Jamberoo Fan

Thunder River Rapids Incident Coronial Inquest

629 posts in this topic

9 hours ago, red dragin said:

I'm not sure plant registration is optional. I used to get emails from the body corporate ensuring that the new sign was up and old sign was down to avoid fines. 

That was for an elevator. 

Maybe poor choice of words? You are supposed to register yearly, thats not what i was meaning. The filling out the paperwork and applying for registration, or renewing and paying the fees, thats done of your own accord.

You could install equipment all over your site, but its your job to send out the requests to worksafe to have it all registered. If you dont, they wont know whats on site unless they ever have need to come out and inspect for compliance. Thats where you could see it falling through the cracks. Maybe one of the recommendations to come out of the inquest will be yearly inspections by worksafe?

Things like air conditioners i could understand. Missing their registrations and overlooking the paperwork or never being noticed, but rides? Surely someone in the department had been to the park as a guest and saw changes/new rides or even just the tv commercials.

Dreamworld admitted they didnt follow proceedure because they felt their inhouse policies/inspections were enough without having government regulators involved, so there were some things that had no registrations at all, while some were "only" years out of date. 

I mean, wtf?! Like you, under threat of fines and a smack by worksafe, surely this should have been picked up by the regulator before it got this far. They seem like they have plenty to answer for, too. The coroner normally doesnt hold back in shaming government departments if they've dropped the ball.

I can see the basic structure of the department reply now though; "we are underfunded and do what we can....", followed by more outrage when, if pushed, they are found to have a backlog of work going back years because they cant fund enough inspectors. :o

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On 10/11/2018 at 12:30 PM, Jamberoo Fan said:

...where it will presumably adjourn again until the 17th of December, when an extra, originally unscheduled 5 days of coronial inquest hearings will be held due to Ardent Leisure delivering requested documents late earlier in the coronial inquest.

I'm sure a lot of Parkz forum members will be surprised to hear the coronial inquest resumed in Southport yesterday at 9:30am and finished completely earlier today.

So here are the most interesting quotes I could find about the final 2 days:

From the Australian Associated Press via the Brisbane Times:

Quote

A major overhaul of all theme park safety including mandatory major inspections has been proposed following the Dreamworld tragedy which claimed four lives.

Workplace Health and Safety executive Bradley Bick told the inquest which resumed on Thursday the recommendations included regulatory amendments to improve amusement device safety.

Mandatory major inspections every 10 years, ensuring competent and properly trained staff operate the rides and theme parks prepare a safety case to protect visitors are also proposed.

Inspections would involve a thorough examination of critical components, stripping down devices, removing paint, grease and corrosion to ensure "effective and safe operation" of all theme park attractions.

Mr Bick said ride operators would be tested to ensure they were competent to operate the attraction.

"This will provide a comprehensive physical check of the ride to ensure that the ride is safe," Mr Bick told the inquest.

There is no time frame for the regulations to take effect, the recommendations are in draft form and will not go before the state government before March.

The inquest was told the role of a public safety ombudsman could be introduced to investigate theme parks.

From the Australian Associated Press via Cowra Guardian:

Quote

WPHS officers will also introduce “spot checks” to ensure theme parks adhere to strict safety guidelines.

“This will provide a comprehensive physical check of the ride to ensure that the ride is safe,” Mr Bick told the inquest.

A group of experts told the inquest mechanical hazards on the attraction meant “catastrophic incidents could have occurred at any time”.

A safety report tendered to the inquest into the deaths of Cindy Low, Kate Goodchild, her brother Luke Dorsett and his partner Roozi Araghihas revealed when the water pump failed on The Thunder River Rapids ride, there was a “massive water drop”, which took less than 10 seconds.

Dr Frank Grigg, of Forensic Engineering Consultants, told the inquest the rafts should have been been fitted with aircraft-style seat belts.

“I believe one of the deceased would still be alive if the raft was fitted with aircraft-style lap belts,” Dr Grigg said.

“Why velcro (seat belts) were used is a mystery to me.”

The inquest was also told there had not been enough thought about the potential risks when a pump failed, with ride operators “not schooled” on the loss of water.

The report stated the “excessive gap” between the conveyor slats and the fact the conveyor continued operating when the pump failed contributed to the accident.

It was also noted that “most” of the ride had been modified with “little or no consideration given to the effects of safety via a detailed and formal risk assessment process”.

“Previous incident on the TRRR, particularly in 2001 and 2014 should have alerted Dreamworld to the hazards present on the ride,” the safety report states.

From 9 News:

Quote

Yesterday marked the start of the final sitting of the hearing, with an expert panel of engineers grilled about a joint report they conducted for Coroner James McDougall.

They were tasked with investigating what went wrong when the raft Cindy Low, Kate Goodchild, Luke Dorsett and Roozi Araghi capsized in October 2016 on the Thunder River Rapids Ride.

They claimed the theme park relied on its 30 year "trouble free" record when it shouldn't have used it as an excuse.

"It's a bit like somebody crossing the road, they've done it many times but there's a risk they're going to get conked down by a car, might be a low probability… but you know it's a hazard" Dr Frank Grigg, a mechanical engineering expert told the inquest.

Dr Grigg also conducted his own report into the safety of the ride's conveyor belt, slamming the removal of two out of every three wooden slats, some 26 years prior to the tragedy.

"It made a big difference to a lot of things," he said.

"When all of the spaces were occupied, if a person had fallen out of the raft and they were on the conveyor they had a fairly good chance of being able to put a foot down to save themselves."

The experts also raised concern about the tired Velcro seatbelt onboard the rafts at the time, as well as the ride operator's control panel, saying it "wasn't designed with safety in mind."

From Australian Leisure Management:

Quote

Bick also suggested that theme parks be required to adhere to a code of practice with minimum operational and safety standards.

However, with Coroner James McDougall not expected to hand down his findings until next year and Coronial recommendations being non-binding, there is no certainty that they will be adopted.

Commenting on the "massive water drop", which took less than 10 seconds, that led to three of the deceased being flung from the ride and into the mechanised conveyor the advisors confirmed that a crucial delay in stopping the ride caused the jammed raft to be shaken and a fourth person to fall from his seat and into the machinery.

From the Australian Associated Press via the Brisbane Times:

Quote

Earlier on Friday, a senior safety engineer joined calls for tougher safety requirements and testing for theme park rides across Queensland.

Workplace Health and Safety's chief safety engineer Michael Chan told the inquest he agreed with a recommendation to tighten the enforcement process.

"We need to expand the scope of the annual inspections to include a risk assessment," Mr Chan said.

He also supported the introduction of a mandatory full risk assessment every 10 years as an "imposition, but a necessary one".

"The system will only work if the system is robust and someone is checking the checker," he said.

Quote

An expert in human behaviour has told the Dreamworld inquest that staff operating the ride had to perform "one task every second" and it was inevitable their performance would suffer.

On the final day of the marathon inquest, Professor of cognitive engineering and human psychology Penelope Sanderson said the stress of the 2016 incident also would have affected reaction times.

"There is a lot of work that people have to do in a given amount of time. If people are spending 80 per cent of their time carrying out tasks, their performance will suffer," Professor Sanderson said.

"This [operating the Thunder River Rapids Ride] is more like 100 per cent. It would be difficult to sustain for a long period of time, raft after raft."

Prof Sanderson said people could experience "cognitive tunnel vision" when under stress.

"The stress would have made it very difficult to work out what to do in the situation, particularly as there was no procedure for what to do in that situation," she told the inquest.

"The stress of seeing the raft approach would have made it more difficult to know what to do."

From 9 News:

Quote

Dr Gary Weiss of Ardent Leisure, which owns Dreamworld, issued a statement to express remorse and deep regret over the accident.

"Our thoughts remain with the victims' families and everyone who has been affected by this terrible tragedy."

Coroner James McDougall is expected to hand down his findings next year.

From The New Daily:

Quote

The marathon inquest into the deaths of four people at Dreamworld has closed with the coroner offering his “deepest condolences” to the families of the victims.

Coroner James McDougall thanked the families who have attended every day of the six-week inquest into the deaths of Cindy Low, Kate Goodchild, her brother Luke Dorsett and his partner Roozi Araghi.

Outside court, family members declined to comment, but indicated they may make a statement when the coroner hands down his findings in 2019.

Now we wait for the coroner's report and just as importantly, his recommendations...

Edited by Jamberoo Fan
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7 hours ago, Gazza said:

The bus is now leaving for Three Month Island, Qld.

I thought it had been much longer than that.

The Bus is now leaving for Forty Year Spring, NSW.

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Dreamworld has it's best day in years yesterday with it's suite of high-profile ride investment announcements and now reality returns...

The Courier-Mail has published an article and an editorial (links below), which are both subscriber-only.

Article: EXCLUSIVE: Funding shortfall families' anguish at coroner court logjam - PLEA FOR TRUTH

Editorial: Editor's view: Time to address our coronial crisis

From what I can gather without subscribing, here is the key point:

There is a funding shortfall which is causing delays in the QLD Coroner's Court and despite DW hoping the findings to be handed down by years end, The Courier-Mail think it will be next year. The victims' families (...and The Courier-Mail) are thus understandably losing patience.

Just found this quote from the investor presentation transcript I found and posted in another topic:

Quote

--------------------------------------------------------------------------------

Sam Teeger, Citigroup Inc, Research Division - Analyst [6]

--------------------------------------------------------------------------------

And I guess heading into the key Christmas trading period, it looks like the Coroner's report is now scheduled to be released just before then. How do you manage any potential risk around attendance if that stuff's thrown out in the news again?

--------------------------------------------------------------------------------

John Osborne, Ardent Leisure Group Limited - CEO of the Theme Parks Division [7]

--------------------------------------------------------------------------------

Yes. So look, the -- we don't know when the Coroner's report is going to be released, to be honest. We believe that it may be before the end of the year. The Coroner's not mandated to any sort of timetable as far as we know so it will be released when it is. The best thing we can do is just continue to provide a really good guest experience, and everybody at Dreamworld's focused on that. Execute on our plans to improve the product in a timely fashion. And certainly, Sky Voyager is the start of that. And that's the best we can do.

In terms of publicity that may or may not occur when the report's released, we'll have to deal with that at the time. What I can say is that our safety systems are, I think, up there with the best of any theme park in the world and they're continuing to be improved with every day that goes by. So we'll certainly be in a very strong position as we are now, and even stronger in the future to demonstrate to our guests and to the marketplace, if I can call that generally, that we're in a very good place in relation to any safety concerns that anybody may have.

--------------------------------------------------------------------------------

 

Edited by Jamberoo Fan
Added investor presentation quote

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5 hours ago, Jamberoo Fan said:

Article: EXCLUSIVE: Funding shortfall families' anguish at coroner court logjam - PLEA FOR TRUTH

FAMILIES grieving from some of the state’s worst tragedies are facing heartbreaking waits for answers as a funding shortfalls lead to lengthy Coroner’s Court delays.

The Courier-Mail can reveal that more than eight months after public hearings into Dreamworld’s Thunder River Rapids ride disaster which left four tourists dead, the inquest has been bogged down by lengthy delays meaning there will likely be no answers until next year.

The Coroner’s Office continues to battle backlogs on high-profile cases including the 1973 Whiskey Au Go Go nightclub firebombing in Brisbane, the 1989 murder of Toowoomba teen Annette Mason, the 2014 Barrett Centre deaths and the Ravenshoe Café explosion.

The state’s peak law body says the Coroner’s Court is being “strangled” by a lack of funding and has called on the Queensland Government to allocate more cash urgently.

Inquest revelations shock family

Ride ‘should never have been in operation’

‘Total failure’ of Dreamworld staff to ensure ride safety

By the numbers

Between 2011-12 and 2017-18

  • Coronial cases that are 24 months old or older increased from 7% to 16%
  • It took pathologists on average more than 4 months to issue their autopsy reports
  • Coroners held 400 inquests
  • Coroners issued 522 recommendations to state government agencies
  • Police officers, doctors or funeral directors reported 35,422 deaths to the coroner for investigation
  • Pathologists performed 18,387 autopsies

In the latest indictment on Queensland’s sluggish coronial system, The Courier-Mail has learned the counsel assisting the coroner in the Dreamworld case is yet to make final submissions.

Sources say that may not happen for weeks and lawyers for parties including the victims’ families will then have to respond.

It means Coroner James McDougall may not hand down his findings until next year, more than three years after the October 2016 tragedy which claimed the lives of Cindy Low, Kate Goodchild, her brother Luke Dorsett and his partner Roozbeh Araghi.

Floral tributes outside Dreamworld following the October 2016 Thunder River Rapids ride tragedy. Picture: Nigel Hallett Floral tributes outside Dreamworld following the October 2016 Thunder River Rapids ride tragedy. Picture: Nigel Hallett

The setback will prolong the anguish for the victims’ families and also delay possible prosecutions and recommendations to improve theme park safety.

 

A damning Queensland Audit Office report handed down late last year found the state’s coronial system was ‘under stress’, with ‘excessive delays’ and a declining clearance rate leading to a growing backlog of coronial investigations.

Auditor-General Brendan Worrall found that coronial cases in Queensland that were 24 months or older had blown out from 7 per cent in 2011-12 to 16 per cent 2017-18.

“Excessive delays and a declining clearance rate reflect a coronial system that is underperforming,” he found. Public hearings in the Dreamworld inquest finished last December and Mr McDougall had been expected to hand down his findings and recommendations earlier this year.

By the regions

2017/18

North Queensland

Total deaths: 732

Clearance rate: 78%

Backlog 24 months or more: 22%

 

Central Queensland

Total deaths: 715

Clearance rate: 99%

Backlog 24 months or more: 15%

 

Greater Brisbane

Total deaths: 3373

Clearance rate: 101%

Backlog 24 months or more: 12 %

 

Southeast Queensland

Total deaths: 863

Clearance rate: 84%

Backlog 24 months or more: 19%

A timeline set out closing submissions from counsel assisting the Coroner, veteran barrister Ken Fleming QC, by the end of February this year with responses from barristers representing the families and other parties due in March.

Mr Fleming took on a job as the head of the NT’s anti-corruption watchdog just before the inquest hearings began but at the time said he was confident he could perform both roles.

A senior member of Mr Fleming’s Dreamworld legal team is believed to have been battling illness in recent months.

Families of the victims, the State Government and Dreamworld are anxiously awaiting the inquest findings and recommendations, which could include prosecutions of theme park bosses and consultants under workplace health and safety laws.

Dreamworld Coroner James McDougall. Picture: Adam Head Dreamworld Coroner James McDougall. Picture: Adam Head

The inquest findings could also lead to multimillion-dollar lawsuits against owners Ardent Leisure.

A lawyer for one of the families said his clients were growing frustrated at the delays. “We would have liked it to have been resolved by now,” he said. “We don’t want to be critical but it’s pretty frustrating.”

Queensland Law Society president Bill Potts said the Coroner’s Office worked ‘very hard’ but was being ‘strangled’ by low funding and resources. He said grieving families of sudden death victims were being forced to wait too long for findings and recommendations which helped prevent other tragedies.

“We believe it’s a matter of urgency for the State Government to start funding the Coroner’s Office properly to allow them to … deliver their findings and recommendations in a timely manner,” he said.

Dreamworld victims (clockwise from top left) Kate Goodchild, Luke Dorsett, Roozi Araghi, and Cindy Low. Picture: Supplied Dreamworld victims (clockwise from top left) Kate Goodchild, Luke Dorsett, Roozi Araghi, and Cindy Low. Picture: Supplied

A spokesman for Attorney-General Yvette D’Ath said the State Government had provided $258,000 in extra funding to help finalise the Dreamworld inquest.

She said implementing the recommendations of the Auditor-General’s report into coronial services was ‘well underway’, with an extra $3.9 million allocated to the system over the next four years.

“Most significantly this includes the allocation of funding to establish a second coronial registrar team up until 31 December 2020 to triage all apparent natural cause deaths reported by police,” she said.

“This will reduce immediate demand pressures across agencies and ensure more timely resolution of these cases.”
 

Editorial: Editor's view: Time to address our coronial crisis

FURTHER delays to the inquest into the Dreamworld disaster that claimed four lives is a sign of a coronial system that is failing the state.

Coronial inquests are only ordered into deaths where authorities have determined there is a further need for investigation.

The inquests are an important part of our criminal justice system, providing much needed answers and closure to grieving families as well as setting out recommendations for action to prevent a repeat of the tragedy.

Inquiries must be conducted with the greatest level of scrutiny and this obviously involves considerable time and resources.

Families’ anguish at ‘strangled’ court’s logjam

But unwarranted delays to already lengthy inquiries risk betraying the families of victims and letting down all citizens.

index&td_contentlistTitle=MORE%2520IN%2520news&td_eventKey=event10&td_group_id=related-articles

Queenslanders are entitled to expect authorities will act swiftly to investigate how preventable deaths occurred and how to guard against the loss of more lives in similar circumstances.

Thorough investigations into accidents like the Dreamworld Thunder River Rapids ride are crucial to identify problems with safety and to come up with recommendations to lift standards.

The findings of the Dreamworld inquest are not expected until next year. Picture: AAP Image/Dan Peled The findings of the Dreamworld inquest are not expected until next year. Picture: AAP Image/Dan Peled

The findings could also prove central to possible prosecutions of people responsible for safety breaches, meaning delays result in a postponement of justice.

As revealed in today’s Courier Mail, more than eight months have passed after public hearings into the Dreamworld tragedy and counsel assisting the coroner is yet to make final submissions.

 

The delay will set back the opportunity for parties to respond and is likely to push back Coroner James McDougall’s findings until next year.

This means it will now likely take more than three years after the horrific deaths of Cindy Low, Kate Goodchild, her brother Luke Dorsett and his partner Roozbeh Araghi at the Gold Coast theme park before the coronial inquest is completed.

Such a delay is unacceptable. But this is not a one-off problem.

The Coroners Office is also struggling with backlogs including into high profile cases such as the 1973 Whiskey Au Go Go nightclub firebombing in Brisbane, the 1989 murder of Toowoomba teen Annette Mason, the 2014 Barrett Centre deaths and the Ravenshoe Café explosion.

Almost a year after the Queensland Audit Office warned the coronial system was “under stress”, these delays are further evidence of a crisis.

The audit report detailed a blow-out in coronial cases that took more than two years to complete from seven per cent in 2011-12 to 16 per cent 2017-18. It also warned of poor communication and support for families, a lack of accountability and inadequate case management practices.

As the audit pointed out, state coroner has reported these delays in successive annual reports since 2014—15.

“Excessive delays and a declining clearance rate are leading to a growing backlog of

coronial investigations,” Auditor-General Brendan Worrall wrote in the report.

“This indicates that Queensland’s coronial system is under stress.”

A series of delays point to a systemic problem that must be addressed by the Queensland Government.

Unnecessary delays to inquests betray the memory of the victims and do a huge disservice to the bereaved who are left behind. They also pose a risk to the entire community if it means safety improvements are put off.

 

There you go kids

Edited by Jdude95

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The old saying "if it bleeds, it leeds" . Disappointed but not surprised that one of our many trash Newspapers are running such a negative Article in an attempt to flatten what would have otherwise been one of  the most positive weeks for DW in years.

 

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And it comes out just a day after DW announces $35 million + in expenditure to be spent next year, the biggest investment in over a decade. How convenient. They were waiting for this to happen, weren't they?

Next.

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Finding are expected to be handed down on February 24th

Here's the actual article if you're paywalled or something. It's just a bunch of filler crap to pad out a full article about a date.

"The findings from an investigation into the deaths of four people at Australia's biggest theme park will be released on February 24.

Kate Goodchild, Luke Dorsett, Cindy Low and Roozbeh Araghi were killed on a ride at Dreamworld on the Gold Coast in 2016.

The four died when a raft on the Thunder River Rapids ride collided with an empty vessel.

Two children who were also on the raft were able to escape.

A month-long inquest in 2018 heard staff didn't have adequate training and some incidents at the park went unreported.

Nine News reported in January the theme park's owner, Ardent Leisure, has already paid out more than $5 million in compensation claims.

It has also been reported this figure could climb as high as $20 million."
 

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1 hour ago, Skeeta said:

I could have saved the Government a lot of money.

Final findings =  DW care more about money than guest.

*Cared

 

I think given a bit of time, with some of the current changes and the management they have things will work out better long term. I will 110% agree that at the time of the incident and a few years after this was still much the same IMO but I really do hope that the current management keep going on the path they are going on and turn the place around.

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56 minutes ago, Spotty said:

*Cared

Spon on. However does not change anything. A few questions:

1. Has Dreamworld done enough to win the trust back from the general public? (if not why) 

2. Do you think Dreamworld if prepared enough for the inquest findings? 

3. What impact will this have on Dreamworld and the theme park industry has a whole? 

  • Fountain of Improbability 1

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Someone, or even multiple people should go to jail for what happened, but sadly, it doesn't seem like they are going to hand down any personal reccomendations.

 Multiple instances of negligence and poor management contributed to their deaths. It was shown during the investigation that, based on their own processes the ride shouldnt have opened. It was shown that a few thousand dollars was put ahead of guest safety. Nobody took any accountability for what happened and the lowest denominators, the ride operators had blame heaped upon them by management and supervisors who had loads to answer for themselves.

Feel so sorry for the families that went through this, have lost loved ones, but also the staff members traumatised by the incident too. The company let everyone down and even another 20 million in civil lawsuits is not enough retribution for management all the way to the top putting personal motives and arrogancy, along with ultimately $$$$ ahead of the personal safety of their guest and staff. 

New industry standards and compliance have followed, but the laws implemented following this tragedy that allowed site operators to be held personally liable, following the deaths that occurred at eagle farm race course during the same period, should be utilised against the operators (those in charge of critical park decisions, not ride operators) and management who failed so completely here too. 

They prosecuted the guy who was to blame for providing no escape for his workers who were ultimately crushed under concrete tilt panels they were errecting, but this seems to have dragged on and on with no action from worksafe qld and its just sickening. 

Was it a wake up call? Yeah, it provided new jobs, more middle management to see compliancy in an effort to bring an entire industry up to a standard. Still leaves a bad taste in your mouth when it feels like justice hasnt been served though.

Edited by Levithian
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13 hours ago, Spotty said:

*Cared

 

I think given a bit of time, with some of the current changes and the management they have things will work out better long term. I will 110% agree that at the time of the incident and a few years after this was still much the same IMO but I really do hope that the current management keep going on the path they are going on and turn the place around.

I hope the current management can turn things around and I’m trying not to be critical but all DW are doing is reacting and not being proactive.

SV fell into DW’s lap.

New Coaster fell into DW’s lap.

WWW purchased the cheapest public pool slides they could.

The shaded “non-shaded” seating area does nothing to replace the Wipeout.

The new amphitheatre.  Never happened. GONE!

The new lazy river.  Never happened. GONE!

Wipeout.  GONE!

TOT. GONE!

V8 cars thingy. GONE!

Log Ride.???????????

DW slapping in a concrete path with no thought to it.

The list goes on, but I think the new coaster will be telling sign to see if DW have a plan or is it going to be MDMC all over again and dumped wherever it fits, without caring if it distracts from the area or looks shit.

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29 minutes ago, Jordan M. said:

The decision to close the park to park access rather than pay for a single staff member to man it strikes me as a current example of putting money over guests. (photo taken this past Saturday)

Its poor form, yes, but nobody's safety is being impacted by this - so its hardly on any comparable level.

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3 minutes ago, AlexB said:

Its poor form, yes, but nobody's safety is being impacted by this - so its hardly on any comparable level.

I was just using it as a current example of the park's lack of care despite change of management. Not implying it has any relevance to safety.

Edited by Jordan M.

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