Root Cause Analysis Blog

 

Join the Conversation: TapRooT® & Facebook Live Tomorrow at Noon EST

Posted: September 25th, 2018 in Career Development Tips, Meet Our Staff, Performance Improvement, Topic of the Week, Video

Join us tomorrow for TapRooT®’s Facebook Live conversation. We’ll begin at noon EST with TapRooT® professionals presenting a workplace-relevant discussion full of insights and improvements to implement in your job and to include in other roles in your organization.

NOTE: Be sure to tap on the Follow button on our videos so you will get notifications the next time TapRooT® goes live.

We look forward to being with you on Wednesdays! Here’s how to connect with us for tomorrow’s Facebook Live session:

Where? https://www.facebook.com/RCATapRooT/

When? Wednesday, September 26

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Do your own investigation into our courses and discover what TapRooT® can do for you; contact us or call us: 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

Start Planning for the 2019 Global TapRooT® Summit

Posted: September 25th, 2018 in Performance Improvement, Summit, Video

NewImage

The 2018 Global TapRooT® Summit was great (see the video below). The 2019 Global TapRooT® Summit on March 11-15 in Houston (Montgomery), Texas, will be EVEN BETTER!

Find out more about the 2019 Global TapRooT® Summit by clicking on the Summit hotel image above (the La Torretta Lake Resort & Spa).

Testimonial Tuesday

Posted: September 25th, 2018 in Career Development, Courses, Testimonials

Are you interested in learning TapRooT®, but you’re not sure where to start? Below I’ve provided some 2-Day and 5-Day TapRooT® Training Testimonials to help you decide which course is right for you.

 

TapRooT® is a world-class software system designed to help investigators solve every day hurdles. TapRooT®’s root cause analysis takes an investigator beyond his or her knowledge to think outside the box. Backed with extensive research in human performance, incident investigation, and root cause analysis, TapRooT® is a global leader in improved investigation effectiveness and productivity, stopping finger pointing and blame, improving equipment reliability, and fixing operating problems.

2-Day Client Testimonials:

  • “I see myself improving on the entire I.I. process, and now I have the tools to improve.” – Mark
  • “Gives you the ability to remove bias out of your investigation.” – Jackie
  • “Excellent course. Gave everyone an opportunity to go through the entire process.” – Breanna
  • “By far the most in-dept root cause training I’ve done.” – Orrin
  • “Will definitely  improve my incident investigations and provides resources for quality corrective actions.” – Ryan

5-Day Client Testimonials:

  • “One of the most important equipment analysis tools.” – Hussain
  • “Excellent course, especially for good supportive docs from lecturer.” Corzetto
  • “Great tool for find things before they become issues, not just a compliance tool.” – Mike
  • “Interesting examples of how multiple root causes can exist.” – Cole
  • “Was useful in driving the desire to find more details and noticing the triggers to seek more information.” – Mike

We take your course evaluations seriously. Without them, we couldn’t continue to improve and grow as a company. So, thank you for your valuable feedback!

Looking for a course near you? Find a course location and reserve your seat today by clicking on the links below.

2-Day TapRooT® Root Cause Analysis Training
5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Building Rapport With Nonverbal Communication

Posted: September 24th, 2018 in Career Development Tips, evidence collection, Meet Our Staff, Performance Improvement, Topic of the Week, Video

Nonverbal communication is important because it reveals how we feel, in spite of what we say. Building positive rapport through nonverbal communication is a vital skill to learn for an investigator. To learn how to build a positive rapport, listen to Benna and Barb as they discuss tips and tricks to use while interviewing individuals.

If you cannot view this video, please CLICK HERE.

Interested in learning more? Check out Barb’s 2-Day Effective Interview & Evidence Collection Course.

Don’t forget to discover the 2-Day and 5-Day public courses available near you!

 

 

Monday Accident & Lessons Learned: HOW MANY INCIDENTS DOES IT TAKE TO LEARN???

Posted: September 24th, 2018 in Accidents, Current Events, Medical/Healthcare, Pictures, Summit

Is it acceptable to have incidents occur over and over again?

Screen Shot 2018 09 07 at 3 37 38 PM

The Daily Mail (a UK paper), ran an article about repeat incidents at a UK hospital (pictured below).

Screen Shot 2018 09 07 at 3 39 11 PM

This first was a hospital acquired infection that caused a patient to sue and win a six figure payout. I’ll let you read the article to find out what essential part of his anatomy that he lost.

That settlement had just been negotiated when a second patient had the wrong testicle operated on. And a third patient had a lesion removed from the wrong brest.

The Daily Mail reported that the hospital spokesperson claimed:

“Southend University Hospital continues to be compliant with the national recommendations
on learning from deaths through better engagement with bereaved families and carers,
strengthened governance arrangements for mortality monitoring by newly introduced
medical examiner roles and increased transparency.”

It would sure make me a more confident patient if the performed advanced root cause analysis and implemented corrective actions to STOP repeat incidents rather than having repeat incidents and “continuing to learn.”

They also said:

We are pleased our mortality indicator score has consistently decreased since
June 2017 and is now within the expected range for the first time since June 2015
.”

Stopping killing patients is a great idea. I’d suggest a better goal. STOP sentinel events including ALL never events.

Investigating never events and learning isn’t enough to make this happen. Hospitals need to become proactive in their improvement programs.

Are you interested in advanced root cause analysis and becoming proactive in your improvement program?

I would suggest attending a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. We hold them around the world … including Europe. See the upcoming courses held around the world by CLICKING HERE.

Want to learn more about proactive improvement? Attend the 2019 Global TapRooT® Summit in Houston, TX. Learn from industry leaders from around the world how they proactively solve problems. get more Summit info HERE.

Career Opportunities for Candidates with TapRooT® Skills

Posted: September 24th, 2018 in Career Development, Courses, Job Postings, Performance Improvement, Training

You’re telling everyone that you’re an effective problem-solver when you have the expertise of TapRooT® training on your resume. Professional training and skill sets in investigation, problem-solving, and root cause analysis convey competency to everyone you meet, especially prospective employers. If you have TapRooT® training and skills, explore your professional advancement through these global opportunities.

Quality Manager

HSE Manager

Regional HSE Advisor

Health & Safety Manager

Patient Safety Program Coordinator (PSPC)

Specialist HES Operations 

Technical Manager

Regional H&S Advisor

Environmental Coordinator

Safety Technician

Project Planner

Assistant Health & Safety Consultant

Health & Safety Manager

Project Manager

Senior HSE Manager 

If you are not TapRooT® trained, becoming TapRooT® trained in troubleshooting and identifying root causes of issues and incidents is the proven path to develop your skills and training. Pursue your goals through one of these TapRooT® courses to advance your professional development and your career.

Aberdeen, Scotland, October 8, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Dubai, UAE, October 14: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Knoxville, Tennessee, October 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Kuala Lumpur, Malaysia, October 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Seattle, Washington, October 24, 2018: 2-Day TapRooT® Root Cause Analysis Training

Houston, Texas, November 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Orlando, Florida, November 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Singapore, Singapore, November 15, 2018: 2-Day TapRooT® Root Cause Analysis Training

Perth, Australia, November 26, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Houston, Texas, December 3, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Amsterdam, The Netherlands, December 3, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Edmonton, Canada, December 10, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

We are global to meet your needs. If you need other times or locations, please see our full selection of courses.

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

Weekly Wisdom

Posted: September 24th, 2018 in Career Development, Wisdom Quote

Friday Joke

Posted: September 21st, 2018 in Jokes

When is a leak in a nuclear reactor minor?

Posted: September 20th, 2018 in Current Events, Equipment/Equifactor®, Pictures

NewImage

I saw an interesting article in the Military News yesterday. The headline read:

Navy: ‘Minor’ moisture leak in nuclear plant prompts sub’s return to Groton base

This caused me to think of several things…

First, if a ship has to return to port, the leakage was not minor.

Second, I’m glad they returned to port for repairs. Much better than having the leak progress into an accident.

Third, why did we hear about this?

The article doesn’t give many details about the problem and the Navy spokesperson downplayed the significance by calling coming back into port for a leak:

…not uncommon, and ensures the ship is maintained at a high state of readiness.

I guess I was in the Navy a long time ago when things like that were uncommon.

In fact, back then if something like this happened, there would not have been a press release. The ship would have gone ito port, been fixed, and gone back out to sea.

Los Angeles class subs are getting old (USS Pittsburgh is over 30 years old) and I hope the Nuclear Navy really is maintaining the high state of readiness that they are known for.

How is your maintenance program? Need help troubleshooting equipment problems? Consider having an TapRooT®/Equifactor® Course at your site. Contact us by clicking here.

5 Cognitive Biases that Influence Incident Investigations

Posted: September 20th, 2018 in Investigations, Root Cause Analysis Tips

Whether we admit it or not, we are constantly under the influence of cognitive biases that distort our thinking, influence our beliefs, and sway the judgments we make as investigators.

Most of us are familiar with confirmation bias (looking for evidence to support a hypothesis, and rejecting any evidence that does not). However, did you know there are over 250 cognitive biases?

Here are five that may be affecting your investigations:

  1. Overconfidence. Yes, overconfidence is a bias even though it doesn’t sound like a fancy psychological term. This can really be a problem with experienced investigators because they know more, and may be more convinced that they are right.
  2. Stereotyping. Expecting a group or person to have certain qualities without having real information about the person. Again, a term that we are familiar with but may not realize we are doing to those involved in incidents. I’m not just referring to gender or racial stereotypes. You can stereotype a person many different ways. Here are some other examples: “She has an MBA. She must be smart.” “He has 20 years in the industry, he must be experienced.”
  3. Choice-supportive bias. When you decide something you tend to feel more attached to your decision, even if the decision has flaws.
  4. Bandwagon effect. Not sure of what to think of an investigation? Take the easy road . . . jump on the bandwagon. The probability of one investigator adopting a belief increases based on the number of team members who hold the same belief.
  5. Blind-spot bias. This simply means that we don’t accept that we could possibly be biased! We tend to notice biases in other people and not within us. We all fall into biases and need to be aware of that.

How do you avoid biases in an investigation? Use a system that doesn’t start with a hypothesis, TapRooT® Root Cause Analysis. Using the guided system, an investigator does not:

  • rely on his/her limited knowledge (no one can possibly know everything!).
  • fit workers into stereotypes that align with our hypothesis.
  • become married to his/her ideas.
  • become easily influenced by others.
  • have to fight his or her biases!

You will learn to use a SnapCharT® to collect information about what happened without jumping to conclusions. Once you understand what happened and identify the mistakes, errors or equipment failures, you will then be ready to analyze why the safeguards failed (find the root causes) without jumping to conclusions by using advanced tools: the Root Cause Tree® Diagram and the Root Cause Tree® Dictionary. This system gets you to think beyond your current knowledge, and decreases investigator bias.

Learn the entire TapRooT® System in just two days. View the upcoming schedule here.

 

TapRooT® Software Academy: Introduction To the TapRooT® Software

Posted: September 20th, 2018 in Uncategorized

TapRooT® is excited to present a new video series called “Software Academy.” Once a month we are uploading helpful videos that highlight our software features and answer some of our frequently asked questions. Today’s video will be a simple introduction into our software.

If you enjoy this video don’t forget to follow us on social media to stay up to date on video releases (social links are listed below).

If you cannot view the video, please CLICK HERE

 

Did you find this video helpful? If so please leave a comment below and tell us what type of video you would like to see next.

Interested in learning more about our software or maybe you need a fresher course? If so, click on the links below to see what public courses are available near you.

2-Day TapRooT® Root Cause Analysis Training
5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

 

You can follow us on:

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How far away is death?

Posted: September 20th, 2018 in Accidents, How Far Away Is Death?, Video

Have respect for the anchor!

If It’s Wednesday, It’s TapRooT® on Facebook Live, Noon EST!

Posted: September 19th, 2018 in Career Development Tips, Investigations, Meet Our Staff, Performance Improvement, RCA Tip Videos, Root Cause Analysis Tips, Topic of the Week

Tune in today for TapRooT®’s Facebook Live conversation. At noon EST, join TapRooT® professionals Benna Dortch and Chris Vallee discussing, Do you perform incident investigations like you watch the news?

We look forward to being with you on Wednesdays! Here’s how to connect with us for today’s Facebook Live session:

Where? https://www.facebook.com/RCATapRooT/

When? Wednesday, September 19

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

NOTE: Be sure to tap on the Follow button on our videos so you will get notifications the next time TapRooT® goes live.

Do your own investigation into our courses and discover what TapRooT® can do for you; contact us or call us: 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort. You don’t want to miss a minute of the TapRooT® Summit!

How Could the Best Process Safety Advice Come from the 1960s/1970s?

Posted: September 19th, 2018 in Performance Improvement, Pictures

RickoverS1W

There are many “experts” in process safety. Their advice has become laws in the USA and Europe. But accidents continue. Why?

Perhaps we should go back to the real expert on process safety – Admiral Rickover.

What did he have to say about process safety (or as he put it, reactor safety)? What are we missing in our current efforts to improve process safety? See this set of articles about normalization of deviation and learn what the expert – Admiral Rickover – had to say about process safety:

http://www.taproot.com/archives/54027

 Then read his semi-official biography:

Rickover: The struggle for Excellnce

Screen Shot 2018 08 02 at 3 41 10 PM

Click on the book above to purchase it on Amazon.

TapRooT® Around the World: Denver

Posted: September 18th, 2018 in Courses, Pictures, Training

Thanks to Marcus Miller for sending in this course photo from Denver! It’s not too late to get into the picture and advance your career!

Are you interested in attending a TapRooT® Training Course? Click on the links below to view our upcoming courses to a city near you.

2-Day TapRooT® Root Cause Analysis Training
5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

TapRooT® Around the World: Cork, Ireland

Posted: September 18th, 2018 in Career Development, Courses, Human Performance, Meet Our Staff, Performance Improvement, Pictures, TapRooT® Instructor, Training

Look into the Two-Day TapRooT® Techniques course in Cork, Ireland, where students and TapRooT® Instructors Thomas Di Giacomo and Chris Vallee gathered at the Imperial Hotel Cork on South Mall. Attendees enjoyed a bit of history along with the TapRooT® course, as guests such as Sir Walter Scott, William Thackeray, Franz Liszt, and Charles Dickens have stayed at the hotel.

In the span of the two-day course, students learned to find and fix the root causes of incidents, accidents, quality problems, precursor events, operational errors, hospital sentinel events, and many other types of problems. Upon course completion, attendees received a certificate and a 90-day subscription to TapRooT® VI, the online software service.

Many thanks to Tom and Chris for capturing and sharing these great pictures of action and insights into the interactive learning during the course!

Put yourself in the picture by becoming trained in troubleshooting and identifying root causes of issues and incidents. Register today for a TapRooT® course and gain advantage, experience, and expertise from our professional instructors. Here are some of our upcoming courses:

Calgary, Canada, September 24, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Amsterdam, The Netherlands, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Atlanta, Georgia, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, September 26, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

Manchester, United Kingdom, October 1, 2018: 2-Day TapRooT® Root Cause Analysis Training

Aberdeen, Scotland, October 08, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Dubai, United Arab Emirates, October 14, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Knoxville, Tennessee, October 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Kuala Lumpur, Malaysia, October 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Edmonton, Alberta, Canada, October 18, 2018: Special 2-Day Equifactor® Equipment Troubleshooting and Root Cause Analysis Course

Bogota, Colombia, October 22, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Seattle, Washington, October 24, 2018: 2-Day TapRooT® Root Cause Analysis Training

Albuquerque, New Mexico, October 29, 2018: 2-Day TapRooT® Root Cause Analysis Training

Orlando, Florida, November 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

New Orleans, Louisiana, November 12, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Monterrey, Mexico, November 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Johannesburg, South Africa, November 19, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Bogota, Colombia, November 21, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

Perth, Australia, November 26, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Houston, Texas, December 3, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Amsterdam, The Netherlands, December 3, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Edmonton, Canada, December 10, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

We are global to meet your needs. If you need other times or locations, please see our full selection of courses.

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

Join the Conversation: TapRooT® & Facebook Live Tomorrow at Noon EST

Posted: September 18th, 2018 in Career Development Tips, Meet Our Staff, Performance Improvement, RCA Tip Videos, Root Cause Analysis Tips, Topic of the Week, Video

Join us tomorrow for TapRooT®’s Facebook Live conversation. We’ll begin at noon EST with TapRooT® professionals presenting a workplace-relevant discussion full of insights and improvements to implement in your job and to include in other roles in your organization.

NOTE: Be sure to tap on the Follow button on our videos so you will get notifications the next time TapRooT® goes live.

We look forward to being with you on Wednesdays! Here’s how to connect with us for tomorrow’s Facebook Live session:

Where? https://www.facebook.com/RCATapRooT/

When? Wednesday, September 19

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Do your own investigation into our courses and discover what TapRooT® can do for you; contact us or call us: 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

What does a bad day look like?

Posted: September 18th, 2018 in Bad day, Pictures

Because signage matters, right?

Monday Accident & Lessons Learned: Fatal Ammonia Accident

Posted: September 17th, 2018 in Accidents, Investigations, Video

What were the Causal Factors? 

Leave your comments here…

Career Opportunities for Candidates with TapRooT® Skills

Posted: September 17th, 2018 in Career Development, Courses, Job Postings, Performance Improvement, Training

You’re telling everyone that you’re an effective problem-solver when you have the expertise of TapRooT® training on your resume. Professional training and skill sets in investigation, problem-solving, and root cause analysis convey competency to everyone you meet, especially prospective employers. If you have TapRooT® training and skills, explore your professional advancement through these global opportunities.

Technical Manager

Regional H&S Advisor

Manager, Health, Safety, & Environment

Safety Technician

Project Planner

Commissioning Engineer

Lab Quality Technician

Environmental Safety & Health Manager 

Quality Inspector

Quality, Health, Safety, & Environmental Manager

Project Manager

Process Safety Advisor

HSE Manager

If you are not TapRooT® trained, becoming TapRooT® trained in troubleshooting and identifying root causes of issues and incidents is the proven path to develop your skills and training. Pursue your goals through one of these TapRooT® courses to advance your professional development and your career.

Atlanta, Georgia: September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Amsterdam, Netherlands, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Manchester, United Kingdom, October 1, 2018: 2-Day TapRooT® Root Cause Analysis Training

Aberdeen, Scotland, October 8, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Dubai, UAE, October 14: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Knoxville, Tennessee, October 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Kuala Lumpur, Malaysia, October 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Seattle, Washington, October 24, 2018: 2-Day TapRooT® Root Cause Analysis Training

Houston, Texas, November 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Orlando, Florida, November 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Singapore, Singapore, November 15, 2018: 2-Day TapRooT® Root Cause Analysis Training

Perth, Australia, November 26, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Houston, Texas, December 3, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Amsterdam, The Netherlands, December 3, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Edmonton, Canada, December 10, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

We are global to meet your needs. If you need other times or locations, please see our full selection of courses.

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

Weekly Wisdom

Posted: September 17th, 2018 in Career Development, Wisdom Quote

Investigative Interviewing Webinar: Tips for collecting better quality and quantity of evidence

Posted: September 14th, 2018 in evidence collection, Investigations, Root Cause Analysis Tips

TapRooT® Instructor, Barb Carr, was a recent guest expert for Intelex, a global leader in EHSQ software. View the recorded webinar to learn how to become a more effective interviewer, and collect better quality and quantity of evidence.


Friday Joke

Posted: September 14th, 2018 in Jokes

Technically Speaking – User Settings

Posted: September 13th, 2018 in Software, Technical Support, Technically Speaking

This week in Technically Speaking we will be going over user settings in TapRooT® VI. View the PDF below and get to know your way around the software better!

Technically Speaking is a weekly series that highlights various aspects of the TapRooT® VI software and occasionally includes a little Help Desk humor. Remember, just because it’s technical, doesn’t mean it has to be complicated!

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