GAC Update Issue 44 - December 2014

By Vivienne Sandercock


1. Message from the Managing Director
2. Error Management
3. Africa's 2014's Hazards, Incidents, Accidents and Safety Occurrences
4. Emergency Response Planning
5. Henley Global Safety and Quality Training
6. Laser Defence for Pilots
7. Airline News
8. News from the Johannesburg Airports
9. Safety and Security
10. SAAFA donations
11. Finale

1. MESSAGE FROM THE MANAGING DIRECTOR

As another year draws to a close, for those of us living here in sunny South Africa, our thoughts turn to summer holidays which inevitably means a long drive to a coastal resort or a flight to join families and friends. Transport here entails a higher level of safety risk than in some other parts and so; if you are the wheel (either up there or down here) take extra care and come home safely. May this Festive Season bring you closer to all those that you treasure in your heart. Love, joy and peace are the ingredients for a wonderful festive season. All the best for 2015.
Rethea Mitchell

2. ERROR MANAGEMENT

The following principles were written by Professor Emeritus James Reason (see Managing Maintenance Error: A Practical Guide which he co-wrote with Alan Hobbs) are valid beyond aviation maintenance and I thought that they are well worth publishing here.

1. Human error is both universal & inevitable: Human fallibility can be moderated but it can never be eliminated.

2. Errors are not intrinsically bad: Success and failure spring from the same psychological roots. Without them we could neither learn nor acquire the skills that are essential to safe and efficient work.

3. You cannot change the human condition, but you can change the conditions in which humans work: Situations vary enormously in their capacity for provoking unwanted actions. Identifying these error traps and recognising their characteristics are essential preliminaries to effective error management.

4. The best people can make the worst mistakes: No one is immune. The best people often occupy the most responsible positions so that their errors can have the greatest impact.

5. People cannot easily avoid those actions they did not intend to commit: Blaming people for their errors is emotionally satisfying but remedially useless. We should not, however, confuse blame with accountability. Everyone ought to be accountable for his or her errors [and] acknowledge the errors and strive to avoid recurrence.

6. Errors are consequences not causes: …errors have a history. Discovering an error is the beginning of a search for causes, not the end. Only be understanding the circumstances…can we hope to limit the chances of their recurrence.

7. Many errors fall into recurrent patters: Targeting those recurrent error types is the most effective way of deploying limited Error Management resources.

8. Safety significant errors can occur at all levels of the system: Making errors is not the monopoly of those who get their hands dirty. …the higher up an organisation an individual is, the more dangerous are his or her errors. Error management techniques need to be applied across the whole system.

9. Error management is about managing the manageable: Situations and even systems are manageable. Human nature - in the broadest sense - is not. Most of the enduring solutions…involve technical, procedural and organisational measures rather than purely psychological ones.

10. Error management is about making good people excellent: Excellent performers routinely prepare themselves for potentially challenging activities by mentally rehearsing their responses to a variety of imagines situations. Improving the skills of error detection is at least as important as making people aware of how errors arise in the first place.

11. There is no one best way: Different types of human factors problem occur at different levels of the organisation and require different management techniques. Different organisational cultures require different 'mixing and matching'.of techniques. People are more likely to buy-in to home grown measures.

12. Effective error management aims as continuous reform not local fixes: There is always a strong temptation to focus upon the last few errors …but trying to prevent individual errors is like swatting mosquitos…the only way to solve the mosquito problem is drain the swamps in which they breed. Reform of the system as a whole must be a continuous process whose aim is to contain whole groups of errors rather than single blunders.

Professor Reason goes on to state that Error Management has three components, which are;

1. Reduction
2. Containment
3. Managing these so they remain effective

According to Professor Reason It is the third aspect that is most challenging as it is simply not possible to order in a package of Error Management measures, implement them and then expect them to work without further attention You cannot put them in place and then tick them off as another job completed. In an important sense, the process - the continuous striving toward system reform - is the product.

3. AFRICA'S 2014 HAZARDS, INCIDENTS, ACCIDENTS AND SAFETY OCCURENCES

ACCIDENTS INVOLVING FIXED WING AIRCRAFT IN AFRICA DURING 2014

DATE A/C TYPE FATALITIES LOCATION

04 Jan Ran s-ses coyote II 1 Breede River between Cape Infanta and Swellendam, WC, RSA
14 Jan FA52 SAB 2 Nr Kabanje, Bwiketo Village, Zambia
20 Jan Antonov 28 0 On the approach into Addis Ababa, Ethiopia
24 Jan Jonker JS-1C Revelation 1 Tempe Airport, Bloemfontein, RSA
28 Jan KR2 (Homebuilt) 1 Wonderboom Airport, Pretoria, RSA
29 Jan Giles G-202 1 Alexandria, EC, RSA
03 Feb Beechcraft C90GTi 3 Lanseria International Airport, RSA
06 Feb PA25 0 Field adjacent to Parys Aerodrome, Free State, RSA
11 Feb C130 Hercules 77 Ouled Gacem, Oum El Bouaghi Province, 500 km east of Algiers, Algeria.
13 Feb Baron 58 0 Lanseria International Airport, RSA
15 Feb Aeros 2 1 Heidelberg, RSA
16 Feb Cessna 182 Tug Plane 1 Orient Hills, Magaliesburg, GP, RSA
17 Feb BAe-748-371 1 Bentiu, South Sudan
21 Feb Antonov 26 11 20 miles from Tunis-Carthage Airport, Tunisia
08 Mar TBA 1 75km from Ondongwa Airport, Etosha National Park, Namibia
11 Mar Tetras 2 Antananarivo, Madagascar
15 Mar Ravin 500 3 Camperdown, Kwazulu Natal, RSA
27 Mar Legacy 0 Spier Wine Estate, Stellenbosch, Western Cape, RSA
15 Apr TBA 1 Farm near Melkbosstrand, Cape Town, RSA
22 Apr Piper PA-46 2 20 km South of Niekerkshoop NC, RSA
26 Apr Challenger 0 Lanseria, RSA
19 May TBA 2 York Farm Area, Lusaka West, Zambia
10 Jun Mirage 2000D 0 Between Gao in Mali and Niamey in Niger
13 Jun Light aircraft 0 Stellenbosch Airfield, WC, RSA
17 Jun Cessna Caravan C208 3 Mpumalanga, RSA
02 Jul Fokker 50 4 Jomo Kenyatta International Airport, Nairobi, Kenya
24 Jul MD83 116 Gao, Mali
10 Aug Cessna 206 0 Victoria Falls, Zimbabwe
0 Aug Microlight 0 Nakazaza, Rundu, Namibia
19 Aug L410 4 southern vicinity of Kahuzi-Biega Park near to the village of Kalika, Mulume Munene (approximate coordinates of crash site: S2.5 E28.6), DRC
22 Aug Cessna 206 0 Fort Portal, Uganda
26 Aug TBA (Light Aircraft) TBA Manda Bay, Lamu West, Kenya
27 Aug L39 2 Taez, Yemen
30 Aug AN12BK 7 Tamenrasset Airport, Algeria
31 Aug F27-500 3 Serengeti National Park, Tanzania
04 Sep SF 260 Genet 2 Charles Prince Airport, Harare, Zimbabwe
13 Sep Scheibe Falke SF25B 0 Springs Airport, GP, RSA
13 Sep Crop Sprayer 1 Heidelberg, in the Southern Cape, RSA
15 Sep Cessna 172 0 White River, Mpumalanga, RSA
15 Sep Cessna 172 2 Newcastle KZN, RSA
15 Sep Air Tractor 802 1 Vrede nr Pietretief, Mpumalanga, RSA
21 Sep L39 6 Cairo Military Airfield, Egypt
13 Oct SU-24 2 Hassi Bahbah Airbase, Algeria
Source, amongst others, PlaneCrash info.com; News24, Aviation Herald, Flight Safety Information

ACCIDENTS INVOLVING ROTOR WING AIRCRAFT IN AFRICA DURING 2014

DATE A/C TYPE FATALITIES LOCATION
07 Jan Eurocopter AS 350 (Squirrel) 0 Grand Central Airport, GP, RSA
12 Jan RH44 1 Nr Gwanda Town, Zimbabwe
27 Feb RH22 0 Virginia Airport, KZ, RSA
09 Mar MI24 0 Nr Zarzaitine Airport, In Ameras, Algeria
10 Mar RH22 0 Northern Cape, RSA
15 Mar Ravin 500 3 Close to Emoyeni Lodge private airfield in a sugar cane field, KZN, RSA
27 Mar RH22 0 Freeway private airstrip, NE of Wonderboom Aerodrome, GP, RSA
11 Apr Military TBA 3 Grootfontein, Namibia
13 Apr Bell 412 0 Dar es Salaam, Tanzania
21 Jul Mi-35 2 South of Bama, Borno Province, Nigeria
22 Jul TBA 6 Benina Airbase, Benghazi, Libya
26 Aug MI18 TBA Bentiu, S. Sudan
01 Sep Super Stallion 0 Gulf of Aden.
22 Sep RH44 2 Nr. Bulwer, KZN, RSA
25 Sep RH44 2 Rand Airport, RSA
14 Oct RH44 1 40 nm from Thabazimbi, Limpopo, RSA
28 Oct RH44 0 Nyabihu District, Rwanda


HAZARDS & INCIDENTS INVOLVING FIXED WING AIRCRAFT DURING OCT &NOV2014

HAZ INC DATE A/C TYPE LOCATION FATAL ITIES CIRCUMSTANCES OP TYPE
INC 04 Oct Vans RV 7A Grass Roots Airfield, Kato Ridge, KZN, RSA 0 The pilot stated that during the approach for landing on Runway 30 the aircraft was higher and faster than normal PVT
INC 10 Oct DH-82A Springs Airfield, GP, RSA 0 During the flight, the aircraft experienced an engine failure TEST
INC 15 Oct Bantam B22J On a gravel runway at Chingwedzi, Limpopo, RSA 0 On his return during landing in a cross wind condition the aircraft landed hard where after the middle engine mounting strut collapsed. The engine dropped onto the nose section and destroyed the windshield. PVT
INC 21 Oct Maule M-7-235B Aerofarm Aerodrome, KZN, RSA 0 The pilot reached the start of the runway and turned to the right in order to align the aircraft for take-off. The right hand main wheel went into a ditch that he couldn't see as it was on the right hand side of the aircraft. The right hand side wing tip dropped and impacted the ground PVT
INC 25 Oct Jabiru SK RWY09 at Mossel Bay Airport, 0 After take-off whilst airborne, the aircraft experienced an engine failure. PVT
INC 25 Oct Bushbaby Explorer Wonderboom GF, GP, RSA 0 The pilot experienced a low fuel pressure warning indication on the annunciator panel followed by a rough running engine and a strong smell of fuel. TEST

HAZARDS & INCIDENTS INVOLVING ROTOR WING AIRCRAFT DURING OCT &NOV 2014

HAZ INC DATE A/C TYPE LOCATION FATAL ITIES CIRCUMSTANCES OP TYPE
INC 14 Oct RH44 II Farm in Limpopo, RSA 0 The helicopter suddenly encountered a strong gust of wind where after the helicopter lost height during low level flight GAME

AERODROME HAZARDS
ALL Goma, DRC Construction Hazards - Aerodrome being fenced and runway is being rehabilitated
ALL Goma, DRC Unmanned aircraft
ALL Goma, DRC Very poor ATC
ALL Lubumbashi, DRC Construction Hazards - runway and taxiway rehabilitation taking place involving RWY closures - check NOTAMS
ALL Kadugli, Sudan Lack of ATC and AR&FFS
ALL O R Tambo, RSA Birds
ALL Cape Town Heliport Birds
ALL Wau, Sudan Eagles
ALL Juba, Sudan Very poor ATC with only 1 frequency. Crews must be on the lookout for other aircraft in their vicinity.
Vehicular traffic not obeying any regulations in terms of overtaking aircraft on taxiways and weaving in and out of aircraft on the apron.

4. EMERGENCY RESPONSE PLANNING

Blake Emergency Services is the International Crisis Management and Contingency Planning Consultancy who, although based in the UK, have serious experience in Africa having handled accidents, incidents, counselling, repatriation, DNA sampling and confirmation, in amongst others Lagos, Nigeria; Fez, Morocco; Pointe Noire, Congo; Moroni, Comores; Maputo, Mozambique. Please go to www.blakeemergency.com or contact rethea.mitchell@blakeemergency.com.

If you are interested in becoming a volunteer for Blake Emergency Services then please do not hesitate to contact Rethea at the address given above.


5. HENLEY/GLOBAL AVIATION TRAINING

Should you wish to make a booking for any of these courses please contact Candice on 011 024 5446 or by email to candice@gaconsultants.net

DATES COURSE LECTURER COST EXCL. VAT PER DELEGATE
14 January 2015 Crew Resource Management - Refresher Verity Wallace R 1,050-00
14 January 2015 Dangerous Goods Verity Wallace R 850-00
27 January 2015 CRM - Refresher Verity Wallace R 1,050-00
27 January 2015 Dangerous Goods Verity Wallace R 850-00
2 - 3 February 2015 Quality Assurance Auditor Course GAC Lecturer R 2,475-00
11 February 2015 CRM Refresher Verity Wallace R 1,050-00
11 February 2015 Dangerous Goods Verity Wallace R 850-00
16 - 17 February 2015 Human Factors (AME and CRM) - Initial Dr. Joel Hughes R 2,475-00
24 February 2015 CRM Refresher Verity Wallace R 1,050-00
24 February 2015 Dangerous Goods Verity Wallace R 850-00
Dates to be advised Part 108 Air Cargo Security Familiarisation Doug Stephenson

Note: Cost per delegate includes all training materials, refreshments and lunch.
Note: Attendees paying in cash on the day are eligible for a 10% discount
Note: Both Recurrent CRM and Dangerous Goods Training Courses are available upon request - even at short notice.
First Aid and the Law, please contact candice@gaconsultants.net
Emergency Response, Incident Response, Operations Control, Emergency Response and Family Assistance training together with the writing of Emergency Response Plans and Procedures training is now offered by Blake Emergency Services. For more information, please contact Rethea on rethea.mitchell@blakeemergency.com

Watch this space for details on the new Henley Global AVSEC Familiarisation Course required by all under Part 111 Regulation 111.01.3 and Safety Induction Training (SMS) as required either under the Part relevant to your operation or Part 140.

6. LASER DEFENCE FOR PILOTS

Canadian product shows promise for civilian use

Aircraft landing at night are particularly vulnerable to laser attack and a laser attack can be terrifying. Incidents causing sudden blindness at low altitude with critical seconds of lost situational awareness have left surviving pilots badly shaken. Photographs and videos cannot capture the impact.

The typical weapon of choice is a laser designed for boardroom presentations, astronomy, or a similar legitimate use, and the perpetrators may be as ignorant as many pilots about the effects on a flight crew during a critical phase of flight. (Aircraft are nearly always targeted at low altitude.) The beam from a low-power device can spread over distance from a pinpoint source to cover a windshield. Green lasers that have grown in popularity in part because they are cheap to make are also the most destructive.

In the USA the number of laser attacks on aircraft has increased sharply in the past decade, from 283 in 2005 to nearly 4,000 in 2013, according to the FAA. In South Africa the numbers are rising but are not available at the time of going to press.

At least half a dozen companies currently advertise laser-blocking eyewear online, though these glasses are generally adapted from other applications - essentially modified sunglasses that use older technologies. They block a significant amount of non-laser light, and have not been certified for aircraft use.

The FAA has provided advice for pilots on how to respond to a laser attack in this document (that makes no mention of eye protection already on the market).

"Green is the colour the human eye is most sensitive to. We see more green information than any other colour," said George Palikaras, a physicist and CEO of Metamaterial Technologies, Inc., and its subsidiary Lamda Guard, based in Nova Scotia. Palikaras' company anchors a coalition including the Canadian government, various university laboratories, helicopter operators, and aerospace giant Airbus that aims to equip civilian pilots with protection from laser attacks that can have profound psychological as well as physical effects. "We have had discussions with pilots who were in tears," Palikaras said. The memory of pain, blindness, inability to see even cockpit instruments carried "such a psychological impact from this that they were in tears telling the story."

While law enforcement efforts have increased in response to a fourteen-fold increase in laser attacks reported between 2005 and 2013 (rewards of up to $10,000 for information that leads to arrest of those who intentionally target aircraft with laser pointers were announced in June), Palikaras said those with malicious intent will not be swayed by public service announcements or the threat of jail.

Glasses, goggles, and other eye protection that filters out the laser beam have long been used to protect eyesight, though it has proved challenging to engineer eyewear for aviators that blocks a laser light while still allowing enough other light through-including the lights used to mark runways, obstacles, and cockpit instruments at night.

Palikaras' company has developed a thin film (made with a process called 3-D holography) that can be applied to curved surfaces (similar films made by others have so far been limited in how much they can curve), block both green and blue laser light simultaneously (many products currently available block only one colour), and retain at least 80 percent transparency to other kinds of light. He said products currently on the market offer no more than 70 percent transparency, and, along with products developed for military use, have other limitations: laser beams striking from angles beyond 10 degrees may not be reflected effectively, while metaAIR, as Lamda Guard's patented thin-film coating has been dubbed, can reflect beams striking at angles up to 45 degrees. "We believe we can improve on that as well," Palikaras said.

Nano technology

The desired properties of selective reflection are achieved by creating a specific geometric arrangement of extremely tiny particles within a clear substrate. The nano-composites (also referred to as metamaterials) reflect laser light but allow other light to pass through a film that can be 100 times thinner than a human hair.

Palikaras said Airbus will lead the effort to test and certify a windshield application for fixed-wing aircraft, and the companies hope to have a windshield film ready for certification testing in 2015. The company is meanwhile working with Canadian police agencies to test a visor coated with the same thin film.

That task is complicated by current protective eyewear technology. A police helicopter crew struck by a laser needs time to don protective gear, and will generally respond first by turning away from the light source. Palinkaras said a visor transparent enough to be worn throughout the flight will make an important difference in identifying and arresting perpetrators: "The impact of this custom solution is that they can turn into the beam right away."

Military option

The U.S. Air Force has developed eyeglasses able to block laser light while remaining mainly transparent to other visible light. The U.S. Air Force has also been contracting for thin film technology to protect pilots' eyes from lasers in recent years. Lt. Col. Scott Bergren of the Air Force Life Cycle Management Centre at Wright-Patterson Air Force Base in Ohio, offered (through a spokesperson) brief, written responses to questions about the laser-blocking glasses made by Teledyne Technologies Inc., which was awarded a contract worth up to $20.4 million in 2012 to develop, test, and deploy up to 8,500 pairs of laser-blocking eye protection. Bergren said eyewear has been developed in preference to a windshield treatment because it may be cheaper to produce (the aforementioned Teledyne contract works out to $2,400 per pair), and eyewear can be donned or doffed at the pilot's discretion.

Palikaras said the advantage of a windshield treatment is that pilots do not need any extra tasks (finding glasses, cleaning them, putting them on)-particularly during phases of flight that are already busy. "All the pilots have such a high workload already we don't want to burden them further," Palikaras said. "We don't really believe that the goggles are the right product for the pilots even though we could be selling now hundreds of pairs of goggles which are transparent enough, by the way."

Palikaras said it remains to be seen how expensive this thin film will be by the time it is fully developed, tested, and certified for aircraft installation. He said there is growing interest from aircraft manufacturers, and expects to find ways to make it available to private aircraft owners as well as commercial operators.

"If I knew that I had ... 100 small planes that would be interested, we can do some kind of arrangement," Palikaras said. While

Frost & Sullivan applauded Lamda Guard for developing a specialized film that can protect pilots from laser attack.

Palikaras would also like to help educate pilots who have not found out first-hand just how dangerous a laser strike can be, and is working to create a realistic simulation of the experience using eye-safe lasers that would show a pilot just how hard it can be to see runway lights, instruments, and other critical details in case of an unblocked laser attack.

"We're happy to give this as a service free of charge," Palikaras said. "We are interested in solving the problem, but also creating the awareness within the pilots group. And get them as a partner to help us make the product the right fit."

Lamda Guard has yet to bring its thin film metamaterial solution to market, but it is already winning kudos for the effort: Frost & Sullivan, a California firm with a global focus on technology, market research, and growth consulting, recognized Lamda Guard Nov. 4 with an award for global product leadership.



7. NEWS FROM THE JOHANNESBURG AIRPORTS

RAND AIRPORT, GERMISTON - www.randairport,co,za
Next Safety Meeting will be held on Tuesday 3rd February 2015 at 09.00 in the Old Customs Hall.

LANSERIA AIRPORT - www.lanseriaairport.co.za
Next Safety, Security and Stakeholders Meeting will be held on 10th February 2015 at 12.00 in the LIA Training School.

8. SAFETY AND SECURITY

Here is a quick round up of health risks on and around the African Continent.
Angola - Anthrax affecting cattle
Zimbabwe - Anthrax affecting cattle
Zambia - African Swine Fever
Namibia - Foot and Mouth Disease (in the Zambezi Region)
South Africa - Low pathogenic avian influenza
Sudan - Hemorrhagic Fever
Benin - Lassa Fever
Egypt - H5N1 Avian Influenza
Sierra Leone, Guinea, Liberia, Nigeria, Senegal Mali - Ebola
St. Helena - Newcastle disease affecting chickens
Madagascar - Plague affecting humans
Saudi Arabia - Dengue Fever in Jeddah

9. SAAFA DONATIONS

Should you wish to make a donation to this more than worthy cause then please pay it (via EFT or as a deposit) into;
Standard Bank Bedford Gardens; Bank Code 018 305; Account Name: SA Air Force Association (JHB Branch); Account Number: 022 605 568. You may use either your Company or Individual name along with the word donation as the reference.

10. FINALE

Helicopter Safety Effort

The Federal Aviation Administration's Rotorcraft Directorate is seeking comments from helicopter pilots, mechanics, flight safety officers and others associated with personal/private, instructional/training and aerial application industries about what you would like to see in a safety forum.

The Rotorcraft Directorate will host a three-day safety forum April 21-23, 2015, in Hurst, Texas, a Fort Worth suburb, USA. The forum's purpose is to discuss ways to improve flight safety particularly among personal/private, instructional/training and aerial application industries. These three industries have consistently high accident numbers. Before we begin planning the forum, we want to know what lectures, displays, events and programs would encourage you to attend and what topics you think would be of the most value. Also, what forums have you attended that you particularly liked and why?

Please contact me directly at eugene.trainor@faa.gov or at the

AA Rotorcraft Directorate,
2601 Meacham Boulevard,
Fort Worth, Texas 76137. For information about our safety conference visit, www.faahelisafety.org

SITUATIONS VACANT. If you are interested and qualified please send your CV to global@gaconsultants.net

Part Time Consultant Air Safety Officers required who comply with the requirements of SA CARS Part 135, Part 121, Part 127, Part 140, Part 141 and Part 145 - must have had appropriate SMS training, previous experience and preferably been approved by the South African Air Services Licencing Council.

Part Time Quality Assurance Consultants required who are appropriately qualified and comply with the requirements of Part 135, Part 121, Part 127, Part 140, Part 141 and Part 145.

Part Time Aviation Security Consultant required who is appropriately qualified for RSA and International Operations



GLOBAL AVIATION CONSULTANTS (PTY) LTD

Can we help you with your aviation safety
and / or quality requirements?

Under SA CAR 140.01.2 if you and your organisation hold one of the following

? a category 4 or higher aerodrome licence;
? an ATO approval;
? an aircraft maintenance organisation approval;
? a manufacturing organisation approval ;
? an ATSU approval;
? a design organisation approval;
? an AOC issued in terms of Part 121, 127, 135, 141;
? a procedure design organisation approval; and
? an electronic services organisation approval,

then you shall establish a Safety Management System for the control and supervision of the services rendered or to be rendered by that organisation.

If you do not already have an approved Air Safety Officer and an approved Safety Management System then please contact us for assistance.

We, at Global Aviation Consultants, deliver the following SA CAA Approved training courses for Air Safety Officers at Rand Airport;

? Safety Management Systems
? Integrated Safety Officer Course
? Quality Assurance Auditor
? Crew Resource Management (Initial and Recurrent)
? Dangerous Goods
? Human Factors for AME's
Should your operation be of a size whereby the full time employment of an Air Safety Officer and/or Quality Assurance Officer is not financially viable then we can provide you with Consultants who have previously held Air Services Licensing Council approval. We can also provide you with a tailor made SA CAA approved Safety Management System.

For further information on how we can help you please contact Rethea or Candice in Hanger 6, Rand Airport, Germiston on 011-024--5446/7 or e-mail global@gaconsultants.net

Global Aviation Consultants accepts no liability for the content of this email, or for the consequences of any actions taken on the basis of the information provided, unless that information is subsequently confirmed in writing. If you are not the intended recipient you are notified that disclosing, copying, distributing or taking any action in reliance on the contents of this information is strictly prohibited.

GAC News Letters








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