123d; 20th Sep 2008 at 16:40.
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Old 20th Sep 2008, 16:36
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Wirelock, in a response to md80fanatic, states:


i think you'll find that the opposite is the case. the md80 does in fact have flap actuators and slat actuators. if they hydraulic system is depressurised they will gravity extend


The preliminary investigation text reads, exactly:

(...)Al menos un pistón de uno de los actuadores de flap se encontraba extendido una distancia de unos 12cm(...)

Literally: 'at least a piston of one of the flap actuators was found extended for a distance of about 12cm'

Now, a piston is a piston... something related -in this context- with a hydraulic or pneumatic actuator. A geared system is a different thing... I don't know how the actuators of the MD80 really are, but the investigation mentions a piston...

XXXavier
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Old 20th Sep 2008, 16:39
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Flaps/Slats...

To justme69 in post #1917:

I think that it is very unlikely that you select F11 without actually getting F11 - without any other warning signs.
In any case the flap handle is connected to the slat handle, meaning that the movement of the handle(s) to first notch will deploy the slats, so even if you for some reason did not get F11 when moving handle(s) to second notch, you would have slats out with the important consequence that the stall speed is lowered with - as far I remember - 40 knots.
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Old 20th Sep 2008, 17:01
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Also, about the found flap's piston extended 12cm, let's not forget Northwest's investigation:

"The two actuators of the inboard flap section remained attached to a 16-foot-long inboard section of the left wing which was found about 2,800 feet beyond the initial impact point.

When first examined, both actuators were extended 16.3 inches when measured between their attachment point to the airplane structure. However, the inboard flap sections of the two actuators exhibited a dirt pattern on both the actuator housing and the rod end with clean piston rod exposed between the housing and rod end. When the actuator rod was positioned so that the dirt areas were continuous, the actuator measured 13 inches between its attachment points. This measurement corresponds to the flap retracted position."

Of course, who knows what piston exactly they are taling about, etc. That's why the CIAIAC, when mentioning something like this, should be more specific as to what piston they are referring to.

PD: Sorry for the off-topics. We are obviously just chatting here, patiently waiting until more of those "official" news bits are given to continue our main discussion.

And thank you grebllaw123d for your answer. Appreciate it.

Last edited by justme69; 20th Sep 2008 at 18:07.
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Old 20th Sep 2008, 18:47
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Air/ground sensor and RAT-TOWS relay

Re Borghha's question in post 1914 the draft report as published by El Mundo mentions a number of significant issues:

On page 5 it says that at rotation the DFDR captured the change of signal from ground to air mode originating from the sensor the nose gear (N/G strut ground sense).

So, at least this part did not previously think the plane was in the air when it was still on the ground. This is in my view important for the origin of the TOWS-failure, since apart from the RAT, based on the data available, other parts of the aircraft were sensing that the plane was in ground mode when it was in take of run and the TOWS should normally have sounded in this case.

However, the said draft report also seems to state to me very significantly that the relay (R 2-5) of the RAT (which was switched off) is the same as the one feeding the CAWS of which the TOWS is a part. So "inop RAT" according to MEL is something completely different than switching the RAT off by pulling the C/B, which apparently also directly compromised the TOWS, which is clearly not MEL-covered.

Intrigingly so the draft report seems to state that on lift of the N/G sensor when transioniting into air mode will send a signal that desenergises the R2-5 relay, which would make the CAWS, including the TOWS as part of that inop.

What I also do not understand compeltely is the length of the take-off run stated in the draft report (1950 m) in relation to the airport CCTV-video, where the plane seems to only get airborne just before the end of the actual end (not the paved surface) of the very long runway. Didn't they commence take-off run at the very beginning ?

And I have difficulties to precisely understand the (elaborate part) of the report text that deals with where the thrust reversers were found and in which state.

Perhaps justme69 could shed more light on these issues in relation to the draft report and make the necessary precisions based on his far more advanced knowledge of the Spanish language than mine....
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Old 20th Sep 2008, 20:11
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However, the said draft report also seems to state to me very significantly that the relay (R 2-5) of the RAT (which was switched off) is the same as the one feeding the CAWS of which the TOWS is a part. So "inop RAT" according to MEL is something completely different than switching the RAT off by pulling the C/B, which apparently also directly compromised the TOWS, which is clearly not MEL-covered.
Lost in translation...first Spanish to English,now Dutch..sorry,Im trying to get my head round that one..zero input from MD engineers so a lot of guesswork..one cb to control relay,one to control heater..no cb to switch it off...its a probe...MEL relates to heater disabled...

On page 5 it says that at rotation the DFDR captured the change of signal from ground to air mode originating from the sensor the nose gear (N/G strut ground sense).
Again we need engineering input which we never had..at a guess,the DFDR is simply recording a parameter(ie a signal caused by WOW switch)...The relay had artificially put the RAT/TOWS(theyre on the same relay-weve had that confirmed) in air mode,by-passing the WOW switch...when they lifted off,the oleo decompresses making the switch,sending the signal and this is what the DFDR records..doesnt mean that the TOWS was not already in air mode...at the end of the day,it matters little what disabled the TOCW.

The translation from Spanish to English will be key.A while back I heard something that made it sound like the flaps had failed to deploy,rather than the pilots failed to deploy the flaps.

"Was this relay pulled at BCN and never subsequently reset?This is unlikely for 2 reasons:
a)it implies a TOCW check was never done for that day"

.........Check could have been done before c/b tripped.
Yes,that is possible but normally the engineer is on board before the pilots.
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Old 20th Sep 2008, 20:49
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On page 5 it says that at rotation the DFDR captured the change of signal from ground to air mode originating from the sensor the nose gear (N/G strut ground sense).
Yeap. I included that piece of information in the summary posted.

It is somewhat puzzling, since the report sort-of-implies the failure may have to do with the R2-5 relay not energizing (in last term) the TOWS, noticing how this relay feeds off the N/G strut ground sensor group, but then the DFDR does record a change of state from those sensors from ground to air.

So one of the two:

-The circuit is such that a signal from the front gear sensors go to the DFR prior to reaching R2-5, and it was R2-5 (i.e.) the relay actually failing to energize on the proper conditions (i.e. faulty relay, not faulty sensors).

-R2-5 didn't fail and the TOWS failure is further down the circuit (i.e. L/H GND CTRL RLY circuit breaker, not the relay itself)

Not having the schematics of related circuits, I have NO IDEA WHAT I'M TALKING ABOUT, but the CIAIAC report doesn't help at all to make it clear(er).

So, at least this part did not previously think the plane was in the air when it was still on the ground. This is in my view important for the origin of the TOWS-failure, since apart from the RAT, based on the data available, other parts of the aircraft were sensing that the plane was in ground mode when it was in take of run and the TOWS should normally have sounded in this case.
But remember the sensing signal captured by the DFR may have come from an EARLIER part of the circuit, before it affected TOWS energizing. An MD-82 engineer could pbbly shed more light here as to how it works exactly, that is, how can the DFR record a front wheel "up" signal and the TOWS/RAT heater be still inop/affected.

Also, remember that some systems depend on the front gear ground sensor while others depend on the ones from the main wheels.

However, the said draft report also seems to state to me very significantly that the relay (R 2-5) of the RAT (which was switched off) is the same as the one feeding the CAWS of which the TOWS is a part. So "inop RAT" according to MEL is something completely different than switching the RAT off by pulling the C/B, which apparently also directly compromised the TOWS, which is clearly not MEL-covered.
The report, once again, doesn't mention exactly which c/b was pulled by the technician in order to disconnect the RAT probe HEATER (not the RAT probe itself). It seems the procedure was outlined in the manual, so there seems to be a fuse somewhere that you can pull out and leave only RAT heater inoperative.

I guess.

What I also do not understand compeltely is the length of the take-off run stated in the draft report (1950 m) in relation to the airport CCTV-video, where the plane seems to only get airborne just before the end of the actual end (not the paved surface) of the very long runway. Didn't they commence take-off run at the very beginning ?
Yeah, that's a little bit puzzling to me also. Let's see. The runaway is about 4400m, and I believe the last (grey) area before the end is at about 600m (guessing, please someone correct me if this is wrong).

The airplane seems to have reached V1 38 seconds after acceleration commenced. Reached calculated Vr 4 seconds later. For all we know, 15 seconds later it had to be on the air (stick shaker on CVR) and before that the change of state (F/G sensor "up") took place.

It's guessed to have stayed on the air around 7 seconds (go up, roll left, roll right, roll left, roll right, aureal warning says "stall" twice 4 seconds after stick shaker, go down).

Reached 40' and max pitch 18º.

Then the first marks of the plane appear on the ground at about the 3207 meter mark on the runaway (and about 60m too much to the right and at a 16º angle).

So perhaps the report is saying that the length is that used until rotation is called (sensor signals "front wheels on the air"), rather than when it became fully airborne, and it was rotation that actually was found unusually long by the witnesses.

So, it is my guess, that the videos we have seen correspond to the time the airplane is actually FALLING DOWN, rather than "going up". Of course, it's an "erratic" fall down, as it was indeed nose up and trying to elevate, but with each consecutive wing stall (and violent roll) it probably descended a bit and then ascended again (I'm no aerodynamics engineer, just plain old physics, so this may be way off).

Also, the video has some obvious missing frames ...

And I have difficulties to precisely understand the (elaborate part) of the report text that deals with where the thrust reversers were found and in which state.
You are not the only one. Basically it says that both reversers were found detached from their engines. One found with many signs being deployed and the other one not. The picture that showed one of the recovered engines seemed to have it still attached, so it doesn't quite make sense to me what they are saying there either.

Literal translation:

"The reverser system of right engine nº2 was found aprox. 235m from the first marks left by the a/c on the ground and at about 846m from where the main body of the engine was found. The buckets were retracted. The left engine reverser system was found, also detached from the main (engine's) body, at 913m from the first marks of the plane on the ground and 144 meters away from the engine's main body. Its inversion buckets were deployed. Examinations didn't reveal previous mechanical defects." (<-- which incidentaly is also "funny", as one of them was out of service for maintenance, so there must have been something wrong somewhere with it, or, at least, it should've been mentioned in the report).

Once more, not a stellar job on CIAIAC's part, it seems ... Hopefully it'll be more clear on the final preliminary report which, BTW, has been delayed by a week or so, they now say.

Some of the members of the CIAIAC's had resigned, but their resignations have not been accepted by the minister. They have to continue working there against their will.

Judge is not happy with the investigation. He has ordered Spanair to release all maintenance and operational procedures data. He has requested Boeing to supply all current operational procedures and any history of repairs on the a/c. He has requested European Civil air authorities to determine current operational requirements for the a/c.

He is just not trusting CIAIAC, and I don't blame him.


Last edited by justme69; 20th Sep 2008 at 21:26.
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Old 20th Sep 2008, 22:12
  #1896 (permalink)  
 
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I have hesitated for a long time before posting as there is so much junk here however facts.
R2-5 is one of 11 relays connected in parallel. They are controlled by the left nose oleo switch. they are energised in the ground condition. R2-5 has four contacts used, they give air/ground state to : AC crosstie, AIR data sensor heating (specifically the RAT probe), TOCW and Radio Rack cooling (something to do with standby cooling).
Flight Recorder inputs from the same system are from several other of the 11 relays, R2-283, R2-58 and R2-212.
It is quite conceivable to me that R2-5 was failed in the de-energised position, i.e. the flight condition, while the remainder of the relays were operational.
The RAT probe heater has it's own cb.
I have thought about this for a long time and as a line engineer, under pressure with a full a/c RTS then I think I would have just pulled the heater cb and dispatched iaw the MEL. The other circuits controlled by that relay are not ones with obvious symptoms.
The Facts are just that, the remainder my opinion only.
The report is needed, it will be interesting to see if 2-5 can be found and it's serviceability established.
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Old 20th Sep 2008, 22:59
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Wodrick:

Thanks for participating. Believe me, we all would like to have the facts, but they are considered "secret" and most of the vital ones are still hidden from the public, so we have to work with what we got.

I have a question perhaps you or other engineers can answer.

Let's assume the sensors in charge and relays in charge of air/ground logic were fine (as the DFR seems to indicate).

Let's assume even the R2-5 relay was fine (i.e. operating as designed).

-Is there a circuit breaker in the system that could've produced "air mode" on the RAT heater and the TOWS alarm with very few other signs?
-What is it called (i.e. "L/H GND CTRL RLY C/B")?
-What other symptons would it have produced? (i.e. does it affect other relays' logic)
-Would the FDR still record a ground logic status change from the sensors with this c/b "off"?
-When you guys have to test "on the air" things on the MD-82's while on the ground (i.e. RAT heater, strobes, etc) ... how do you do it?

Regards.

Last edited by justme69; 20th Sep 2008 at 23:21.
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Old 20th Sep 2008, 23:23
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justme69,

Basically it says that both reversers were found detached from their engines. One found with many signs being deployed and the other one not. The picture that showed one of the recovered engines seemed to have it still attached, so it doesn't quite make sense to me what they are saying there either.
Apart from two pictures published of the same deployed reverser, I have not seen a picture of the stowed/deactivated reverser. The pictures i have seen of the two engines appear both to be missing the reversers. One engine (with part of the stubwing still attached) is photographed at the main wreckage site near the stream, resting against a slope or river bank and later shown being transported on a red truck which is definitely missing the reverser. The other engine is photographed, seen hanging from a crane and it appears to be also missing its reverser.

There is also a piece of aft engine ducting, without a reverser, photographed resting against the left side of the tail section.

Perhaps you are referring to a picture unknown to me?

From your translation of the draft report it is confirmed the deployed reverser is from engine number 1 (left).

Thanks for translating the reports into English in many of your posts. You are doing a great job


Regards,
Green-dot
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Old 20th Sep 2008, 23:52
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I must admit having paid little attention to the pictures. Not being that familiar with the "insides" of the airplane, I can't make heads of tails.

I thought I saw a picture of an engine with the reverser deployed. Perhaps it was just the reverser itself and some parts sticking out and the actual engine was missing.

Thanks for clarifying.

All of you thanking me etc for translations: you are most welcome. It's the least I can do to see if we can help somehow.
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Old 21st Sep 2008, 00:09
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Wodrick,
I think everyone here would appreciate an answer to whether or not this relay c/b is pulled routinely when performing the daily check and whether there has ever been any MD SB/AD warning engineers/crews of the danger of leaving this cb pulled.Thank you.
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