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Part 1: Pel-Air revisited – The ditching of Australian aviation governance

written by Ben Cook | October 19, 2019

Think about the reason you’re reading this article. I suspect, like myself, your passion for all things aviation began at a young age. Perhaps it was influenced by a family member already working in the industry, or it seemed part of your genetic makeup – something flowing in your veins.

For me it began when I was very young. I spent hours daydreaming, staring into the sky to watch aircraft fly past. I watched endless movies about aviation, space and action heroes, especially Superman, and ran around the backyard with my arms out pretending I could fly.

My first opportunity to experience the true thrill and exhilaration of flying began in a glider in my early teens. My sense of comfort in the sky became immediately apparent. It became difficult to explain to others why having the horizon appear at unusual angles felt so good!

The key players in this article, Dom and Karen, also followed their dreams to live a life where they could describe their careers as a passion. What’s better than waking up and thinking, “I get paid to do this”? It’s the ultimate motivation when work and life blend into a passion, leading to positive releases of the brain’s feel-good chemicals.

In Dom’s case, a flight in a Tiger Moth at 13 was life-changing – a defining moment where he knew aviation was his chosen career path and not just a hobby. He put in the hard yards, saving money for flying lessons and taking jobs that many would reject; all for the love of building hours to eventually become the captain of a small business jet.

For Karen, her journey started a little later. At the age of 27, already married and with three children, she decided to become a registered nurse. Full-time study for three years took passion and perseverance, but Karen was driven by her years of watching other family members experience congenital heart conditions. Her specialisation in cardio-thoracic, intensive care and pre-hospital trauma nursing led her to an aviation workplace, where she cared for critically ill patients.

Both Dom and Karen were fortunate to have good health, great family and friends, and a passion flowing through their veins – for which they were also getting paid.


For many, aviation can be all-consuming, making you feel complete, satisfied, energised and alive. Yet the joys of aviation can turn to nightmares as the skies around you can change so quickly. For Dom and Karen, this began on the night of November 17 2009 – all-consuming stress, physical and emotional pain, and sleepless nights have been part of their lives for almost a decade since their Pel-Air Westwind II ditched into the ocean off Norfolk Island.

Sadly, the two organisations whose core role is to ensure the Australian aviation industry upholds adequate professional standards and gains positive lessons from these types of accidents, are also at the heart of their nightmare.

It is important to note that this article is by no means a reflection of the present organisations or their senior leaders, but I believe both the Civil Aviation Safety Authority (CASA) and the Australian Transport Safety Bureau (ATSB) still have a hard road ahead to rebuild trust within the aviation industry.

Short notice aeromedical evacuation – is this flying at its best?

It’s Tuesday morning and another beautiful late spring day in Sydney. Dom is up a little earlier than normal at 5.30am. Later in the morning he receives a call from his company regarding a possible patient medical evacuation that will require a long night flight to Apia, the capital and largest city of Samoa, a small island about 4,300km north-east of Sydney. Later, Karen and the other crew members (a flight doctor and first officer) are also notified of the planned flight.

For Karen, having been awake since 6.30am, it was a short notice request to cover for another nurse who was unable to make the flight. Given the lack of formal regulations and applied fatigue management practices for the flight doctors and nurses employed within the air ambulance sector, it was not uncommon to work extended periods with limited sleep.

These types of aviation operations are on the top of the list of challenging and exciting roles. Highly-motivated crews are saving lives and flying demanding missions all over the world. The work can be tough for sometimes modest pay, but it meets an intrinsic need to make a difference for the benefit of the community.

Typically, these operations contain all the human factors elements that can degrade normal performance: stress and time pressure (short-notice planning, sick patients needing help quickly); fatigue (lots of late nights and early mornings); distractions (dealing with multiple stakeholders); egos; a reliance on accurate and timely communication; complacency; and most importantly, a high trust relationship and reliance on a broad collective team (the crew, operations support, refuellers, air traffic controllers, meteorological forecasters, the aviation regulator and so on).

The crew spend most of the day waiting for confirmation the flight is happening, including planning to ensure they deliver the necessary response and critical care to protect the life of the patient. At the aircraft that night, the team looks forward to another flight – they’ve done this many times before. While the long night flights and disrupted sleep are a down side, they know when it gets busy their adrenaline will mask their tiredness (and sometimes boredom) and help them deliver the performance required to get the job done.

A Westwind at Sydney Airport

They like the jet, a Westwind, registration VH-NGA, which performs well at high altitude and gets them where they need to be nearly as quickly as the larger jets used by the airlines. What the crew is less aware of is the impact of inadequate company training, standards and regulatory oversight regarding crew resource and fatigue risk management. These are the processes for teaching teams how to better support each other’s roles, to monitor for errors, to cross-check each other, to manage fatigue and have a genuine understanding of the impact of lack of sleep on decision-making. They are also unaware of what will be some lapses in the standards for fuel management and broken communication, including critical weather updates.

Just like the air crash investigation television shows, there are many systemic (organisational) and regulatory deficiencies that are all about to line up – sometimes referred to as the Swiss cheese model – and set this crew up for failure. It’s also going to test their ability to perform under extreme pressure, particularly at the critical moment between life and death.

The Swiss cheese moments

The flight departs Sydney late that night and it’s a long flight requiring a refuel at Norfolk Island. Just like a few times before, the weather forecast for Norfolk Island is far worse than the actual weather they experience on arrival. On the ground you could see the stars, the night looked quite clear, yet the automatic weather reporting system was suggesting the weather should have been much worse.

When asked about this the local aerodrome support person at Norfolk Island mentioned the automatic system often overstates how bad the weather is. Little do they know this has the potential to set up expectation bias: a false sense of security based on past experiences or norms.

Once refuelled the crew departs Norfolk Island around 2.45am (local time) for Apia. All aboard are looking forward to a bed in a hotel room before the return flight the next night.

The captain, like many of the company pilots, has a history of making conservative decisions, including carrying extra fuel, as flights to remote islands such as these leave little margin for error should there be a need to find another airport to land.

While this approach to carrying extra fuel is appropriate, the company policy refers to other, more complicated, fuel calculations for helping to determine when to divert to other airfields.

For many pilots, these calculations are not a normal part of what they’ve been shown to do – an example where policy exists for the sake of policy. Ever wonder about the possible adverse influence of other more senior pilots in shaping the workplace culture and norms?

Is what you actually do, even when you know it’s different to what is stated in the company policy, what everyone does?

It’s likely you too have experienced this; an initial feeling of discomfort with not wanting to be a lone voice that asks a difficult question. Instead, you accept the workplace practice to fit in with the group.

Although the weather forecast doesn’t require it, on this evening Dom has planned an alternate aerodrome in addition to Apia as part of the flightplan – again another conservative decision. They’ve now flown all night and land around 7am local time. It doesn’t take long to put the aircraft to bed and head to the hotel for some well-earned sleep.

Yet, as sometimes happens, there is a delay with hotel check-in and the already tired crew have to wait a little longer before they get their room keys. The recovery sleep and down time cannot come quickly enough and the delays at check-in are frustrating. It would be easy for the crew to lose it but understanding that fatigue and long nights are linked to being more irritable helps keep the relationship with the check-in staff professional.

Every minute is a minute of lost recovery time, so critical to manage the performance of medical evacuation flights, with the potential to push the body closer to a danger zone, where decision-making is severely diminished. The ongoing delay is time lost for sleep and every hour is moving the body closer to a circadian cycle that makes it harder to get to sleep.

After finally getting the keys to his room, Dom takes a quick shower to raise his body temperature (for some, the normal sleep cycle is made easier when the body is cooling back down and the shower helps recreate this natural process).

Dom’s room is not ideal. Poor curtains mean a fair amount of daylight is streaming into the room. He’s also fighting his normal body clock, which right now, regardless of the extended hours awake, is working against him when it comes to getting good quality sleep during the day. At best, the sleep at this time of day won’t be great.

Now Dom’s mind is working a bit too hard and thinking too much about the real need for sleep and this anxiety is making it even harder to get to sleep. Trying to relax the mind, counting slowly, slowing down the breathing rate, eventually the eyes slowly close and Dom drifts off to sleep.

But just to make matters worse, once eventually asleep housekeeping enter his room twice, waking him momentarily; yet another unnecessary and avoidable disturbance.

Awake, wide awake, Dom wonders what time it is. It’s only 11am. He knows he needs more sleep. He decides to get up and make a couple of calls to home to try to stay relaxed, sure he can get some more sleep later. He manages a little more sleep before getting up around 2.30pm to start the planning for the return flight (Apia–Norfolk Island–Sydney–Melbourne). He can’t get an internet connection and tries to call operations back home to help with the planning but there is no answer. He eventually does the best he can over the telephone to get some weather and to submit a flightplan. It’s not ideal but he has enough to get started and can get further updates once airborne.

Dom is making a number of these decisions at a critical time: the afternoon window of circadian low (WOCL) – a fancy name for that time later in the afternoon where your body experiences a natural degradation in performance. It’s a typical time when you may struggle to stay awake during an afternoon presentation and it’s also a good time to take a nap. At this time, Dom also makes a decision that is not consistent with his normal thought processes: he only fills up the main fuel tanks but not the tip tanks.

The crew conducts a combined brief, loads the patient and her husband into the aircraft and departs for Norfolk Island. Karen and the flight doctor have not had the luxury of any further sleep (other than the three to four hours they managed to get in the aircraft on the flight over) as they’ve been busy all day getting the patient ready for the medical evacuation.

There remains another layer of Swiss cheese that further exacerbates the upcoming problems for this crew: some critical weather information was either passed incorrectly or not at all. This, combined with the relaxed and inconsistent company-wide approach to fuel planning, means a number of critical decision gates have been missed, exacerbated by lax regulatory oversight.

Many factors have now combined to set this crew on a doomed path and one that will expose them to outcomes they will carry with them for the rest of their lives.

Ditching a business jet into the ocean

“What’s happening, did the captain just say we’re going to ditch the aircraft?”

“Could this really be happening?”

“Just a few hours ago I remember a blue sky and light breeze standing on the tarmac at Apia, deeply satisfied that we were about to get a sick patient to a medical centre.”

These are the random thoughts facing the crew. Yet right now, the pilots are solely focused on landing a small jet onto the ocean.

Other thoughts will flood later: “Why didn’t I do some further checks of the fuel? Where did this weather come from – the forecast looked good when we left? What did I miss? How could this happen?”

From a human performance perspective, it would be ideal to still be under the influence of the parasympathetic nervous system (PNS), which for most parts of this flight has been responsible for sitting back, comfortable, warm, sometimes bored, but mostly helping keep the body in a relaxed state (storing energy) as the aircraft cruises towards Norfolk Island.

Right now, it’s the sympathetic nervous system (SNS), commonly known as a ‘fight or flight’ response, that is in charge. Luckily at this stage, with little to no conscious knowledge, Dom is largely unaware that his body’s stress drugs (epinephrine and norepinephrine) have been released. They’ve increased his heart rate. His bronchial tubes within his lungs and his heart vessels have dilated, allowing more oxygen to flow around the body and tensing his muscles. He’s having to consciously keep himself relaxed and to not tense up too much to ensure his fine motor skills still allow him to fly the aircraft accurately onto the water.

This is the difference between getting it right and wrong, it’s a life and death scenario. He’s delivering this performance under extreme pressure, and courtesy of all his years of training, he’s able to fly the aircraft rather than freeze up, which could result in an aircraft stall and an uncontrolled crash into the water with almost no chance of survival for those on board.

With about three-and-a-half hours of broken sleep, Dom should be experiencing a response similar to combat veterans, such as stress diarrhoea or loss of fine motor control. Yet he’s doing a remarkable job under very difficult circumstances.

No time for other random thoughts. It’s dark, it’s cool and Dom has no sense of the temperature – he is only focused on landing a business jet onto the ocean.

Concentrating, time feels like it has slowed down, and Dom can clearly hear the first officer calling the altitude to the water. Dom thinks, “I’ve got to get this right; make power adjustments to keep the airspeed steady; quickly scan between attitude indicator, the airspeed indicator and the vertical speed indicator to fly a controlled approach.”

It’s now 9.25pm. The aircraft is around 440ft above the water and the first officer instructs the passengers to brace. An automated aircraft system continues to announce, “too low terrain”, and this is just another distraction that luckily does not impact the performance of this team.

Below 400ft the aircraft is established in a stable descent and airspeed, a pretty impressive outcome under such trying conditions. The first officer calls out 200ft and the same automated system announces, “terrain ahead, pull up”.

During all of this, the first officer recognises the gear needs to be raised (the aircraft is now about 115ft above the water) and calls for “gear up”, which in addition to ongoing annunciation of “terrain ahead, pull up” also activates a gear warning horn.

Think about it: the constant noise and distractions, a dark night, trying to hold a constant rate of descent and airspeed, flying an approach onto an ocean and keeping it together – at this moment it’s certainly an example of human performance at its finest, not perfect by any means but definitely a good standard of performance when confronted with so many stressors.

Furthermore, Dom is performing a task he’s never practised or been adequately trained for, a novel task under extreme pressure, which with consideration to the aviation environment is about as risky as it gets. For many this stress would cause fixation and loss of fine motor skills. Yet Dom has airspeed almost constant, at a constant rate of descent, 80ft to go (descent stabilised at 360ft per minute, airspeed 108kt); 50ft to go (airspeed 103kt and decreasing); the first officer calling out the final descent heights, 40ft, 30ft, 10ft …

BANG… bang… bang. Three impacts as a business jet skips across the water.

Landing on water at such speeds is like landing on concrete, but somehow the aircraft is still right side up. The fuselage separates into two sections soon after coming to a stop, with the tail section afloat.

Surreally, there is no more engine noise and it’s relatively quiet. The primary sound is water flowing very quickly into the aircraft. Fight and flight drugs are still pumping through the bodies of the crew.

And for the patient – at one stage happily on her way to a medical facility – strapped on a bed, unable to release herself, in an aircraft sitting on the ocean and flooding with water; her stress and panic is likely unbearable.

Right now, in a small aircraft cabin quickly filling with water, with a sick patient strapped to the medical bed, Karen, briefly knocked unconscious, has opened her eyes with water already half way up her shins. She feels no pain (due to her own release of fight and flight chemicals), allowing her to immediately collect her thoughts and respond with the flight doctor to get the patient and her husband out of the aircraft. The severe impact has torn muscles and nerves that will result in lifelong damage and severe pain for Karen.

Dom has already reacted instinctively and exited the rear door, which has been partially damaged by the impact and is also flooding with water. The first officer, initially knocked unconscious, has also quickly recovered and is the last to leave the aircraft.

Six people are now out of the aircraft, all huddled together and a few miles off the coast of Norfolk Island. As time goes on, the fight and flight chemicals will start to wear off, but for now it’s a state of ‘high performance’ and shock, so no one has a real sense of the cold, nor fear. Reality will set in not long after the rescue boat picks them out of the water.

A lucky rescue

Even during the high pressure ditching with less than 600ft above the water, the first officer passed critical information to an aerodrome support person on Norfolk Island stating: “We’re going to proceed with the ditching”.

This aerodrome operator contacted the Norfolk Island emergency services coordinator (ESC) to advise him of the situation, who then called out the other members of the airport rescue and firefighting services, including coordination to contact the owners of two fishing charter vessels that could be used for a search.

One of the firefighters responding to the call-out elected to travel via some cliffs west of the airport. He stopped his vehicle to check the sea to the west of the island, believing that it was possible the aircraft had ditched there. He recalled looking out to sea and seeing what he thought was an occasional and intermittent glow of light (which was from Dom’s torch). After looking for a few minutes, he was convinced the light was real and at about 10.20pm he phoned the observation through to the ESC.

This initial information was critical and helped deliver a quick response. At about 10.50pm, after about one hour and 25 minutes in the water, the aircraft’s five evacuees were located and assisted on board the search vessel.

Interestingly, Norfolk Island locals had recently completed emergency response scenario training, further enabling them to respond quickly and efficiently.

The real nightmare begins

So where were you on Thursday 19 November 2009 when the news broke across the country that an Australian aircraft had ditched into the ocean off Norfolk Island? You may have been very interested in the story, or this article may be the first you’ve heard about this tragic accident.

When was the last time you were confronted with extreme levels of stress that have the capacity to cause emotional instability and loss of fine motor skills? In this case, Dom had to make small and fine inputs to aircraft controls (one- or two-degree changes in pitch) and power. He had to almost subconsciously control the fine line between muscle tension that could cause paralysis and a complete loss of control.

Unless you’re a human performance subject matter expert, it’s important to be careful about making too many assumptions. I know personally, having flown aircraft to Norfolk Island many times, that my first thoughts were very critical of the organisation and the pilots. Luckily, I’ve been well-trained as both an investigator and as a human factors practitioner to recognise these initial thoughts were not helpful.

Like thousands of aviation professionals within corporate culture, Dom was doing the best he could aligned to the normal practices, and positive reinforcement, of more senior pilots around him. Certainly, Dom accepts he could and should have done some things differently. Unfortunately, CASA and the ATSB pointed the finger too heavily at the aircraft captain. It’s his passion for aviation and strong perseverance that has kept Dom going since the accident.

Through any post-accident process, it’s vital that ATSB investigators and CASA auditors use self-awareness – to seek other evidence to support initial assumptions, be aware of biases, and be cautious about the influence of strong-minded personalities.

The combination of bias and strong egos can adversely influence an aviation accident investigation, ultimately leading to breakdowns in communication, assumptions, inadequate collection of critical investigation evidence and, in the worst case, a re-write of a preliminary investigation to align with possible political agendas (this will never be proven).

This only makes the suffering worse for survivors and destroys the careers of seasoned and competent ATSB investigators.

For many of us, we assume that CASA and the ATSB are the key players to make sense of the why in these types of accidents – that they will search for the root causes to ensure the broader aviation community can genuinely learn some lessons to prevent reoccurrence. Yet it appears this wasn’t the case for those aboard that medical evacuation flight in 2009.

The pilots’ union criticises Pel-Air Aviation for its poor record on managing fatigue (ABC News Australia).

Most importantly, getting to the cause of what happened and implementing processes to address these is vital for the crew, the passengers, and their families and friends, to get some closure.

A taste of things to come

No surprises but there is talk of a future movie based on this scenario. If you thought the movie Sully (the story about the ditching on the Hudson River) was interesting, some of that content was not factual but rather Hollywood hype.

Our local version has the trademarks of a great documentary, including extracts such as the following made by the Transport Safety Board of Canada after completing an independent review of the ATSB:

  • lapses in the application of the ATSB methodology with respect to the collection of factual information;
  • errors and flawed analysis stemming from the poor application of existing processes were not mitigated;
  • an early misunderstanding of the responsibilities of CASA and the ATSB in the investigation was never resolved;
  • this misunderstanding persisted throughout the investigation, and as a result, only two ATSB interviews were conducted with managers and pilots of the aircraft operator.

And the list goes on.

So why should you trust my interpretation of the events in a series of upcoming articles?

First and foremost, I have one strong belief: we all need a better balance around organisational issues and pilot culpability to genuinely learn some lessons from this accident. If nothing else, the survivors deserve a more balanced understanding as to what caused this accident.

In the most tragic of circumstances, the patient, suffering heavily from post-traumatic stress disorder and fighting for basic medical compensation, lost her will to fight and lost her life to an overdose in February 2015.

Dom and Karen are continuing to battle with a basic need to feel the system has learnt lessons from the tragedy. Just a glimmer of hope will help them get on with their lives and to feel the real story is known.

At the time of the accident I was CASA’s human factors manager and I have a good appreciation of the processes that occurred post-accident. I was actively involved with the CASA special audit of the operator. I’ve read volumes of correspondence – accidents and independent review reports from cover to cover – and where necessary, to help manage my own bias and prejudice from a human factors perspective, I’ve had certain material independently reviewed by a former head of a human performance aviation accident investigation division, recognised as one of the best in the world.

So what’s coming in future articles? I’m going to explore the many human factors involved in this accident. I’ll review elements such as egos, trust, expectation bias, professionalism, fatigue, inconsistencies within the systemic investigation report, culture and its influence on behaviour. These insights from a real scenario provide lessons for each of us, and ways for all of us to better manage human factors.

To reiterate, I’ve worked for both the present CASA Director and the Commissioner of the ATSB and I have the utmost respect and faith in their professional standing to return both CASA and the ATSB back to where they need to be – with the trust and confidence expected by the Australian aviation community and the travelling public. My review in these articles is focused on the culture and processes prior to their appointments.

Until next month, safe flying and enjoy those positive feel-good chemicals you get to release every time you head to the skies.

This feature article first appeared in the April 2018 issue of Australian Aviation.


  • William Mulloy


    Wow ! Gripping article . I am from Canada and am now retired after 40 years of flying . I think back of how lucky I am to have survived through my career . My last 30 years were for the most part influenced by a good safety culture oversite from Transport Canada at the airline I flew for but I can say this ; my first 10 years of bush flying ; charter flights & medevac flights where there was very little oversite from either your management or higher ups & I was virtually on my own and doing everything myself ( most of that time single pilot ) on aircraft like Mitsubishi MU-2 & piper PA-31 it is a wonder I managed to keep an unblemished track record . I know that I was extremely lucky because I can tell you this : I scared the hell out of myself more than once & I put myself there but I sometimes think if ther was a bit more oversite in my small company I wouldn’t have exposed myself to several of the questionable situations that I ended up in . Anyway thank you for reading my letter as I have nothing but compassion for those pilots & pax in your article . I really feel for those pilots because I know they set out with the best of intentions in that westwind & other factors helped put them where they ended up . I hope to see the film if it is ever produced. Thank you from Captain W Mulloy CRJ-900 .

  • James


    Great article Ben. Every pilot involved in IFR charter should be all over this incident.

  • Jaco


    Great article. I’ve followed this accident since it happened back in 2009. To be honest when I first read the few sketchy details about the accident I had my own biased opinions about what might have happened.
    But as more details emerged with the investigation and then the review of that investigation, this accident has proved to be a treasure trove of really good points that everyone in aviation can take away and learn from no matter what sort of organisation you might be involved in.
    As Ben pointed out in his article, this accident touches on a very wide range of issues and I sincerely hope that we can all learn from it.
    I feel genuinely sorry for the people involved. Like all of us they tried to do the most professional job with the tools they had in the situation that presented itself.
    Thank you for the article, Ben. Really well written. Cannot wait for the next one.

  • Thanks for the very well researched and written account of this accident. I remember it well. I was in a room of professional aviators and we all scoffed at how the crew must have stuffed up. After reading what Human Factors contributed, it’s a strong reminder that passing judgement does not help one little bit. Knowing all of the facts, knowing how well the ditching was handled and communicated, how this all contributed to the crew and passengers being rescued. We all make mistakes, for many reasons. Some have no repercussions, some clearly do. Well done to all involved and very sorry to hear of the patient passing due to PTSD.
    I look forward to the follow on article.

  • Sandy Reith


    Ben Cook has written a highly descriptive story with some interesting analysis.
    But with respect there might be other judgements that go right to the most critical element of cause. Quote:-
    “exacerbates the upcoming problems for this crew: some critical weather information was either passed incorrectly or not at all.”
    This surely is the question; and if “not at all” or “incorrectly” is true then surely it is very difficult to see that any appreciable blame should fall on the shoulders of the crew. Reading other analysis by PAIN contributors at the AuntyPru website, with time lines, it seems that if certain weather reports had been passed to the crew then they would have had reason, and sufficient fuel, for a diversion to an alternate airport.
    Thus a failure to communicate critical weather information did not “exacerbate the upcoming problems” because to that point there was no problem(s).
    In which case it then might also follow to give less weight to sleep deprivation as a factor of cause, though obvious enough that proper procedures seemed to be lacking and corrective action was called for.

  • Bob Grimstead


    As a lifelong professional airman and 35-year aviation journalist I can say this is one of the best and most balanced articles I have ever read about what was clearly a poorly-conducted accident investigation.
    A few years ago I was asked to provide expert opinion on another ATSB investigation and also found it unprofessional and heavily biased towards blaming the inexperienced pilot rather than his chief pilot whom he was following at very low level over hostile terrain in a single-engined aircraft.
    I applaud your campaign Ben, to get a balanced view of the events and systems leading to this accident.

  • Peter


    Wow, what a great review of the Pel Air ditching by Ben Cook. I know the investigation was a shambles. I am looking forward to Part 2.

  • James


    @ Bob Grimstead
    Very well said. I always enjoyed reading your articles in AA. I learnt quite a bit from your golf course landing a few years back.
    Hope to see some more articles from you moving forward.

  • Peter J CESNIK (QF Staff no 553370 /02/06/71 - now retired


    Great and sobering article……

  • Paul


    @Bob Grimstead Can you say which investigation that was please?

  • Ian Sawley


    Great article. I have a son flying for Adria in Europe and there is a number of lessons he could learn from this.

Comments are closed.


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