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Md. Medical Helicopter Faced Problems in Air and on Ground Before Fatal Crash

By Mary Pat Flaherty and Jenna Johnson
Washington Post Staff Writers
Sunday, August 23, 2009; A01

Tall and imposing at nearly 300 pounds, Stephen Bunker had a personality that matched his frame. Outgoing, proud of his three grown children, eager to share his love of flying, he had been a helicopter pilot for the Maryland State Police for more than two decades, making mostly trauma trips.

At 59, he wore bifocals and was slightly hard of hearing, but once he settled at the controls, he was the picture of confidence.

Bunker had a late lunch with his wife at Red Lobster on Sept. 27 before heading to the late shift on the Trooper 2 helicopter housed at Andrews Air Force Base in Camp Springs. As the night unfolded, it looked like it would be a washout for Trooper 2. Rain and ground fog were settling across Maryland. Helicopter requests were being assessed call by call.

When a State Police dispatcher in Baltimore called shortly after 11 p.m. asking Bunker whether he could fly to the scene of a car accident in Southern Maryland, the pilot hesitated. "Maybe they will change their mind," Bunker said of the local emergency crews.

"If you tell them you're going to go, they want you to go," said Cpl. George Noyes, the dispatcher. "That's up to you, man. Can you fly it?"

Bunker studied the weather reports. Word of another helicopter completing a mission came across the radio.

"If they can do it," he told Noyes, "we can do it."

Just 56 minutes later, Bunker and State Police paramedic Mickey C. Lippy were dead, along with a patient and a volunteer medic. The lone survivor, 18-year-old Jordan Wells, was hurled from Trooper 2 with too many broken bones to count.

The cause of the crash has not been determined. But nearly a year later, a Washington Post review of previously unreleased radio communications, along with dozens of interviews, points to failings in the air and on the ground.

Trooper 2 pushed through deteriorating weather, carrying patients with low-level injuries. Federal air controllers fed Bunker hours-old weather information. A few miles short of Andrews, Bunker asked for extra guidance to get him safely in. The controller told him that she couldn't help because she wasn't trained in what he needed.

In one of the most secure airspaces in the country, a helicopter vanished and no one immediately responded.

State Police eventually launched a fractured, scattered and misguided search across three counties.

Maryland's medical helicopter system is unique in offering a statewide, taxpayer-funded service. With 11 helicopters and seven bases, it flies patients for free. A portion of car registration fees funds the program, which had not had a fatal accident since 1986. It was praised nationally as efficient and effective.

But after last year, a national panel of experts concluded that Maryland flew too many people who could have been moved by ground ambulance.

The guidelines for calling a helicopter have tightened, dramatically decreasing the number of flights.

Under the new system, Trooper 2 might never have taken off.

Small-Town Saturday

On a rainy Saturday, two friends cruised their Southern Maryland town, catching up and looking for something to do.

Jordan Wells had stayed in Waldorf to take classes at the community college after graduating from Westlake High School. Ashley Younger, 17, had gone to Frostburg State University in Western Maryland but returned for a U.S. Army promotion ceremony for her mother, Stephanie. Ashley was to pin a sergeant first class insignia on her mother's uniform.

As they drove on a four-lane road in Waldorf, Jordan lost control of her dad's blue Taurus. They crossed the median and collided with an oncoming yellow Honda carrying two teenagers.

At 10:45 p.m., calls flooded the Charles County 911 line. "I hear a bunch of people screaming and yelling and crying," one woman reported.

The first ambulance at the scene brought Samantha Smith, a volunteer emergency medical technician with Waldorf's Westlake fire station. At 17, she was the officer in charge of her crew. Minors as young as 16 can volunteer to fight fires and handle accidents in Maryland, with their parents' approval, and Smith did that, declaring a passion to help people while still in high school.

Tonya Mallard, a 38-year-old EMT who had ridden in with Smith, tended to the less-seriously injured passenger and the driver of the second car. Mallard had volunteered at the station for several months, dazzling people with her smile. She was due off at 11 p.m.

Full-time rescuers arrived next, including Jackie Martin, 26, a paramedic who had more advanced training than Smith or Mallard and been on the county payroll for nearly two years.

The full-time paramedics assessed Jordan and Ashley, running through a formal checklist: The girls had chest, neck, back and stomach pains that were not obviously life-threatening but could be from internal injuries. The trunk of Jordan's car was shoved more than 18 inches into the back seat. The nearest trauma center, at Prince George's Hospital Center, was more than 30 minutes away by ambulance.

The injured teenagers needed to go to a trauma center, the rescue crews determined.

Driving there would take two ambulances more than 45 minutes. A helicopter could take both patients and arrive in less than 10 minutes after takeoff.

A helicopter request was passed to J.R. Hayden, a Westlake assistant fire chief. Martin asked for the helicopter, Hayden said. Martin's request followed one from another member of the ground crew, according to Charles officials, who declined to name that person.

Hayden told his emergency call center that night that the two teenagers were Category D patients, the lowest category for trauma transport. The request was relayed to the State Police communications center in Baltimore.

From the center, Noyes put out a call for a pilot.

"Hey, Mr. Bunker. You guys able to fly for a mission?"

"Where?"

"Charles County. Waldorf. Where else?" Noyes said. "Those guys never want to drive to the hospital."

In the previous two years, Charles had used helicopters for 94 percent of trauma patients, among the highest rates in the state. Hayden recently bristled at any suggestion that a helicopter was called for an inappropriate reason. "We wouldn't have changed a thing," he said about the decision.

In the hangar, Bunker looked at weather reports. North of the Prince George's hospital, at College Park, clouds were thick and low-hanging at 810 feet, only 10 feet above the State Police standard for refusing a flight. But at Reagan National Airport, the sky appeared to be clearer. Audiotapes reveal that as he weighed those reports, Bunker heard radio traffic that MedStar, a helicopter service working for Washington Hospital Center, had just completed a trip in the area.

Bunker decided to fly.

He and his helicopter looked to be in good shape. The day before, Bunker had passed his annual medical checkup for his license. Trooper 2 had passed an inspection that week.

As he headed out, he left his computer open to the weather page.

With Trooper 2 launched, medic teams strapped Jordan and Ashley to backboards for the drive to the landing zone at a nearby school.

Again and again, Jordan asked for her cellphone. I need to call my dad -- he's going to be so mad I crashed the car, she said.

Ashley had called her mother, who came to the accident scene and kissed her as she was loaded into an ambulance.

An emergency worker told Stephanie Younger that if she left right then she could probably meet her daughter at the hospital, Younger recalled. With that, Younger pulled away.

Jordan and Ashley were an unusual "double lift": two patients loaded into one helicopter. But each needed monitoring.

Trooper 2, like all Maryland state helicopters, had just one paramedic onboard, not the two-person medical team used by most private and public helicopter programs. For a double lift, the State Police ask ground crews to ride along. That saves the state about $2 million a year. But the 1,200 rescue workers who piggyback do not receive flight training, equipment or insurance from the State Police.

Smith and Mallard longed to take a medevac ride, Smith recalled. But looking at the two frightened teenage girls, "Tonya had that mom thing going." Smith told her to "hold their hands and comfort them" and "go for it."

Mallard climbed aboard, and Lippy handed her a headset.

More than a half-hour after she should have been off duty, Mallard, smiling, lifted into the only helicopter ride of her life.

Smith headed back to the ambulance but reminded herself to call Mallard around breakfast time to hear about the trip.

'Trooper 2 to Tower'

Ground crews saw an occasional star piercing the clouds as Trooper 2 rose at 11:37 p.m. for an eight-minute trip to the Prince George's hospital helipad.

It was fogged in.

Jordan listened as Mallard leaned in to say that they couldn't make it to the hospital and were trying another route.

On an increasingly uncertain night, Trooper 2 turned and headed toward an airport that crew members knew well: their home base at Andrews.

Inside a Federal Aviation Administration center in Fauquier County, Kendall Young, a controller who had been with the FAA for 29 years, was on the midnight shift and walked away from his station without a headset.

Trooper 2 twice called for a clearance. More than a minute passed as Trooper 2 waited.

When Young finally responded, Bunker asked to be lined up for Andrews. He estimated it would take 10 minutes to arrive. "I've got patients onboard," he said. "I'm trying to get them down."

Young passed along the weather: seven miles' visibility with broken cloud cover at 1,800 feet.

But the skies looked nothing like that.

The report was five hours old, stalled by a failed switch at an Air Force base in Nebraska that relays weather information to nonmilitary sites. The information is time-stamped when it appears on controllers' consoles, yet the lag had gone unreported by at least 200 sites nationally and took 18 hours to correct.

A weather report 15 minutes later at Andrews put visibility at four miles, with mist and scattered clouds settled in at a mere 500 feet.

Bunker asked Young to provide instrument headings for his approach to Andrews, which would guide him more precisely, particularly if visibility were dropping. Bunker had flown from Waldorf under visual flight rules, meaning it was clear enough to see the ground. Most of his 5,200 flight hours were that type of flying.

Bunker's pilot log shows that he had clocked only about eight hours of instrument approaches in the previous two years, most of it in simulators, but was "above average" at it.

Bunker -- like all Maryland State Police pilots -- also was flying without night-vision goggles, which enhance sight in the dark but do not help see through clouds or fog. His helicopter also did not have a terrain-awareness system to alert him if he got too close to the ground or an obstruction. The troopers' chief pilot told federal investigators that the terrain system "would have helped" Trooper 2.

When Bunker was close to Andrews, he called for even more direct help, asking a controller to call out turn-by-turn and altitude directions for his approach. He spoke to Teal Hyman, a 23-year veteran of the FAA who was working alone in the Andrews tower.

Hyman, like most of the Andrews controllers, was not up to date on how to provide the help he needed.

At three minutes before midnight, Hyman replied: "I don't have anybody to do that, um, I'm not current on that. I can't do it."

There was silence on the other end.

Trooper 2 was a little more than two miles north of Andrews, aiming for Runway 19R, when Hyman saw the helicopter disappear from her radar. She did not radio to Bunker.

Inside the control tower, it was sweltering because of a recurring heating problem, and the wall of windows was so thick with condensation that Hyman couldn't peer out through the curtain of water.

Inside Trooper 2, Bunker was battling as he dropped down in the dark.

Mallard let go of Jordan's hand, and Mallard and Lippy desperately grabbed for any hold as Jordan felt the helicopter shear the tops of trees, rocking violently.

It was 11:58 p.m.

'Not Sure What's Going On'

Paul Tackish, assistant fire chief for Andrews, leaned into the soupy night.

Prince George's County communications had called earlier to say two ambulances were coming on base for a pickup from Trooper 2.

The ambulances arrived shortly after midnight.

After 29 years at Andrews, Tackish knew the flight crews' behavior and wondered why Trooper 2 wasn't "squawking anything." He called Hyman, who told him several times that she had lost the helicopter on radar.

Picking up her radio, she called out: "Trooper 2 ground. Trooper 2, you on tower?"

"I'm not sure what's going on," she told Tackish before asking him to search around the base to see whether Trooper 2 had landed. She did not activate a crash plan.

Tackish, 51, squelched his radios and drove with his window down, straining to hear the distinctive sound of the Maryland helicopter.

The only swoosh was from traffic on the Capital Beltway. "It was eerie," he recalled.

No helicopter at the hangar, Tackish soon told the tower. No one in the darkened Trooper 2 office.

At 12:08 a.m., Tackish called the nearby State Police barracks in Forestville -- the first alert to State Police that something was wrong: "Hey, have you guys got any radio contact with Trooper 2? . . . Andrews Tower lost them on radar."

A barracks supervisor called Baltimore and reached Noyes.

"Do you have Trooper 2 on anything?"

Noyes began to explain the car accident, but the supervisor abruptly interrupted: "Where is Trooper 2 now?"

"They're right at Andrews," Noyes said.

The supervisor pressed. "Are you sure that everything is okay?"

Another Baltimore dispatcher called the hangar: one ring, two, five and ultimately 10 unanswered rings. Calls to crew cellphones went to voice mail.

Separately, Hyman, at Andrews, called Young, the FAA controller in Fauquier, asking where Trooper 2 had been coming from. "He landed on one nine right," said Young, whose duties included tracking aircraft to the runway.

"He never made it," Hyman said. "You think he would have said something. He never said anything."

Controllers at National, the Fauquier site and Andrews had watched Trooper 2 at some point in the night. So, too, had the Baltimore center, where Noyes, as the State Police duty officer, and two employees of Maryland's statewide EMS agency sat in low light before computers and a wall of monitors.

From liftoff to touchdown, the duty officer's main job is to know "the whereabouts of helicopters and crew members at all times," according to the operation manual for the center.

Hyman, Young and Noyes declined to be interviewed for this report. Hyman told investigators that nothing in Bunker's voice indicated he was in trouble.

The State Police center in Baltimore has a constant-monitoring system. But police officials have had to warn communications staff to keep the alarms on and loud enough to be heard throughout the center, records provided to federal investigators show. And in 2005, a duty officer at the center was removed after a surprise drill in which a State Police helicopter appeared to go missing -- and no one noticed.

Even on normal days, the tracking program lacked pinpoint accuracy; on a bad night, it bolstered faulty assumptions.

On monitors in the front of a control room, icons shaped like helicopters floated across a digital state map. When a flight stopped, the icons were designed to halt, flash and sound an alarm.

But the cues were the same whether a helicopter was at its expected destination, was stopped mid-flight or had crashed, state officials said. And the icons were so out of scale with the map that each covered a seven-square-mile area. The evening of the Trooper 2 crash, the system had no feature for drilling down to street level.

Maryland pilots drawing close to a landing normally radio in that their landing gear is down, said Andrew J. Pilarski, civilian director of the Baltimore center. Bunker didn't make that call, Pilarski said, "and that should have set something off here. But it didn't." The "complacency" was part of an overarching "inability" to accept that something terrible had happened, Sgt. R.F. Adams, the State Police official in charge at Baltimore, told accident investigators.

Panic was growing inside Stephanie Younger's car as she and her family called police agencies trying to find Ashley. At the barracks in Forestville, a state trooper picked up a line at 1:03 a.m.

"We are trying to find out where someone was medevaced to. . . . We were told that she was taken to P.G. We called P.G. She is not there. . . . We were told she's at Andrews, and she's not there."

The trooper muffled the phone as he asked, "What do you want me to tell this mother, Sarge?"

He came back on the line: "At this time, we are unable to ascertain where the Trooper landed at, and, I mean, we are trying to find that out ourselves."

"So you don't know where she is?"

A pause.

"Not at this time, ma'am."

The Search

Throughout the night, a State Police helicopter team based in Montgomery County had listened to the Trooper 2 radio traffic.

At 12:25 a.m., as Trooper 8 pilot Scott Russell read a book, Baltimore asked whether he could get up in the air. Trooper 2 was missing.

Along with State Police paramedic John Preston, Russell scrambled, lifting from their base at Norwood. Within 10 minutes, a wall of fog drove them back.

Russell was certain that his colleagues had crashed, he told federal investigators, because helicopters just don't go missing for 25 minutes.

Russell and Preston asked Baltimore for the last known latitude and longitude for the missing helicopter and typed the coordinates into Google Earth. Out came turn-by-turn directions to Walker Mill Regional Park in District Heights.

Baltimore had provided the coordinates as raw numbers, without specifying that they were in the older-style mapping language of degrees, minutes and seconds: 38 52 17, -76 52 26. Russell and Preston understood what Baltimore was relaying, but other emergency teams did not. Noyes would tell crash investigators that he failed to understand the need to be more explicit about the numbers. As a result, Prince George's dispatchers and others mapped the coordinates differently, rendering them as decimal degrees, such as those used by global positioning systems: 38.5217, -76.5226.

Viewed that way, the numbers plotted to the coastline in Calvert County, 40 miles southeast of where Trooper 2 last was flying -- and searchers from several agencies tracked over Calvert in one of the night's misguided hunts.

Instructions to searchers came from an array of communications centers, with many calls made on cellphones rather than radio channels to tamp down public disclosure of the search. Other updates went out over channels only troopers can monitor, leaving out many county officers and fire crews.

In Prince George's, the search rolled through parking lots, fields and construction sites -- any open area where a helicopter might have landed. FedEx Field was scoured over and over. County officers searched the grounds of a school and reported that Trooper 2 was not there. Minutes later, state troopers arrived and searched the same place.

Listening from his truck outside the fire station at Andrews, Tackish "kept thinking there has got to be a playbook for this stuff, why isn't this running better?"

It would take 90 minutes from Tackish's call to State Police before the Baltimore center brought out the playbook and launched the "mishap plan" that by policy was supposed to kick in and coordinate the response the moment a State Police helicopter goes missing.

Trooper 2 Is Found

On the Beltway, Russell and Preston hit close to 100 mph racing to Walker Mill Regional Park. They arrived at 1:10 a.m. and found county police there, drawn by the possibility that Trooper 2 might have landed in the 100-space parking lot.

Russell and Preston stuck a receiver out a car window, trying to pick up the chirp of a helicopter's distress signal. Nothing.

They were debating the daunting task of searching the 470 acres in the pitch-black night when they got a lead.

Prince George's thought it had located a crew member's cellphone.

Radios crackled "for any units that can respond" and gave an address in Capitol Heights. The wireless company, a dispatcher radioed, had called "in reference to one of the subjects' cellphones."

The crowd at the park rushed two miles to the spot and found itself at the base of a cell tower in a shopping center lot. The cellphone company had been clear that it could focus the search only to a three- to five-mile radius around a tower, but that limitation got lost as information was passed down the line and among police.

Frustrated, Russell called Hyman, the controller at Andrews, who gave him more information about the exact runway and Trooper 2's approach.

Preston pulled a county atlas from his car trunk and opened it to Andrews. Russell took a pencil, drew a straight line from the center of Runway 19R and stopped two miles out.

His pencil line was resting in the southern part of Walker Mill Regional Park.

Russell and Preston drove off in their cruiser, trailed by a caravan of officers. Within minutes, Russell and Preston spotted a park entrance off a lane. They made a U-turn, losing the other officers, who barreled toward another gate.

Russell and Preston parked and headed on foot down a main path.

Within a few yards, Russell hollered: "You smell that? That's fuel. They're here."

A few steps more and a scream set them racing.

Every step took them across more debris. A white helmet with "Bunker" written on the back. A helicopter door. A cellphone, working but backlogged with missed calls.

Squarely on the trail, crushed under a fallen tree, sat the crumpled helicopter. Beside the wreckage: Jordan, slick with jet fuel, her legs a mash of broken bones and exposed muscle.

Two hours after Trooper 2 went missing, Russell radioed Baltimore:

"I'm with the patient right now. She survived. I think we've lost the pilot and medic."

Bunker and Lippy were dead inside. Preston and Russell didn't know then to look for Ashley and Mallard. In the chaos of the night, the Baltimore dispatchers had not alerted ground crews that more than three people were onboard.

Jordan was hosed down.

She clutched Preston's arm and pleaded, "I don't want to go in a helicopter."

He rode with her in an ambulance to the Prince George's trauma unit, where she was wheeled past Ashley's mother.

"Where is Ashley?" Stephanie Younger screamed.

A hospital worker tried to steer her into the family waiting area. Younger refused to move. "I knew what that meant, and I thought if I could stay out of it, things would work out okay."

In the hallway, she overheard hospital staff talking: helicopter crash, one made it.

Watching her anguish, Preston eventually got permission to tell her what she already knew: one survivor.

Jordan's parents were notified about 4 a.m. It took days before they pieced together the story, with the help of Russell and Preston.

Kenneth Mallard, Tonya's husband, had been waiting for hours at the Westlake fire station, asking where his wife was. On the helicopter, he was told. The troopers would fly her back soon.

As radio newscasts began reporting about a missing helicopter, dozens of volunteers gathered at the station. They knew that Mallard had gone onboard, even if the search teams did not.

Eventually, Baltimore tracked down Hayden, assistant fire chief of the Westlake station. Had an extra EMT joined the trooper crew? Who was she? Did he know her cellphone number?

Just after 2 a.m., Hayden heard again from Baltimore. Mallard was in his office, leaning against a file cabinet.

Hayden hesitated, keeping the receiver pressed to his ear to buy himself some time.

"You can't lie to this guy," Hayden recalled thinking. "You have to tell him the truth, no matter how hard it is."

They had found Tonya's body.

Hayden watched Mallard run from the station and found him at a school, sobbing. Mallard thrust his phone into Hayden's hands and told the chief to break the news to some of Tonya's family.

Epilogue

Within hours of the crash, state EMS officials descended on the Westlake station to scrutinize decisions made that night. Within a week, Robert R. Bass, executive director of Maryland's statewide EMS system, said the patients "met the criteria for transport to a trauma center" by helicopter.

Yet nine days after the crash, the state EMS board tightened guidelines for when low-level trauma patients, such as Ashley and Jordan, should be flown. Now ground responders must consult with a trauma doctor before flying Category C and D patients and are more hesitant to use the helicopters.

The effect was immediate. The number of monthly trips dropped by half and have continued at that diminished rate. Instead of 300 or 400 flights a month, State Police are flying about 200 or fewer.

At the Baltimore center, known as Syscom, there have been unannounced drills this year in which helicopters appeared to vanish. This time, employees noticed and launched emergency procedures, which now are detailed on a card at each workstation, said Pilarski, the operations manager. "We are not casually overseeing things anymore," he said.

A software update includes a zoom-in for street locations, but there still is no unique alarm for lost contact.

The State Police reviewed their efforts and concluded that the search teams "did an amazing job given the circumstances," said Maj. A.J. McAndrew, commander of State Police aviation. "There is some aircraft that takes days to find," he said in an interview. "It only took us two hours."

This spring, State Police aggressively lobbied for, and received, $52.5 million to begin purchasing top-of-the-line helicopters. The agency also received $635,000 for safety upgrades to the current fleet.

Troopers continue to pluck ground crews for trips, bringing them onboard without helmets, fire-resistant flight suits or flight training. State Police said it would be impractical to stock the extra gear. "We have no means of carrying all sizes of helmets onboard the aircraft," McAndrew said.

It is a practice that national experts said is "less than ideal" for care and safety. The practice also has left Mallard's husband and two sons in legal limbo over death benefits.

Mallard was not a State Police employee when she got onboard, State Police spokeswoman Elena Russo said, and "had no coverage at all through us." Mallard's husband has hired a lawyer, and attorneys for the state are reviewing the "complicated situation," Russo said.

Bass says he will continue to allow ground providers on the helicopters: "It's not a common practice, but we're not a common system."

Kenneth Mallard has declined to speak publicly about the crash but in April attended a ceremony to dedicate an ambulance at Westlake in his wife's memory.

George Noyes was transferred from the Baltimore center in October to the aviation material management division, where he stocked helicopter parts. This month, he moved to a barracks in Howard County.

In a brief telephone conversation, he referred a reporter to a State Police spokesman, who in turn declined interviews of any State Police troopers, citing investigations and possible lawsuits. Asked why he had thought Trooper 2 had safely landed, Noyes said before he hung up, "Thank you, ma'am, but I have nothing to say."

Kendall Young and Teal Hyman remain controllers at their same posts. They referred all questions to their union representatives.

Most of the "lessons learned" cited by FAA supervisors after the crash were minor lapses, said Brendan Connolly, a union representative.

"No reasonable person would expect one person at Andrews to watch the scope as [Trooper 2] approaches," Connolly said. "There was nothing going on to indicate constant monitoring was needed."

Jackie Martin, the professional paramedic at the scene, provided a statement through a Charles County spokesman: "I remain committed to performing my job in a professional manner and providing quality care for my patients. The Sept. 27, 2008, incident has only reinforced my commitment."

The week after the crash, four funerals were held in two days.

Mickey Lippy's widow held their baby daughter, wrapped in a fluffy blanket, and watched her husband's flag-draped coffin loaded onto a yellow fire engine. Lippy was 34 and had been a State Police flight paramedic for only 18 months.

In April, Bunker's son, Scott, accepted an award posthumously for his father.

Ashley Younger, runner and softball player, maker of scrapbooks in which she tracked her considerable ambitions on purple sheets of paper, is buried in a family plot in Spartanburg, S.C. Her mother bypassed the ceremony that went with her promotion to sergeant first class, "because it just wasn't ever going to be the same."

Jordan Wells, a competitive swimmer and marathon text-messager, has had more than 20 surgeries, including the amputation of her right leg. Now 19, she has slowly relearned to walk and swim and is resuming college this fall.

Scott Russell has told Jordan that her survival helps him cope with the fatal crash.

John Preston named his newborn daughter Jordan.

Both men still fly with the State Police.

And as memorial services for the Trooper 2 crew have stretched into this year, the Maryland State Police continue to fly overhead in the missing man formation, dipping the front end of a helicopter and genuflecting to the crowds below.

Staff writer Gilbert M. Gaul contributed to this report.

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