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00:00V-1, rotate.
00:03As Air Algerie Flight 6289 lifts off from Tamanrassit, Algeria,
00:09Gear up.
00:10Air traffic controllers hear an explosion.
00:21The plane crashes into the desert.
00:24102 people are killed.
00:28Investigators examine engine debris found on the runway.
00:32Looks like there's a fatigue crack in the nozzle guideway.
00:35They know an engine failed, but not why the pilots couldn't recover.
00:40Pilots are expected to fly out of a situation either on takeoff or landing where they've lost an engine.
00:46The investigation reveals a crew that was struggling, not with the plane.
00:51Let go. Take your hand away.
00:52I let go. I let go.
00:54But with each other.
00:55Which one of them is actually flying the plane?
00:59B-day, B-day.
01:03Oh, fuck.
01:06I mean, 1-0-3, I'm going to go.
01:08I'm going to go.
01:10I'm going to go.
01:11I'm going to go.
01:11I'm going to go.
01:12I'm going to go.
01:34B-day, B-day.
01:39There are 97 passengers on board.
01:43Among them, members of the local football team headed to a tournament and military personnel.
01:49Seatbelt, seatbelts.
01:50Though there are some European nationals, almost everyone on board is Algerian.
02:06Now that instrument transfer switches...
02:10normal.
02:12In the cockpit, pre-flight checks are underway.
02:17Your damper...
02:20on.
02:22Today's flight is operated by Air Algerie, a state-owned national carrier.
02:28Air Algerie is a publicly-owned company that is owned by the country of Algeria.
02:33The country takes a lot of pride in this particular airline, because it is the face name of the
02:42country as it goes all around the world.
02:486280, now you're casting latest weather.
02:50Yes, the wind is calm.
02:52Temperature 23, QNH 1020, QFE 965.
02:58Copy.
02:59We'll call you back for engine start.
03:0244-year-old Fatima Yousfi is the first officer of this flight.
03:07She is Algeria's first female commercial pilot.
03:12The female first officer was one of the first women to be hired in an airline in Algeria,
03:19which would be a big deal in such a male-dominated field, especially in that country.
03:25As the first woman to pilot a Boeing 747 trans-oceanic flight,
03:30Lynn Rippelmeyer knows what it's like to blaze a trail.
03:37Aviation was then and still is in some cases a boys' club.
03:44Back in the beginning of when women were initially beginning in aviation here in the States,
03:50maybe it's like it was for her, that it was unusual.
04:00Tamaracet, 6289.
04:02We request clearance for Khardaya.
04:04Received.
04:05We will call you back.
04:10Hey, Boualem.
04:11Hey.
04:12We've got some Tamaracet football players back there.
04:15Oh.
04:16Tell them we're rooting for them this weekend.
04:1948-year-old Captain Boualem Benawicha has over 10,000 flying hours.
04:24A thousand of those hours are on the Boeing 737.
04:28The captain was highly experienced, had been flying for over 20 years,
04:32and then flown all kinds of aircraft from small aircraft to large jetliners.
04:386289, Tamaracet.
04:40Go.
04:41Start approved.
04:42Call back for taxi.
04:43Roger.
04:46At 3 p.m., the pilots get clearance to start up the engines.
04:52Okay, before I start checklist.
04:54Fuel quantity.
04:569,800 kg.
04:59Pumps.
05:02On.
05:05Flight 6289 is a Boeing 737-200,
05:09an early generation of the popular twin-engine jetliner.
05:15The Boeing 737 is one of the most common types of commercial airliners in the world,
05:21and there are different variations of it.
05:24The Boeing 737-200 is an original version of the 737,
05:30so it's an older model,
05:32and it's not as highly sophisticated in technology as the current 737s.
05:42Flight 6289 will be departing from Tamaracet,
05:46with a scheduled stop in Gardaia,
05:49and then on to the capital, Algiers.
05:52The total flying time is approximately 3 hours.
06:01That is taxi, Air Algiersi, 6289.
06:066289, Tamaracet, taxi onto runway 02 and backtrack.
06:11Wind 030 at 10 knots.
06:14Roger.
06:15Taxing for runway 02, then backtracking 6289.
06:22As they taxi to the runway, passengers settle in for the journey.
06:39We are ready, 6289.
06:446289, Tamaracet, cleared for takeoff runway 02,
06:47wind 330 at 12 knots.
06:50Clear for takeoff on runway 02 at Ejiri, 6289.
07:03You have 90 knots.
07:05100 knots.
07:22V1.
07:24Rotate.
07:29But seconds after takeoff...
07:32Gear up.
07:34...a loud explosion rocks the airplane.
07:43Bismillah.
07:44What's going on?
07:45The pilots assess the situation.
07:48Let go, let go.
07:49I let go, I let go.
07:50I let go.
07:53Passengers sense something has gone wrong.
07:58We have a small problem, 6289.
08:016289, Tamaracet.
08:06The 737 is approaching a stall.
08:166289.
08:176289, are you in emergency?
08:176289, are you in emergency?
08:286289, are you in emergency?
08:38The three?
08:58Amer, yesi, you are out, sir.
09:04is immediately activated and firefighters rush to the scene the impact and fire that ensued
09:18afterwards made survival very unlikely for the passengers in the aircraft but then against all
09:26odds rescuers discover a survivor not within the wreckage but lying in the distant sand
09:33clinging to life a gentleman seated all the way in the back that didn't have a seat belt on so
09:40when
09:40the airplane crashed and broke apart he was thrown free he shows only faint signs of life as an
09:48ambulance rushes him to hospital in critical condition defying all expectations the man's
09:55condition soon stabilizes and he begins to recover this passenger's luck cannot be overstated in what
10:03was algeria's worst aviation accident at the time he is the sole survivor out of 103 passengers and crew
10:14while the country mourns the tragic loss of a football squad algerian and french families
10:21grieve their loved ones and soon demand answers
10:29the investigation into the crash of flight 6289 is conducted by a commission of inquiry established by
10:38the algerian ministry of transport they receive support from several international agencies
10:45including the ntsb america's national transportation safety board i was the u.s accredited representative
10:53for this accident to assist the algerians initially i wasn't going to travel to the scene however the
10:58u.s ambassador to algeria requested our assistance while algerian investigators await the arrival of their
11:09american colleagues they interview the taman rasset air traffic controller
11:16did the pilots indicate that there was an issue
11:21the first officer called only seconds after takeoff
11:27we have a small problem 6289
11:30pilots typically are hesitant to call mayday mayday or
11:35uh announce some type of emergency particularly if they really don't know what the situation and
11:42the critical nature of the situation is and what was the problem they didn't say but i heard something
11:51that sounded like an explosion seconds later the plane was falling out of the sky
11:59you said an explosion that's what it sounded like like a bomb
12:10couldn't say
12:15so in 2003 algeria was not the safest place there was bombings and terrorist activities
12:20because they were coming out of 11 years of civil war
12:26when the plane fell was it in one piece yes it was investigators found the airplane intact there
12:35are no claims of responsibility by terrorists so it pretty much ruled out that there was some type
12:41of nefarious means to bring the aircraft down can you describe how the plane fell it was
12:50it was nose up and crashed near the threshold of runway 20.
12:57the controller and other witnesses saw that the airplane was struggling to climb
13:02had a nose high pitch attitude and then impact the ground
13:09eyewitnesses recall that the plane struggled to gain enough lift to remain airborne an indication it was in
13:15a stall one week after the incident algerian investigators are joined by a member of the ntsb
13:27air traffic controller and witnesses described seeing a stall
13:31and one witness remarked that the landing there was down
13:36if the landing gear is still down while the aircraft is trying to climb it creates a lot of drag
13:43on that
13:43airplane it takes a lot of thrust and a lot of power to maintain the climb to overcome all that
13:50drag from
13:50the landing gear that would affect a plane's ability to climb but that alone wouldn't cause a stall
13:57that has to have been something else to the load sheets yes right here
14:04one of the big questions is about the aircraft weight because if you're too heavy
14:08you won't climb as well as if you're within the weight envelope investigators review the plane's load
14:16sheet to see if the plane was overweight before takeoff looks like the first officer made some corrections
14:22here while reviewing the load sheet the first officer notices the fuel weight is wrong
14:30and changes it from 8 800 kilograms to the correct amount of 9 800 kilograms
14:42so with those corrections the way to take off would have been
14:4648 708 kilograms and the maximum weight allowed at takeoff would be 49 500 kilograms
14:54the first officer noticed that there was a thousand kilo difference and uh passenger count was a
15:01little bit off which didn't make a whole lot of difference in the overall weight and balance
15:05but did show that she was very attentive in her duties
15:09the aircraft weight was right up against the maximum takeoff weight even though it was heavy
15:14the aircraft weight shouldn't have affected the performance too much
15:18what mechanical failure i'll get the maintenance reports
15:25investigators make sure that the maintenance is clean
15:28and the aircraft has a clean bill of health prior to the flight
15:35it was up to date in its maintenance cycle no work deferred no technical exemptions
15:42the maintenance reports provide no leads
15:46maybe there was an environmental factor at play
15:51take a look at this did the location of the airport have something to do with the stall
15:59temperatures 23 degrees celsius so it's hot tamaraset is in a harsh desert climate
16:05and the high temperatures can affect the aircraft performance and climb
16:11and the airport sits at 4518 feet above sea level at this altitude the air is already thin if you
16:19factor
16:20in the heat it's high density altitude that affects the performance of the airplane so it's generating much
16:27less lift over the wings so it takes longer to get the airplane airborne so just a few pounds below
16:34max takeoff
16:35weight high elevation airport high temperature landing gear extended that could definitely cause a plane to stall
16:44but that doesn't explain the explosion right what are we missing
16:56investigators study the crash site of flight 6289 for evidence that could explain the explosion
17:03heard seconds after takeoff so the first point of impact is here
17:145396 feet from the takeoff point skidded through the airport perimeter fence across the road and came to rest
17:21here less than 300 feet outside of the airport
17:34plane's destroyed by the fire but the main wreckage is practically in one piece except for the rear section
17:40and look at this debris this was on the runway right about here
17:48engine debris
17:52on the runway we found a large quantity of engine debris which is indicative of an engine shelling
17:57when a large quantity of engine blades are thrown out the back end of an engine
18:04it's an old adage in accident investigation what fails first falls first
18:12so if they find debris prior to finding the wreckage then they know that happened prior to the accident
18:18so one of the engines blew out that must have been the explosion the controller hurt
18:24what caused the engine failure
18:29we needed to get our eyes on those engines to determine which failed and why it failed investigators
18:35begin a visual inspection of the plane's engines starting with the right one take a look at the fan blades
18:44heavy deformation
18:47it was definitely rotating at the time of impact
18:51on the right engine we showed that it was turning at impact we don't know what exactly what level of
18:56thrust it was rotating at
19:00if the right engine was operating on impact then did the left engine fail
19:10these turbine blades have far fewer deformations than the right engine looks like it was barely moving
19:17the hot section is completely torn apart
19:21in an engine's hot section fuel is ignited in a combustion chamber generating a powerful stream of hot air
19:29that spins the turbine blades
19:33the damage is evidence that the left engine failed
19:37we knew that the failure was in the hot section so we had to follow
19:41every lead that we could to determine where the failure occurred
19:51there's a bunch of blades missing from the hot section
19:55the missing pieces are most likely the debris that we found on the runway
19:59we found that the hot section was basically corn cobbed as we say there was
20:05not many blades left in the hot section and there was metal all over the place
20:10what caused the blades to break let's get some of these parts out on the table
20:16and we wanted to further tear down the engine we wanted to look at the failures under the
20:21microscope we want to look at the metallurgical aspects of the failure we wanted to look to
20:25see if there was a bird strike investigators begin by examining components from the hot section
20:31in search of pre-existing defects
20:36we managed to remove the sediment from the nozzle vein
20:44nozzle guide vanes direct the hot air flow in the combustion chamber
20:49to the blades of the high-pressure turbine causing them to spin
20:59interesting
21:14looks like there's a fatigue crack in the nozzle guide vanes
21:18investigators find evidence of fatigue cracks in two of the left engine's nozzle guide vanes
21:26this type of cracking occurs over time and as the engine ages these cracks get slightly larger and
21:32and eventually they will fail and it will destroy the entire engine
21:38if this was a progressive failure why wasn't it caught earlier
21:45this type of cracking is typical of an older engine and it's a progressive failure
21:49so that gets us into the question of what was the maintenance history what was the inspection
21:53criteria that was used by the operator investigators look into the engine's repair history
22:02it looks like the left engine was completely overhauled four years ago
22:07when would have been the last time they looked at the nozzle guide vanes during the hot section
22:12maintenance inspection which was last year and he mentioned a cracking any work done on
22:18i hear them inspections of the hot section are meant to catch fatigue cracks so why weren't these
22:27found since this was an algerian registered aircraft it falls under the authority of the algerian
22:33civil aviation authority for oversight of the inspection not the faa which typically has more stringent
22:40requirements the crack formed at some point it was missed during the inspection last year it grew and
22:47grew until point of failure and then blew out at takeoff that explains why the engine failed
22:54not why the plane stalled pilots are expected to demonstrate their ability to fly out of a
23:02situation either on takeoff or landing where they've lost an engine investigators examine the
23:08crew's training records to determine if they knew how to handle a single engine failure on takeoff
23:17the first officer's last exercise in engine failure during takeoff was four months ago
23:22the captain's training was even more recent only two months before the crash
23:25they both should have known what to do in this situation
23:31they've got the airplane veering to the left there's no way they didn't know that engine failed
23:39so what did they actually do
23:46investigators prepare to listen to the cockpit voice recorder from air algeri flight 6289
23:54it was very important for us to listen to the cvr to determine how the pilots dealt with this
23:58engine failure i've got it queued up to right before i take off
24:07v1 rotate
24:15gear up
24:19they hear the sound of the engine failing five seconds after takeoff
24:25bismillah what's going on
24:29let go let go i let go i let go
24:35they transferred control in the middle of an emergency that didn't even sound like a proper transfer
24:41he just took the controls for another pilot to take control from the pilot who is flying the pilot
24:49needs to say i've got it taking control of the airplane without saying he was taking control
24:55made things worse for him and for the first officer the captain is the pilot monitoring he shouldn't be
25:01taking over he should be diagnosing the problem so do either of them identify a left engine failure
25:10after handing over control to the captain the first officer realizes they aren't properly configured
25:16to climb with only one engine
25:20get up or are we okay but there's no response from the captain
25:26we have a small problem 6289 6289
25:33just seconds after the engine failure the situation deteriorates as the plane begins to stall
25:45there are no attempts by the pilots to work together to identify or troubleshoot the problem
25:52let go take your hand away i let go i let go let go take your hand away let go
25:56don't think seconds later the ground proximity warning activates indicating the plane is getting
26:04dangerously close to the ground please take your hand away both pilots really didn't know what
26:13the other was doing didn't know what the other expected of them and may well have been working
26:18at cross purposes and as a result of that the team performance broke down
26:25don't think don't think
26:32i don't hear a single mention of engine failure and why was he telling her to let go so many
26:37times was
26:38she trying to take back control of the plane which one of them is actually flying the plane when all
26:44is
26:44said and done the pilots did not work together without more information from the flight data
26:49recorder we really don't know exactly what they did to control the airplane
26:54investigators turned to the flight data recorder or fdr from flight 6289 to determine how the pilots
27:01tried to recover from the loss of the left engine flight data recorders are important to investigators
27:08because it gives them information on how the pilots were operating the airplane and how they were
27:14managing the critical situation they were in not much here older plane older fdr
27:25it doesn't actually tell us how the pilots were handling the engine failure
27:30because we only had five parameters on the fdr
27:32we had to go to boeing and ask for a detailed aircraft performance analysis to determine what
27:39happened on this accident flight
27:43using the fdr's limited data boeing's performance study includes a reconstruction of engine operations
27:51and flight controls in the final moments of the flight
27:56so there is the left engine losing its thrust after it blows out that's odd the data from the fully
28:05functioning right engine shows something unexpected look at the thrust from the right engine yes it
28:13seems to be going up and down but we know it was working fine that can only mean one thing
28:23bismillah what's going on the team finds evidence of thrust being added to the right engine
28:31let's go let go and then pulled back i let go i let go when one engine fails
28:39what you need is maximum power on the other engine not reduce it
28:44so thrust is pulled down then back up then down then back up again we have a small problem 6289
28:566289
28:57let go
29:06it's as if they were having some sort of a tug of war
29:10it shouldn't have been first officer did the right thing by increasing the power of the right
29:16engine what likely happened is that the captain wasn't fully aware of which engine had failed
29:21however the first officer knew that the the left engine had failed and was trying to push up the
29:27throttle on the right engine to keep them from stalling
29:34let go take your hand away i let go i let go let go take your hand away let's go
29:39i let go i let go the captain's basically telling the first officer to get out of his way to
29:48leave
29:49him alone to let him be in charge of the airplane by himself which he was knowing that the left
29:57engine
29:57had failed the first officer might have been trying to help things out by increasing the power on the
30:01right engine please take your hand away
30:11the moment the captain reduced the thrust on the right engine and never returned it to take off
30:16thrust with the gear down it doomed the flight
30:22pilots should have been able to work together to recover the plane
30:25these planes are designed to fly with a team pilot flying pilot not flying both have very specific
30:33roles that they are trained to do but especially in emergencies they stay in their roles they help
30:41each other they work as a team and this crash could have been avoided if they would have done that
30:48why didn't the crew of air algeri flight 6289 work together to prevent the loss of 102 lives
30:59okay i'll queue it up to the pre-flight preparations
31:05investigators returned to the cockpit voice recording of flight 6289 to understand why there
31:11was a lack of coordination between the two pilots
31:16modern instrument transfer switches
31:19normal your damper on
31:26they listen as the first officer works through the pre-flight checklist
31:31they're surprised by what they don't hear
31:35where's the captain is she doing the flight preparation by herself
31:41authorization mode selector auto okay flight instruments
31:48we found that the first officer was actually in the cockpit by herself conducting most of the pre-flight
31:54work without the captain
31:59it's unusual for the captain not to be present during the pre-flight because there are responsibilities that the captain
32:06has to get his side of the airplane ready
32:09it's just inappropriate for the captain not to be in the cockpit during the pre-flight and it's actually kind
32:17of rude
32:18it's only after the first officer completes the pre-flight preparations that the captain enters the cockpit
32:25the last q and h 1019 1019 roger
32:30good afternoon captain how are we looking oh good i completed the pre-flight checklist i tested your oxygen and
32:38everything is set to go good good
32:43captain benwisha is late
32:45leaving his responsibilities to the first officer when the captain showed up he was not in the mindset of
32:52getting brought up to speed or being part of the team of setting the cockpit up for the flight
33:01heading
33:02zero two zero altitude
33:06investigators then hear the pilots performing their before start checklist
33:10two eight zero you know i could have been on the team with those boys back there give me a
33:17break
33:18who's the third voice flight attendant
33:23the only male flight attendant is the chief flight attendant
33:28okay takeoff speeds
33:30as part of the checklist the first officer reviews the takeoff speeds
33:38we won 144 knots vr 146 knots you're saying you were good enough to turn pro
33:46yeah i was a good footy blair you wanted a scout come watch me blair yeah they were scouting you
33:52to
33:52more the pitch um v2 150 knots okay that's enough i understand can we go i got it i got
34:02it let's go
34:08so the captain is just carrying on a conversation with his friend while they're doing their before
34:12start checklist what is even worse is he cuts her off before they could even finish it
34:18one of the most important parts of the information that she was trying to give were the takeoff speeds
34:24and then there should have been a briefing of an engine failure departure
34:31at this airport that was a special departure that needed to be briefed it was ignored
34:39did the captain become more focused once they began to taxi
34:48what investigators find most shocking is what they hear next
34:57where are we eating tonight that place across from the hotel
35:01oh you always go back to the same place i like what i like
35:06we are now cheers plenty of good spots to eat
35:10they are completely distracted they're violating every sterile cockpit rule
35:16during critical phases of flight extraneous conversations and non-essential conversations
35:21between the crew members are prohibited not only is the captain dismissing the first officer he has this
35:27casual attitude about basic safety practices it's possible he was more interested in talking to the
35:34flight attendant than reviewing the briefing with the first officer it's possible that he had been
35:40through so many pre-flight takeoff briefings that at that time he felt it was unnecessary
35:56as a result of his dismissive attitude the captain is unprepared to properly respond when the crisis occurs shortly after
36:05takeoff
36:09after the pilots completed their pre-flight safety briefing their response to the engine failure might have been very different
36:38once the plane was stabilized the pilots could have returned safely to the airport
36:45engine failure is actually a relatively common occurrence every pilot needs to be prepared and trained
36:52so instead of letting the first officer fly the plane while he diagnoses the issue
36:56he tries to do everything himself and transferring control during an emergency situation
37:02there was never a positive transfer of control the captain just took the control yoke away from
37:09the first officer so he injected himself in the emergency
37:18let go let go i let go i let go the captain took control at the worst possible time when
37:26he was out of
37:27the loop and by not assigning responsibility to her he gave himself the responsibility of doing two things at
37:33once diagnosing the nature of the engine problem and then flying the airplane
37:40please by trying to fly the plane and diagnose the problem on his own the captain took on too much
37:49it put the first officer in a very difficult position she's now in the supportive role the
37:56non-flying role waiting to be told what to do and he's not giving any helpful orders other than let
38:04go
38:07why would an experienced captain so brazenly dismiss his first officer's help risking the lives of everyone on board
38:30so the captain actually had twice as many flying hours as the first officer
38:36the captain was both qualified as a captain on a 737 but also as a first officer on a 767
38:43perhaps his attitude was that flying the 737 was not that big of a deal because i fly a 767
38:51which is
38:52much more sophisticated and highly technical but she had more hours on the 737 not only did she have
38:59more experience flying the 737 that's the only plane that she was flying i think there's a good chance
39:06that had she been left alone she would have flown the airplane out of the scenario that we saw in
39:12this
39:12accident the question is would he have reacted the same way if the first officer was a man
39:20in 2003 at the time of this crash here in the states female airline pilots only constituted
39:27less than six percent of the pilot population and it really hasn't changed that much in the 20 years since
39:34then
39:35the first officer was algeria's first female commercial airline pilot my friend male pilots in this
39:44part of the world aren't used to sharing a cockpit with women i think algeria is becoming fairly
39:53westernized but in some cultures there is the feeling that a man has to be up in the cockpit in
39:58case
39:58anything goes wrong why did this captain take control from the first officer when she was doing
40:04an okay job at that point and i think you can't rule out the possibility that there may have been
40:10some
40:10uh gender stereotyping on his part that played a role in it sadly this accident was totally preventable
40:18uh
40:24investigators now have a clear picture of what led to the crash of flight 6289
40:32v1 144 knots vr 146 knots you were good enough to turn pro after arriving late and allowing the flight
40:42attendant into the cockpit the captain interrupted a crucial pre-flight safety briefing um v2 150 knots
40:51okay that's enough i understand can we go i got it i got it let's go the captain demonstrated a
40:59lax
40:59attitude towards cockpit protocols
41:04fatigue cracks in a nozzle guide vein in the plane's left engine were reaching their braking point
41:10and when the guide vein failed it set off a chain reaction high speed metal fragments ripped the
41:18engine apart let's go let go i let go i let go when crisis struck the captain decided he needed
41:27to be
41:27the one to handle the controls and took over flying from his first officer before even identifying the
41:34problem the engine failure alone was not the cause of this accident engines fail and pilots are trained
41:42to handle those emergencies failing to retract the landing gear after the engine failure made recovery
41:51more difficult let go take your hand away i let go i let go let go take your hand away
41:56let go
42:05it was captain's assumption of patrol of the aircraft without properly identifying the nature of the
42:11emergency his failure to raise the landing gear and his lack of adherence to standard operating procedures
42:18that eventually doomed the flight as a result of this accident algeria's commission of inquiry makes
42:28several recommendations they recommend that air algeri along with other operators ensure that their
42:36crew resource management training programs emphasize the importance of handover procedures and task sharing
42:43in the cockpit but in the 1980s they had captains who were trying to fly a team airplane solo
42:53so a lot of training went into it to teach that your best resource is your team you support each
42:59other and work
43:00together as a team for the safety of the airplane the fact that the captain insisted on taking over control
43:07of the airplane at that critical moment cost everybody on that airplane their lives
43:17i felt particularly affected when i saw that the accident was preventable and i think the investigators
43:24did the best job they could trying to discover why the crew made the errors that they did the next
43:29time
43:30that happens people won't die as a result of that for lynn ripple meyer it's one more example of why
43:38the industry needs to continue evolving the airlines now are much more open to hiring women to not having
43:48gender bias realizing that women do have a lot to contribute to the industry and i think it's up to
43:56women now to step up to the plate and take the opportunities that the career offers they're amazing
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