013 Accident and Incident Reporting and Investigation
013 Accident and Incident Reporting and Investigation
013 Accident and Incident Reporting and Investigation
RECORD OF AMENDMENTS
Page
13-1 2 21 January 2013
CONTENTS
FOREWORD
This Philippine Civil Aviation Regulation (PCAR) Part 13 s-2012, titled: Aircraft Accident
and Incident Investigation, contains amendments to implement the new provisions of Standards
and Recommended Practices (SARPs) of Annex 13 under Article 26 of ICAO (Chicago) Convention,
and the Corrective Actions Proposed (CAPs) per USOAP Audit Findings on Accident Investigation
Group (AIG) conducted to CAAP in CY-2009 which were duly considered and accepted by ICAO.
This is the first revision from the original Republic of the Philippines Civil Aviation
Regulation (CAR) Part 13 initially developed by CAAP in CY-2009, titled: Aircraft Accident and
Incident Investigation.
SUBPART A: GENERAL
13.001 APPLICABILITY
(a) This Part contains requirements of the Republic of the Philippines pertaining to
(1) Personal responsibility for initial notification and later reporting of aircraft
incidents and accidents and certain other occurrences in the operation of aircraft,
wherever they occur, when they involve civil aircraft registered or operated by
Republic of the Philippines; when they involve certain public aircraft, as specified
in this part, wherever they occur; and when they involve foreign civil aircraft
where the events occur in Republic of the Philippines.
(2) Preservation of aircraft wreckage, mail, cargo, and re cords involving all civil and
certain public aircraft incidents and accidents, as specified in this part, in Republic of
the Philippines.
(3) Conformance to the international Standards for accident and incident reporting.
(b) This Part is applicable to the
(1) Organizations and operators that operate aircraft or provide services associated
with the safe operation of aircraft; and
(2) All Government agencies necessary to ensure the timely and correct investigation
and reporting of accidents.
(c) This Part is also applicable to
(1) All persons associated with the safe operations of aircraft;
(2) The general public where they have information pertinent to an accident or
incident investigation; and
(3) The technical persons that participate in the investigations.
(13) Flight recorder. means any type of recorder installed in the aircraft for the
purpose of complementing accident or incident investigation;
Note. Refer to Annex 6 ICAO, Parts I, II, III, for specifications relating to flight
recorders.
(14) Flying display. means a civilian organized event (including any rehearsal for
such event) which
(i) consists, wholly or partly, of an exhibition of flying of any civil or military
aircraft; and
(ii) takes place at an aerodrome or premises other than a naval, military or air
force aerodrome or premises;
(15) Government. The Government of the Philippines.
(16) Incident. An occurrence, other than an accident, associated with the operation
of an aircraft which affects or could affect the safety of such operation;
Note 1: The Mandatory Reportable Incidents are listed in IS 13.175 1, 2, & 3.
Note 2: The types of incidents which are of main interest to the ICAO for
accident prevention studies are listed in IS 13.030. (List of Examples of Serious
Incidents).
(17) Investigation. A process conducted for the purpose of accident prevention
which includes the gathering and analysis of information, the drawing of
conclusions, including the determination of causes and/or contributing factors
and, when appropriate, the making of safety recommendations.
(18) Investigator. means an Investigator of Accidents appointed under paragraph
13.100(b);
(19) Investigator-in-charge. means a person designated by the Chairman on the
basis of his or her qualifications as such under paragraph 13.100(d) and
charged with the responsibility for the organization, conduct and control of an
investigation;
Note. Nothing in the above definition is intended to preclude the functions of an
investigator-in-charge being assigned to a commission or other body.
(20) Maximum mass. Maximum certificated take-off mass.
(21) Military aircraft. means an aircraft
(i) belonging to the Republic of the Philippines Armed forces; or
(ii) belonging to any of the naval, military or air forces of any State;
(22) Non-contracting state. means any State which is not a party to the Chicago
Convention;
(23) Operator. means a person, organization or enterprise engaged in or offering to
engage in aircraft operation;
(24) Owner. in relation to an aircraft which is registered, means the registered owner
of the aircraft;
(25) Pilot-in-command. in relation to an aircraft, means a person who for the time
being is in charge of the piloting of the aircraft without being under the direction
of any other pilot in the aircraft;
(26) Preliminary Report. means the communication used for the prompt
dissemination of data obtained during the early stages of the investigation;
(27) Republic of the Philippines aircraft. means an aircraft that is registered in the
Republic of the Philippines;
(28) Republic of the Philippines operator. means an operator whose principal
place of business is located in or permanent residence is in Republic of the
Philippines;
(29) Safety recommendation. A proposal of an accident investigation authority
based on information derived from an investigation, made with the intention of
preventing accidents or incidents and which in no case has the purpose of
creating a presumption of blame or liability for an accident or incident. In
addition to safety recommendations arising from accident and incident
investigations, safety recommendations may result from diverse sources,
including safety studies;
(30) Serious incident. An incident involving circumstances indicating that there was
a high probability of an accident and is associated with the operation of an
aircraft which, in the case of a manned aircraft, takes place between the time
any person boards the aircraft with the intention of flight until such time as all
such persons have disembarked, or in the case of an unmanned aircraft, takes
place between the time the aircraft is ready to move with the purpose of flight
until such time it comes to rest at the end of the flight and the primary propulsion
system is shut down.
Note 1: The difference between an accident and a serious incident lies only in
the result.
Note 2: The types of incidents which are of main interest to the ICAO for
accident prevention studies are listed in ICAO Appendix 4. (List of Examples of
Serious Incidents.
(31) Serious injury. in relation to a person. An injury which is sustained by a person
in an accident and which:
(i) requires hospitalization for a period of more than 48 hours, commencing
within 7 days from the date the injury was received; or
(ii) results in a fracture of any bone (except simple fracture of fingers, toes or
the nose); or
(iii) involves lacerations which cause severe hemorrhage, nerve, muscle or
tendon damage; or
(iv) involves injury to any internal organ; or
(v) involves second or third degree burns or any burns affecting more than 5%
of the surface of the body; or
(vi) involves verified exposure to infectious substances or injurious radiation;
(32) State aircraft. An aircraft used only on behalf of the Government (except for
commercial purposes) or exclusively leased for at least 90 continuous days.
(33) State of design. means the State having jurisdiction over the organization
responsible for the type design of the aircraft;
(34) State of manufacture. means the State having jurisdiction over the organization
responsible for the final assembly of the aircraft;
(35) State of occurrence. means the State in whose territory an accident or incident
occurs;
(36) State of the operator. means the State in which the operators principal place of
business is located or, if there is no such place of business, the operators
permanent residence;
(37) State of registry. means the State on whose register the aircraft is entered.
Note: In the case of the registration of aircraft of an international operating
agency or other than a national basis, the States constituting the agency are
jointly and severally bound to assume the obligations which, under the Chicago
Convention, attach to a State of Registry. Refer to the Council Resolution of 14
December 1967 on Nationality and Registration of Aircraft Operated by
International Operating Agencies which can be found in Policy and Guidance
Material on the Economic Regulation of International Air Transport (Doc 9587).
(38) State Safety Program. An integrated set of regulations and activities aimed at
improving safety.
(39) Substantial damage. Damage or failure which adversely affects the structural
strength, performance, or flight characteristics of the aircraft, and which would
normally require major repair or replacement of the affected component.
Note: Engine failure or damage limited to an engine if only one engine fails or is
damaged, bent failings or cowling, dented skin, small punctured holes in the skin
or fabric, ground damage to rotor or propeller blades, and damage to landing
gear, wheels, tires, flaps, engine accessories, brakes, or wingtips are not
considered "substantial damage" for the purpose of this Part.
(c) The accident investigation authority shall have independence in the conduct of the
investigation and have unrestricted authority over its conduct, consistent with the
provisions of ICAO Annex 13. The investigation shall include
(1) the gathering, recording and analysis of all relevant information on the accident or
incident;
(2) if appropriate, the issuance of safety recommendations;
(3) if possible, the determination of the causes and/or contributing factors; and
(4) the completion of the Final Report.
(8) the number of crew members and passengers; aboard killed and seriously
injured; others, killed and seriously injured;
(9) a description of the accident or incident and the extent of damage to the aircraft
so far as is known;
(10) an indication to what extent the investigation will be conducted or is proposed to
be delegated by the State of Occurrence.
(11) the physical characteristics of the area in which the accident or incident occurred
and any indication of access difficulties or special requirements to reach the site;
(12) the identification of the originating authority and means to contact the
Investigator-in-Charge and the accident investigation authority of the State of
Occurrence at any time; and
(13) the presence and description of dangerous goods, explosives, radioactive
materials or other dangerous articles on board the aircraft.
(b) Where an incident, other than a serious incident as listed in IS 175-1, IS 13.175-2, IS
13.175-3 (Mandatory reportable incidents), occurs
(1) in Republic of the Philippines; or
(2) outside Republic of the Philippines involving a Republic of the Philippines
registered aircraft or an aircraft operated by a Republic of the Philippines
operator/AOC holder, the owner, operator, pilot-in-command or hirer of the
aircraft shall notify the Authority/Chairman using the fastest means available and
if so required by notice in writing by the Chairman, send to the Chairman, such
information as is in his possession or control with respect to the incident in such
form and at such time as may be specified.
attach a statement setting forth the facts, conditions, and circumstances relating to
the accident or incident as they appear to him.
(b) If the crewmember is incapacitated, he shall submit the statement as soon as he is
physically able.
(1) remove the goods or passenger baggage from the aircraft subject to the
supervision of a police officer not below the rank of inspector of police; and
(2) release the goods or passenger baggage from the custody of the Chairman or
the investigator-in-charge subject to clearance by or with the consent of an officer
of customs, if the aircraft has come from a place outside Republic of the
Philippines.
(d) The Chairman may designate himself or any Investigator as investigator-in-charge for
the purpose of carrying out an investigation referred to in 13.095 paragraph (a) or (b).
(e) Without prejudice to the power of an investigator-in-charge to seek such advice or
assistance as he may consider necessary in carrying out an investigation, the
Chairman may appoint any person as an adviser to assist an investigator-in-charge
in a particular investigation carried out under this Part.
(f) In any case where the Chairman is of the view that more than one Investigator is
needed to carry out an investigation, he may designate one or more Investigators,
one of whom shall be designated Deputy investigator-in-charge, to assist the
investigator-in-charge.
(iii) make copies of and retain any such books, papers, documents and articles
until the completion of the investigation;
(2) take statements from all such persons as he thinks fit and require any such
person to make and sign a declaration of the truth of the statement made by him;
(3) on production, if required, of his credentials, enter and inspect any place, building
or aircraft the entry or inspection whereof appears to him to be necessary for the
purposes of the investigation;
(4) on production, if required, of his credentials, remove, test, take measures for the
preservation of or otherwise deal with any aircraft other than an aircraft involved
in the accident or incident where it appears to him to be necessary for the
purposes of the investigation;
(5) take possession of, examine, remove, test or take measures for the preservation
of any object or evidence as he considers necessary for the purposes of the
investigation;
(6) require an immediate listing of evidence and removal of debris or components for
examination or analysis purposes;
(7) require the readout of the flight recorders;
(8) in the case of a fatal accident, require a complete autopsy examination of fatally
injured flight crew, and, subject to the particular circumstances, of fatally injured
passengers and cabin crew members, by a pathologist, preferably experienced in
the investigation of aircraft accidents, provided provisions of local law protecting
religious beliefs with respect to autopsies shall be observed;
(9) where appropriate, require the medical and toxicological examination of the crew,
passengers and aviation personnel involved in the accident or incident by a
medical practitioner, and if a medical practitioner experienced in the investigation
of aircraft accidents is available, by such medical practitioner;
(10) require the crew, passengers and aviation personnel involved in the accident or
incident to undergo such other tests (including a breathalyzer test) as he
considers necessary for the purposes of the investigation;
(11) ensure that the autopsy and medical examinations shall be expeditious and
complete.
(12) seek such advice or assistance as he considers necessary for the purposes of
the investigation including professional or expert opinions on technical and
medical matters related to the investigation.
(d) Every person summoned as a witness in accordance with paragraph (c) shall be
allowed such expenses as the Authority may, from time to time, determine.
(e) Without prejudice to the generality of sub-paragraph (c)(12), the investigator-in-
charge may request another Contracting State to provide such information, facilities
or experts as he may consider necessary for the purposes of an investigation.
(2) any adviser appointed by the Chairman under paragraph 13.100(e) to assist the
investigator-in-charge, but only to the extent specified by the Chairman.
(b) The investigator-in-charge shall, where an investigation is carried out into an incident
involving an aircraft of a maximum certificated take-off mass of more than 5,700 kg,
send to the International Civil Aviation Organization after the completion of the
investigation into the incident
(1) the Final Report of the incident, if the Final Report has been released; and
(2) the Incident Data Report.
(c) The Final Report of an investigation shall state the sole objective of the investigation
as set out in paragraph b.
(d) The Final Report shall be forwarded by the Chairman or investigator-in-charge to the
Authority for Notation and subsequent submission to the Civil Aeronautics Board for
final consideration before its dissemination to any contracting State under this Part or
its subsequent publication.
(e) In this Part, Accident Data Report and Incident Data Report mean the Accident
Data Report and Incident Data Report referred to in ICAO Annex 13.
(2) address, when appropriate, any safety recommendation arising out of the
investigation to the accident investigation authorities of the other Contracting
States concerned and where International Civil Aviation Organization documents
are involved, to the International Civil Aviation Organization.
(b) The Chairman shall cause to be communicated to such relevant person or authority
in Republic of the Philippines as he may determine
(1) the recommendation of preventive action or safety recommendation referred to in
sub-paragraph (a)(1); or
(2) any recommendation of preventive action or safety recommendation forwarded to
the Authority or Chairman by another Contracting State.
(c) Any person or authority in Republic of the Philippines to whom or to which a
recommendation for preventive action or safety recommendation is communicated
under sub-paragraph (b)(2) shall, without delay
(1) take that recommendation into consideration and, where appropriate, act upon it;
(2) send to the Chairman
(i) full details of the measures, if any, he or it has taken or proposes to take to
implement the recommendation and, if such measures are to be
implemented, the schedule for the implementation; or
(ii) a full explanation as to why no measures will be taken to implement the
recommendation; and
(3) give notice to the Chairman if at any time any information provided to the
Chairman under sub-paragraph (b) concerning the measures it proposes to take
or the schedule for securing the implementation of the recommendation is
rendered inaccurate by any change of circumstances.
(d) A recommendation for preventive action or safety recommendation shall, in no case,
create a presumption of liability for an accident or incident.
(e) Where any recommendation for preventive action or safety recommendation has
been forwarded to the Authority or the Chairman by another Contracting State, the
Chairman shall notify the State of the preventive action taken or under consideration
or the reasons as to why no action will be taken.
any occurrence of which he has positive knowledge, even though this may not be
first hand, unless he has good reason to believe that appropriate details of the
occurrence have already been, or will be, reported by someone else.
(e) A report should also be submitted on any occurrence which involves a defective
condition or unsatisfactory behavior or procedure which did not immediately
endanger the aircraft but which, if allowed to continue uncorrected, or if repeated in
different, but likely, circumstances, would create a hazard to aircraft safety.
SUBPART I: MISCELLANEOUS
13.220 NON-DISCLOSURE OF RECORDS
(a) Subject to paragraph (b), no person shall disclose or make available to any other
person any of the following records for any purpose other than an investigation
carried out under this Part unless the High Court determines that the benefits
resulting from disclosure outweighs the adverse domestic and international impact
the disclosure may have on that or any future investigation:
(1) any statement taken from persons in the course of an investigation;
(2) any communication between persons having been involved in the operation of
the aircraft;
(3) any medical or private information regarding persons involved in the accident or
incident;
(4) any cockpit voice recording and transcript from such recording;
(5) any ATS recording and transcript from such recording;
(6) any opinion expressed in the analysis of information, including flight recorder
information.
(b) A record referred to in paragraph (a) shall be included in a Final Report or its
appendices or in any other report only when it is relevant to the analysis of the
accident or incident.
(c) Such parts of the record which are not relevant to the analysis of the accident or
incident shall not be included in the Final Report.
Sec 13.110(b)&(c), shall be borne by and be recoverable from the owner or operator
of the aircraft or both.
(c) The expenses incurred in moving or removing such aircraft involved in
accident/incident as ordered by the Chairman or the investigator-in-charge under Sec
13.080, shall be borne by the owner, operator or hirer of the aircraft or all of them.
Likewise, where the aircraft is removed from the accident site to an accessible place
as ordered by the Chairman or the investigator-in-charge under Sec 13.080 in the
absence of the owner, operator or hirer of the aircraft, the expenses incurred shall be
recoverable from the owner, operator or hirer or from all of them.
13.235 OFFENCES
(a) Any person mentioned in Section 13.035 who contravenes Section 13.025, Sec
13.065, Sec 13.160, Sec 13.175, Sec 13.220,& Sec 13.225) shall be guilty of an
offence and shall be liable on conviction to a fine ranging from Fifty thousand pesos
(Php50,000.00) but not exceeding Two hundred thousand pesos (Php200,000.00) or
equivalent penalty as may be prescribed by the Authority or to imprisonment for a
term not exceeding three (3) years or to all.
13.250.1.1 EFFECTIVITY
(a) This Philippine Civil Aviation Regulation (PCAR) Part 13 takes effect upon its
approval by the CAAP Board.
IMPLEMENTING
STANDARDS
(IS)
I S 13.030
LIST OF EXAMPLES OF SERIOUS INCIDENTS
The incidents listed are typical examples of incidents that are likely to be serious
incidents. The list is not exhaustive and only serves as guidance to the definition of
serious incidents.
1. A near collision requiring an avoidance maneuver to avoid a collision or an unsafe
situation or when an avoidance action would have been appropriate.
2. A controlled flight into terrain only marginally avoided.
3. An aborted take-off on a closed or engaged runway, on a taxiway (excluding
authorized operations by helicopters) or unassigned runway.
4. A take-off from a closed or engaged runway, from a taxiway (excluding authorized
operations by helicopters) or unassigned runway.
5. A landing or an attempted landing on a closed or engaged runway, on a taxiway
(excluding authorized operations by helicopters) or unassigned runway.
6. A gross failure to achieve predicted performance during take-off or initial climb.
7. Fire and smoke in the passenger compartment, in the cargo compartment or engine
fire, even though such a fire was extinguished by the use of extinguishing agents.
8. An event requiring the emergency use of oxygen by the flight crew.
9. An aircraft structural failure or engine disintegration, including uncontained turbine
engine failure, not classified as an accident.
10. Multiple malfunctions of one or more aircraft systems seriously affecting the
operation of the aircraft.
11. Flight crew incapacitation in flight.
12. Fuel quantity requiring the declaration of an emergency by the pilot.
13. Runway incursions classified with severity A. (per Manual on the Prevention of
Runway Incursions (Document 9870)
14. A take-off or landing incident such as undershooting, overrunning or running off the
side of runways.
15. A system failure, weather phenomenon, an operation outside the approved flight
envelope or other occurrence which could have caused difficulties controlling the
aircraft.
16. Failures of more than one system in a redundancy system mandatory for flight
guidance and navigation.
17. Aircraft collide in flight.
18. Damage to property, other than the aircraft, estimated to exceed $25,000 for repair
(including materials and labor) or fair market value in the event of total loss,
whichever is less.
19. For large multiengine aircraft (more than 5,700 kg maximum takeoff weight);
(a) In-flight failure of electrical systems which requires the sustained use of an
emergency bus powered by a backup source such as a battery, auxiliary power
unit, or air driven generator to retain flight control or essential instruments;
(b) In-flight failure of hydraulic systems that results in sustained reliance on the sole
I S 13.175-1
MANDATORY INCIDENT REPORTS: AIRCRAFT FLIGHT OPERATIONS
(a) Occurrences during operations of an aircraft that involve
(1) Avoidance maneuvers
(i) Risk of collision with another aircraft, terrain or other object or an unsafe
situation when avoidance action would have been appropriate;
(ii) An avoidance maneuver required to avoid a collision with another aircraft,
terrain or other object;
(iii) An avoidance maneuver to avoid other unsafe situations.
(2) Take-off or landing incidents, including precautionary or forced landings.
Incidents such as
(i) Under-shooting, overrunning or running off the side of runways
(ii) Take-offs, rejected take-offs, landings or attempted landings on a
closed, occupied or incorrect runway; and
(iii) Runway incursions.
(3) Inability to achieve predicted performance during take-off or initial climb.
(4) Critically low fuel quantity or inability to transfer fuel or use total quantity of
usable fuel.
(5) Loss of control (including partial or temporary) regardless of cause.
(6) Occurrences close to or above V1 resulting from or producing a hazardous or
potentially hazardous situation (e.g. rejected take-off, tail strike, engine-power
loss etc.).
(7) Go around producing a hazardous or potentially hazardous situation.
(8) Unintentional significant deviation from airspeed, intended track or altitude
(more than 300 ft.) regardless of cause.
(9) Descent below decision height/altitude or minimum descent height/altitude
without the required visual reference.
(10) Loss of position awareness relative to actual position or to other aircraft.
(11) Breakdown in communication between flight crew "C R M" (crew resource
management) or between flight crew and other parties (cabin crew, ATC [air
traffic control] engineering).
(12) Heavy landing - a landing deemed to require a "heavy landing check".
(13) Exceeding of fuel imbalance limits.
(14) Incorrect setting of an "SSR" (secondary surveillance radar) code or of an
altimeter subscale.
(15) Incorrect programming of or erroneous entries into, equipment used for
navigation or performance calculations, or use of incorrect data.
I S 13.175-2
MANDATORY Incident REPORTS: AIRCRAFT TECHNICAL
(a) Structural occurrences, including
(5) Defects of common origin which could cause an in-flight shut-down rate so
high that there is the possibility of more than one engine being shut down on the
same flight.
(6) An engine limiter or control device failing to operate when required or operating
inadvertently.
(7) Exceedance of engine parameters.
(8) "FOD" (foreign objects damage).
(9) Propellers and transmission
(d) Occurrences involving rotors and transmissions, including
(1) Failure or malfunction of any part of a propeller or power-plant resulting in any
one or more of the following
(i) An over-speed of the propeller;
(ii) The development of excessive drag;
(iii) A thrust in the opposite direction to that commanded by the pilot;
(iv) A release of the propeller or any major portion of the propeller;
(v) A failure that results in excessive imbalance;
(vi) The unintended movement of the propeller blades below the
established minimum in- flight low-pitch position;
(vii) An inability to feather the propeller;
(viii) An inability to change propeller pitch;
(ix) An un-commanded change in pitch;
(x) An uncontrollable torque or speed fluctuation;
(xi) The release of low-energy parts.
(2) Damage or defect of main rotor gearbox/attachment which could lead to in-flight
separation of the rotor assembly and/or malfunctions of the rotor control.
(3) Damage to tail rotor transmission and equivalent systems.
(e) Occurrences involving APUs, including
(1) Shut down or failure when the APU is required to be available by operational
requirements, e.g. ETOPS, "MEL" (minimum equipment list).
(2) Inability to shut down the APU.
(3) Overspeed.
(4) Inability to start the APU when needed for operational reasons.
(f) Human factors occurrences, including any incident where any feature or
inadequacy of the aircraft design could have led to an error of use that could
contribute to a hazardous or catastrophic effect.
(g) Other aircraft technical occurrences, including
(1) Any incident where any feature or inadequacy of the aircraft design could have
led to an error of use that could contribute to a hazardous or catastrophic
effect.
(2) An occurrence not normally considered as reportable (e.g., furnishing and cabin
equipment, water systems), where the circumstances resulted in endangering the
I S 13.175-3
MANDATORY INCIDENT REPORTS: AIR NAVIGATION OCCURRENCES
(a) Near collision incidents (encompassing specific situations where one aircraft and
another aircraft/the ground/a vehicle/person or object are perceived to be too close
to each other)
(1) Separation minima infringement;
(2) Inadequate separation;
(3) "Near-CFIT" (near-controlled flight into terrain);
(4) Runway incursion where avoiding action was necessary.
(b) Potential for collision or near collision (encompassing specific situations having
the potential to be an accident or a near collision, if another aircraft is in the vicinity)
(1) Runway incursion where no avoiding action is necessary;
(2) Runway excursion;
(3) Aircraft deviation from ATC clearance;
(4) Aircraft deviation from applicable "ATM" (air traffic management) regulation
(i) Aircraft deviation from applicable published ATM procedures;
(ii) Unauthorized penetration of airspace;
(iii) Deviation from aircraft ATM-related equipment carriage and operations, as
mandated by applicable regulation(s).
(c) ATM-specific occurrences (encompassing those situations where the ability to
provide safe ATM services is affected, including situations where, by chance, the safe
operation of aircraft has not been jeopardized. This shall include the following
occurrences
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