aviation occurrence report fuel contamination …€¦ · a division of conair aviation ltd. bell...

AVIATION OCCURRENCE REPORT

FUEL CONTAMINATION

FRONTIER HELICOPTERSA DIVISION OF CONAIR AVIATION LTD.

BELL 206B JETRANGER III (HELICOPTER) C-GLGFWATSON LAKE AIRPORT, YUKON 1.8 nm S

26 JULY 1994

REPORT NUMBER A94W0124

MANDATE OF THE TSB

The Canadian Transportation Accident Investigation and Safety Board Actprovides the legal framework governing the TSB's activities. Basically, theTSB has a mandate to advance safety in the marine, pipeline, rail, andaviation modes of transportation by:

! conducting independent investigations and, if necessary, publicinquiries into transportation occurrences in order to make findings asto their causes and contributing factors;

! reporting publicly on its investigations and public inquiries and on therelated findings;

! identifying safety deficiencies as evidenced by transportationoccurrences;

! making recommendations designed to eliminate or reduce any suchsafety deficiencies; and

! conducting special studies and special investigations ontransportation safety matters.

It is not the function of the Board to assign fault or determine civil or criminalliability. However, the Board must not refrain from fully reporting on thecauses and contributing factors merely because fault or liability might beinferred from the Board's findings.

INDEPENDENCE

To enable the public to have confidence in the transportation accidentinvestigation process, it is essential that the investigating agency be, and beseen to be, independent and free from any conflicts of interest when itinvestigates accidents, identifies safety deficiencies, and makes safetyrecommendations. Independence is a key feature of the TSB. The Boardreports to Parliament through the President of the Queen's Privy Council forCanada and is separate from other government agencies and departments.Its independence enables it to be fully objective in arriving at its conclusionsand recommendations.

The Transportation Safety Board of Canada (TSB) investigated this occurrence for thepurpose of advancing transportation safety. It is not the function of the Board to assign faultor determine civil or criminal liability.

Aviation Occurrence Report

Fuel Contamination

Frontier HelicoptersA Division of Conair Aviation Ltd.Bell 206B JetRanger III (Helicopter) C-GLGFWatson Lake Airport, Yukon 1.8 nm S 26 July 1994

Report Number A94W0124

Synopsis

The Bell 206B helicopter was being utilized to transport a two-person initial attack fire crew to arecently spotted forest fire. Shortly after take-off, at an altitude of approximately 300 feet aboveground, the engine lost all power. The pilot attempted to autorotate to the only available road;however, the helicopter overshot the intended landing area, struck trees, and crashed beside the road. The pilot sustained fatal injuries and the two passengers received serious injuries. The helicopter wasdestroyed.

The Board determined that the engine lost power due to water-contaminated fuel. It is probable thatthe pilot mistakenly introduced water into the fuel system through the fuel cell vent tube when heattempted to back-flush the adjacent engine pan drain tube with a water hose. The low altitude atwhich the loss of power occurred precluded successful autorotation to a suitable landing site.

Ce rapport est également disponible en français.

TABLE OF CONTENTS

TRANSPORTATION SAFETY BOARD iii

Table of ContentsPage

1.0 Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.1 History of the Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.2 Injuries to Persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.3 Damage to Aircraft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.4 Other Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.5 Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.6 Aircraft Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.6.1 The Engine Pan Drain Tube . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.6.2 The Fuel Cell Vent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31.6.3 Recent Inspection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41.7 Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41.8 Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41.9 Fuel System Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41.10 Wreckage and Impact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51.11 Medical Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51.12 Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51.13 Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51.14 Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51.15 Additional Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

2.0 Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72.2 The Introduction of Water into the Fuel System . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72.3 The Autorotational Forced Landing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

3.0 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93.1 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93.2 Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

4.0 Safety Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114.1 Action Taken . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114.1.1 Operator Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114.1.2 Vent Lines Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114.1.3 Manufacturer Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

TABLE OF CONTENTS

iv TRANSPORTATION SAFETY BOARD

5.0 AppendicesAppendix A - List of Supporting Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Appendix B - Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

List of FiguresFigure 1 - B206 Engine Pan Drain and Fuel Cell Vent Tubes . . . . . . . . . . . . . . . . . . . . . . . . . . 3

FACTUAL INFORMATION

TRANSPORTATION SAFETY BOARD 1

1.0 Factual Information

1.1 History of the Flight

The pilot and Bell 206B helicopter had beenplaced on standby for initial attack (IA)1 at theDepartment of Indian and Northern AffairsForest Resources Fire Centre, at the WatsonLake Airport, Yukon. The pilot arrived at theFire Centre in the early afternoon,accomplished a five-minute IA performanceflight, and returned to the landing pad. Later inthe afternoon, he washed and groomed thehelicopter. At 1840 Pacific daylight time(PDT)2 the pilot was dispatched to a nearbyBritish Columbia Forest Service (BCFS) IAbase to pick up and transport an IA crew to anew forest fire located 20 miles away inNorthern British Columbia. Immediately afterboarding the two-person IA crew, the pilotdeparted to the southwest. Approximately twominutes after take-off, at an altitude of about300 feet above ground, the engine (Allison 250C20B) lost all power. The pilot transmitted aMAYDAY, and advised his passengers that hewas experiencing a problem and would have toset the helicopter down. The helicopter wasobserved to turn right 180 degrees, descend,turn right an additional 90 degrees, and crashinto trees

1 See Glossary for all abbreviations and acronyms.

2 All times are PDT (Coordinated Universal Time [UTC]minus seven hours) unless otherwise stated.

3 Units are consistent with official manuals, documents,reports, and instructions used by or issued to the crew.

immediately adjacent to a secondary road. Thepilot sustained fatal injuries, and the two IAcrew members sustained serious injuries. Thehelicopter was destroyed.

The accident occurred at latitude60°05'N and longitude 128°49'W atapproximately 1900 PDT, during daylighthours, at an elevation of 2,240 feet above sealevel (asl)3.

1.2 Injuries to Persons

Crew Passengers Others Total

Fatal 1 - - 1Serious - 2 - 2Minor/None - - - -Total 1 2 - 3

1.3 Damage to Aircraft

The helicopter was destroyed by the impact.

1.4 Other Damage

The helicopter crashed into standing spruceand pine trees. No other significant propertydamage occurred.

1.5 Personnel Information

Pilot-in-Command

Age 28Pilot Licence CPLMedical Expiry Date 01 Jan 95Total Flying Hours 2,947Hours on Type 2,147Hours Last 90 Days 69Hours on Type Last 90 Days 69Hours on Duty Prior to Occurrence 13Hours off Duty Prior to Work Period 9

The pilot was certified and qualified forthe flight in accordance with existingregulations. He was characterized as beingsafety conscious. He had flown for Frontier

FACTUAL INFORMATION

2 TRANSPORTATION SAFETY BOARD

Helicopters for approximately five years, andcurrently held the position of Watson LakeBase Manager. The pilot was involved in anaccident two years earlier when he autorotateda Bell 206B into trees following an engineflame-out. The helicopter was destroyed andthe pilot sustained minor injuries.

The pilot prided himself in keeping thehelicopters he flew clean. He was observedwashing and grooming C-GLGF with a bucketof soapy water and a water hose at the WatsonLake Fire Centre pad for approximately threehours before the flight. At one point headvised bystanders that the engine pan draintube was clogged, and he was observed probingthe tube from the engine compartment andfrom the lower right side of the fuselage with awire. Later he advised two Fire Centreemployees that he had succeeded in uncloggingthe drain tube.

The pilot was observed draining a smallquantity of fuel from the fuel cell sump after helanded at the Fire Centre pad, before he washedthe helicopter.

1.6 Aircraft Information

Manufacturer Bell Helicopter TextronType and Model 206B JetRanger IIIYear of Manufacture 1978Serial Number 2421Certificate of Airworthiness (Flight Permit) ValidTotal Airframe Time 6,646 hrEngine Type (number of) Allison 250-C20B (1)Propeller/Rotor Type (number of) Semi-rigid (1)Maximum Allowable Take-off Weight 3,200 lbRecommended Fuel Type(s) Jet A, Jet A1, Jet BFuel Type Used Jet B

Log-book entries stated the helicopterhad been maintained in accordance with theapplicable standards of airworthiness. Theweight and centre of gravity were within theprescribed limits.

1.6.1 The Engine Pan Drain Tube

The Bell 206B is fitted with an enginecompartment stainless steel drain tube whichdischarges fluids overboard from the enginepan. The drain tube routes from the bottomlower centre of the engine pan, horizontally tothe right above the baggage compartment, andvertically down the right side of the fuselage toexit approximately three inches aft of the fuelcell vent tube. The drain tube has an outsidediameter of approximately ½ inch andprotrudes approximately 3 inches from thefuselage. Field reports indicate

FACTUAL INFORMATION


Figure 1 - B206 Engine Pan Drain and Fuel Cell Vent Tubes

that the engine pan drain tube frequently clogs. Foreign material such as bugs, dirt, and smallleaves may collect in the engine pan duringnormal operation and wash into the tubewhenever fuel is drained onto the pan from theairframe or engine fuel filters.

The Bell 206B Maintenance and OverhaulManual does not identify a procedure to cleanthe engine pan drain tube. Operators reportthat the tube is normally cleaned by probingwith a wire and/or purging with shop air orsolvents. The pilot reportedly carried a twistedpiece of wire in the helicopter for use as aprobe when the drain tube clogged.

1.6.2 The Fuel Cell Vent

The fuel cell vent is an aluminum tube whichexits the Bell 206B on the right lower side ofthe fuselage, aft of the right cabin door andforward of the engine pan drain tube. Theoutside diameter of the tube is approximately½ inch, and it protrudes approximately 3 inchesfrom the fuselage skin. There is no check valvein the vent tube to prevent fluids from enteringthe fuel cell if the tube is back-flushed.

The fuel cell vent tube was notidentified externally by label or decal, and therewas no requirement for markings to exist. Chapter 11 (Placards and Markings) of the Bell206B III Maintenance Manual identifies that a"FUEL CELL VENT" decal is applicable tothe Bell 206B III S/N 3890 and subsequent.

The engine pan drain tube and the fuelcell vent tube were submitted to the TSBEngineering Branch Laboratory forexamination (see Appendix A). The tubes weresectioned and visually inspected. Scratches onthe inner wall of the fuel cell vent tubeindicated that the tube had recently beenprobed with a wire or a similar instrument. Theharder stainless steel engine pan drain tube didnot display clear evidence of recent probing. Faint rub lines existed on the inner wall of thetube; however, it was not certain that theseindistinct marks had been made as recently asthe scratches in the vent tube.

1.6.3 Recent Inspection

A 1200-hour inspection had been completed onthe helicopter on 29 June 1994, 62.7 hoursprior to the occurrence. The helicopter was aBell 206B3 model; however, Bell 206A/Binspection sheets had been utilized for theinspection. Although the inspection sheets foreach model are similar, the Bell 206B3 100-hour inspection sheets include a specificrequirement to "Inspect and ensure the enginepan drains are free from obstruction." Thisrequirement is not identified on the Bell

FACTUAL INFORMATION


206A/B 100-hour inspection sheets. The 1200-hour inspection includes 100-hour items.

The pilot had not recently reported tothe maintenance staff that the engine pan draintube was clogged.

1.7 Meteorological Information

Good visual meteorological conditions existedat the time of the occurrence, and weather wasnot considered to be a factor. An AUTO5automated weather observation system(AWOS) located at Watson Lake Airportrecorded the weather conditions at 1900 PDTas no clouds below 10,000 feet asl, temperature25 degrees Celsius, visibility greater than ninestatute miles, and winds calm. Witnessesreported similar weather conditions. One ofthe IA crew members reported that smokefrom the fire they were transitting to was visibleimmediately after they lifted off from the BCFShelicopter pad.

1.8 Communications

Several aircraft were operating in the vicinity ofWatson Lake at the time of the occurrence. Two Forestry FM frequencies, the very highfrequency (VHF) aerodrome traffic frequency(123.2 MHz) and the VHF water bomber airattack frequency (122.7 MHz), were in use. A"bird dog" aircraft and three water bomberswere departing the Watson Lake Airport tofight the forest fire. The pilot of the helicoptertransmitted a MAYDAY distress call on theForest Resources Fire Centre FM frequencyshortly before impact. The crew of the birddog aircraft heard the distress call and observedthe helicopter strike the trees. They proceededwithout delay to circle the crash site andadvised the Forest Resources Fire Centre dutyofficer of the accident. The duty officerimmediately initiated an emergency response bycalling the local police and ambulance services. The bird dog crew continued to circle, and

subsequently guided responding groundpersonnel to the accident site.

1.9 Fuel System Examination

Fuel samples collected from the airframe fuelfilter, the engine-driven high-pressure fuelpump filter cavity, the fuel control unit, and thefuel nozzle supply line contained largequantities of water. Fuel from the three mostrecent refuelling sources was examined withwater detecting paste, and found to be clear andfree of water. The hose and filter housings ofthe portable barrel pump which was on boardthe helicopter contained no detectable water. No discrepancies which would permit waterleakage into the cell were noted during anexamination of the fuel tank range extender andcap. The pilot was known to frequently drainthe airframe fuel filter and fuel cell sump tocheck for water.

1.10 Wreckage and Impact Information

The helicopter crashed approximately 60 feetnorth of a secondary road which accessed alocal campground. It had crossed the road andcollided with several 30- to 40-foot-tall treesprior to ground impact. The wreckage trail wasapproximately 60 feet long. Damage andground scars indicated that the helicopter hadstruck the ground in a right-side-low attitude, ata high impact angle and a high rate of descent.

The helicopter broke into severalsections at impact. The cross-tubes andfuselage floor detached, the fuel cell ruptured,the tail boom detached, and the cockpitcollapsed. The forward right side of thecockpit adjacent to the pilot's position sustainedsevere impact damage.

1.11 Medical Information

There was no evidence of incapacitation orphysiological or psychological factors whichwould have adversely affected the pilot'sperformance.

1.12 Fire

FACTUAL INFORMATION


There was no evidence of fire either before orafter the occurrence.

1.13 Survival Aspects

Both surviving passengers sustained seriousback injuries due to the high verticaldeceleration forces. The fuel cell ruptured atimpact. Both survivors were doused with jetfuel, and sustained chemical burns as a result.

1.14 Tests and Research

Laboratory testing determined that the water inthe fuel samples and the water in the hose usedto rinse the helicopter were similar in hydrogenion concentration (pH) and mineral content.

1.15 Additional Information

Reports from industry indicate that Bell 206fuel systems have previously beencontaminated when the fuel cell vent tube wasmistaken for the engine pan drain tube andinadvertently back-flushed with water orsolvent. In all reported incidents, the conditionwas identified and rectified before flight.

ANALYSIS


2.0 Analysis

2.1 Introduction

The investigation determined that the Allison250 C20B engine lost power due to water-contaminated fuel. The analysis will focus onthe introduction of water into the helicopterfuel system, and on the subsequentautorotational forced landing. Althoughimproper inspection sheets had been usedduring a recent 1200-hour inspection, there wasno evidence to indicate that this was a factor inthe accident. The pilot had not reported aproblem with the engine pan drain tube duringthe 60 hours of flight since the last scheduledinspection, which suggests that the tube hadonly recently clogged.

2.2 The Introduction of Water into theFuel System

The engine pan overboard drain tube and fuelcell vent tube are easily misidentified wherethey protrude from the Bell 206B3 fuselage. The tubes are visually similar and are locatedvery close to each other. They are not requiredto be labelled on the first 3,889 Bell 206production helicopters. The engine pan draintube is susceptible to blockage due to the flatrouting of the horizontal portion of the tube,the minimal size of the line, and the migrationof engine compartment debris.

The pilot had the time and facilityavailable to him on fire standby to wash thehelicopter and clean the clogged engine pandrain tube. He was familiar with the problemof a blocked drain tube, as evidenced by hishabit of carrying a twisted wire to probe thetube. Scratches on the inside wall of the fuelcell vent tube indicate that he may have probedthe vent tube when he was clearing the cloggeddrain tube. It is probable that he alsomistakenly back-flushed the fuel cell vent tube,instead of the drain tube, with the availablewater hose and thereby introduced water intothe fuel system.

2.3 The Autorotational ForcedLanding

The loss of power occurred at low altitude overheavily treed terrain. The proximity of theaccident location to an available secondary roadand the manoeuvring that was observed by theairborne bird dog crew suggest that the pilotattempted to force land on the road. The lowaltitude at which the loss of power occurredmay have precluded successful autorotation tothe site. The pilot's previous experience of aforced landing in a heavily wooded area mayhave motivated him to attempt to reach theroad rather than again autorotate into trees.This most likely resulted in a loss of main rotorautorotational rpm and control, a high rate ofdescent, and the subsequent overshoot of theintended landing site.

CONCLUSIONS


3.0 Conclusions

3.1 Findings

1. The engine lost all power due to waterin the fuel.

2. The low altitude at which the loss ofpower occurred precluded autorotationto a suitable forced landing site.

3. The pilot was observed washing thehelicopter and probing in the vicinityof the lower end of the engine pandrain tube with a wire prior to theflight.

4. Laboratory examination identified thatthe fuel cell vent tube had recentlybeen probed with a wire or a similarinstrument.

5. The fuel cell vent tube was notexternally identified by label or decal,nor was it required to be by existingregulations.

6. Field reports indicate that the enginepan drain line frequently clogs due toaccumulation of bugs, vegetation, anddirt.

7. The helicopter was a Bell 206B3 model;however, Bell 206A/B inspectionsheets were utilized for the recent1200-hour inspection.

3.2 Causes

The engine lost power due to water-contaminated fuel. It is probable that the pilotmistakenly introduced water into the fuelsystem through the fuel cell vent tube when heattempted to back-flush the adjacent engine pandrain tube with a water hose. The low altitude

at which the loss of power occurred precludedsuccessful autorotation to a suitable landingsite.

SAFETY ACTION


4.0 Safety Action

4.1 Action Taken

4.1.1 Operator Action

The operator has issued a technicalmemorandum requiring that all drain lines andvent lines on company Bell 206 helicopters beidentified. In addition, the memorandum statesthat a drain line that is blocked must beremoved for cleaning or flushed from the topdown to the exit. The memorandum alsocontains the following warning: "UNDER NOCIRCUMSTANCES IS IT PERMISSIBLE TOBACK FLUSH ANY LINE, AS THISCOULD CAUSE CONTAMINATION OF ASYSTEM."

4.1.2 Vent Lines Identification

On 09 September 1994, the TSB forwarded anAviation Safety Advisory to Transport Canada(TC) suggesting that TC require that the fuelvent and engine drain tubes on all Bell 206helicopters be clearly identified. TC hasindicated that a Service Difficulty Advisory willbe released to inform operators of the hazardsof backflushing vent lines, and recommendingthat a warning decal be installed near the fuelvent tube outlet. An article on this issue waspublished in the 4/94 edition of the TC safetypublication Maintainer.

4.1.3 Manufacturer Action

Bell Helicopter Textron has indicated that anew Technical Bulletin will be released topermit operators of JetRangers with serialnumbers prior to 3890 to use the "Fuel CellVent" decal if they so desire. Also, on19 January 1995, the manufacturer releasedOperations Safety Notice OSN-GEN-95-26 toall operators of Bell helicopters. This OSNaddresses improper washing techniques, and

refers operators to appropriate cautions andprocedures published in the Bell HelicopterCorrosion Control Guide.

This report concludes the Transportation Safety Board'sinvestigation into this occurrence. Consequently, the Board,consisting of Chairperson John W. Stants, and membersZita Brunet and Hugh MacNeil, authorized the release ofthis report on 10 May 1995.

SAFETY ACTION


APPENDICES


Appendix A - List of Supporting ReportsThe following TSB Engineering Branch Laboratory report was completed:

LP 118/94 - Tube Assembly Examination.

The following supporting report was completed by the Alberta Research Council:

Lab number G0-94-1344 to G0-94-1347.

TSB Engineering reports are available upon request.

APPENDICES


Appendix B - Glossary

asl above sea levelAWOS automated weather observation systemBCFS British Columbia Forest ServiceCPL Commercial Pilot Licencehr hour(s)IA initial attacklb pound(s)Ltd. limitedMHz megahertznm nautical milesOSN Operations Safety NoticePDT Pacific daylight timepH hydrogen ion concentrationrpm revolutions per minuteTC Transport CanadaTSB Transportation Safety Board of CanadaUTC Coordinated Universal TimeVHF very high frequency° degrees' minute(s)'' second(s)

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