657
1 INTRODUCTION Maritime safety has been developed by fatal or
environmentdisasteraccidentsastheaccidentshave
revealeddeficienciesinlegislation, managementand
The Importance of Reporting All the Occurred Near
Misses on Board: The Seafarers’ Perception
G.Georgoulis&N.Nikitakos
UniversityoftheAegean,Chios,Greece
ABSTRACT:Improvementof maritimesafetyhas previously been based on a reactive regulatory approach,
whereregulatoryimprovementshavebeenimposedtopreventrecurrenceofaspecifictypeofaccidentalevent
oraccidentalscenario, after suchanaccidental event has happened. The ISM Code requires
that hazardous
situationsaretobereportedtothecompany,investigatedandanalyzedinordertopreventfuturehappenings.
Nearmissreporting ispositivelyevaluated inthis respect,because,nearmisses arerepresented experiences
andmistakesthatshouldbesharedtolearnfrominordertopreventtheoccurrenceofaccidents.

Theexpressionthatwastoocloseonships’bridgesbetweenthemasterandtheofficersisrarelytransferred
toanearmissreportform,preservingtheprobabilityofreoccurrence.Nearmissesoccurredandnearmisses
reportedmightpresentabigdifferenceinnumber.Officerseasilyforgetthenearmiss
situationwhenthesafety
oftheshipisrestored.
Hazardsidentificationwillbebasedondocumentedmanagementsystem(SMS‐TMSA‐ISO).Theanalysisof
thedocumented safety andquality management willaddress the gapin orderto improve the implemented
systems.
Theobjectiveofthisresearchis tofindoutthe
bestpracticesaboutnearmiss reportingfromthecompanies
considered to have high level of commitment to safety within their organization. The study is based on
interviewswithatotalof35seafarerswhoarejoiningonGreekoceangoingvessels,and4representativesfrom
safetydepartmentsofGreekmaritime
companies.
The research also aims to address the seafarers’ perspective of reporting all near misses which have been
experienced while they were in charge of specific duties (bridge watch, engine room watch) or any other
operation(mooring,maintenance,drill)carriedoutonboard.
The majority of both the seafarers and the
companies’ representatives believe that prior to the near miss
reportingissueasafety cultureenvironmentonboardistherealgainpursuit.Intheirperspectivethisisfirst
prioritytoimprovethegeneralsafetyonboard.Itseemsthatnearmissreportingiscarriedoutonboardasa
compulsory
compliance to the regulatory framework (ISM implementation). Further, it seems that the
companies are not yet utilizing the reported data to improve feedback and the followup within the
organization.
Theauthorswouldliketothankcompanies’representativesandseafarerswhohaveparticipatedinthisstudy.
http://www.transnav.eu
the International Journal
on Marine Navigation
and Safety of Sea Transportation
Volume 13
Number 3
September 2019
DOI:10.12716/1001.13.03.24
658
construction of ships. Major accidents have trigged
huge amendments in regulatory framework,
sometimeswithmajorchangesinthewaysafetywas
evaluatedonboardships.Thismeansthatsafety has
developed step by step in a reactive way. Sacrifices
have been made, sacrifices counting human lives.
Eventually,thishas led
to improvedsafety atsea.It
hasbeenagreedbyallindustry’sstakeholdersthatis
notacceptabletowaitforanotheraccidenttohappen
before safety work can develop further. Instead, the
ideahas come upto usenotonly accidents butalso
occurrencesthatmighthaveresultedinaccidents
but
forsomereasondidnot(i.e.nearmisses).
But what is really the difference between an
accidentandanearmiss?Theoutcome,ofcourse,but
thecircumstancesendingupineitheranaccidentora
nearmiss are most likely similar in many ways.
According to ISM Code, near
misses should be
considered as incidents regarding reporting
procedure. If so, this would mean that also near
misses could deliver experiences valuable to the
future safety strategy. This would also mean that it
mightbepossibletoreachaproactivewaytohandle
futuremaritimesafety.
Nearmissisdefined
asthesequentialhappenings
thathaven’tresultedinlossand/orinjurybuthasthe
risk to do so. Loss can be a personal injury,
environmental damage and/or negative financial
effect on the trade. Mentioned loss has been
preventedbyafortunatebreakinthechainofevents
(IMO MSCMEPC.7/Circ.7, 2008).
In view of its
definition, reporting nearmisses plays an important
role in learning from mistakes, preventing accidents
and suffering from their serious consequences.
Section 9 of the ISM Code requires companies to
establish procedures for the reporting and
investigation of hazardous situations together with
the implementation of corrective actions.
IMO has a
guidance to encourage nearmiss reporting, not a
mandatoryregulation. Therefore,companies and the
nationalauthoritiesaretheoneswhotakeinitiatives.
Every company forms its own reporting system,
either a paper reporting procedure or a computer
system. After all, crew’s understanding of it and
involvement in the
reporting are the core values to
achieve the intended level of reporting, both within
thecompanyandatthenationallevel.
The research was carried out among Greek
seafarers and Greek managed shipping companies.
Thescopeofthestudy was to answer the following
questions:
Whataretheexistingreportingroutinesonboard
ships?
Arethereanybetterpractices thatcanbeproposed
to maritime industry to reach a better reporting
level?
How really seafarers evaluate the near miss
occurrencetowardsnear missreporting onboard
vessels?
Are there motivations provided by the managing
companytoincreasereportingofnearmisses?
Are there any proposals by the seafarers to
increasethenumberofnearmissreported?
What is the perception of companies’
representatives related with external reporting
databases?
Overall aim is to collect the best practices inside
theindustryandmaketheothersthatareaimingata
better level of safety culture, be aware of them and
make use of them. To be able to
reach the main
purpose, existing situation of safety culture, in
connection to nearmiss reporting, will be
investigated.
2 LITERATUREREVIEW
Inthispartofthestudy,thetopicswhicharehighly
relatedtonearmissreportingandsafetycultureand
which are mentioned in the previous studies are
givenwith
ascientificbackground.Itisimportantto
focusonthem,becausetheyhaveaconsiderableeffect
on both people’s resistance to report and for the
futuredevelopmenttoachieveasuccessfulreporting
levelandprocess.Besides, thesepointshaveformed
theframeoftheinterviewscarriedout.
2.1 Backgroundof
relatedstudies
PriortoISMadaptionandenforcement,thenearmiss
reportingissue was implementedin other industries
suchasaviation,nuclearetc.Studieswheretheissue
of near miss reporting was triggered is the iceberg
pyramidtheory(Heinrich1959,Bird1969).According
Heinrich’sstudyforeverymajoraccident, thereare
29
minorincidentsand300nearmisses.FrankE.BirdJr.
drilled even deeper in his study of industrial
accidents, during which he analyzed more than 1.7
million accidents reported by 297 companies. The
essential finding was that for every reported major
accidenttherewere9.8reportedminoraccidents.For
eachminoraccidentwithlosttime,therewerearound
30.2 minor incidents. Diving deeper during this
extensivestudy,Birdfoundoutthatbelowthosereal
accidents, there was a bottom layer of around 600
nearmissesorincidentsthatmighthavecausedmajor
accident.Overall thesefindings are usuallydepicted
in
apyramidwitha11030600ratio.
Figure1.AccidentPyramidSourse:Bird(1969)
Studiesonenhancingsafetyhavebeenmultiplied
since the ISM Code came into force. The focus has
beentheimplementationoftheISMCodeatfirstbut
whilesearchingonthatmanyissuescametosurface,
suchas ithas been perceivedas ahugepaper work
andtimelostby
theseafarers.
Later,thestudiesfocusedonmoredetailedissues
whichmightbethereasonsfortheISMCodetogain
some resistance from seafarers. Nearmiss reporting
has been concluded as being the failing part of the
659
ISM Codeʹs implementation (Lappalainen, 2011). In
manyshipsitisreportedonapaperformataccording
SMS (Safety Management System‐ provided by the
company) requirements which is again perceived as
another extra paper work. Criticisms started on the
sideofthecompanyasisthedirectresponsibleforthe
“excessiveuselessworkload”intheeyesofseafarers.
Company has represented theʹwritten proceduresʹ
whiletheseafarershasrepresentedʹthewaythatthe
workactuallydoneonboardʹwhicharebelievednot
to match each other (Dekker, 2003).
Recommendationsand/orpracticalapplicationsfrom
otherindustries,suchasnuclear,chemical,have
been
proposed in the same studies. Finally, the issue of
ʹblamecultureʹhasappearedtobeconsiderableeffect
on near miss reporting. All these mentioned are
mostlyinvestigatedseparately,however,theyallled
us at the end to think about creating safety as a
ʹcultureʹ both in the company, including
all
management levels, and on board the ships, in the
minds of seafarers. Althoughʹcultureʹ itself is a
complex issue, the aim with the ISM Code is
identifyinghazardousoccurrencesincludingtherisks
to individuals, ships and marine environment, then
reporting them regularly to the company and
continue with proposing
corrective and preventive
actions with an end to apply them to reduce those
identifiedrisks(IMOMSCMEPC.7/Circ.7,2008).One
of the challenges in the maritime industry is
increasing of the work load for seafarers due to
paperwork added. It has always been criticized by
seafarers and gained resistance since the
ISM Code
wasintroduced.Whenahighamountofpaperworkis
introduced, the number of crew working on board,
thescheduleofshipsshouldalsobeconsidered.Ifthe
number of people onboard stays the same or even
decreases together with tight schedule, that causes
high workload for people and
a compromise for
safety. As a result of conducted studies, it is agreed
that paperwork should be reduced. It is a matter of
adaptation which was also mentioned in Dekker’s
(2003)study.
The study carried out in 2006 in Norway
controlled 83 liquid and dry bulk cargo vessels
showed that feedback
from the company is a
positively influencing factor for reporting more
frequently(Oltedal&McArthur,2011).
Theinterviewresultsfrompreviousstudiesclearly
show that, especially, experienced seafarers perceive
some of the events are not worth reporting. They
think that those events are somehow inevitable and
donotcompromisesafety.
Whentheyarerequiredto
reporteventhoseminorones,theirperceptionisthat
this reporting scheme is being made more
bureaucraticwhichisconsideredasanegativefactor.
2.2 Thehumanelementnoblameculture
Mistakes are included in human element.
Contributing factors to human error can be both
individual
andorganizationalfactors.Individualcan
bestress,fatigue,insufficienttrainingandexperience,
poorlevelofcommunicationwhiletheorganizational
influences can be lack of time, poor design of
equipment, and poor level of safety culture. MCA
GuideonHumanBehavior(2010)explains theeffectofa
good safety culture as
the serious approach of the
senior management towards all these mentioned
factors which contribute on mistakemaking. Senior
management is waited to invest on these factors.
Whenitisclearthatitisnormalforpeopletomake
mistakes, it is also clear at the same extent that
organizational factors have
a considerable effect on
helping create the human behavior which includes
mistakesaswell.Thisleadsustoshiftfromtheʹblame
cultureʹtoaʹjustcultureʹ(MCA,2010).Sameissueis
emphasized by IMO Guidance on Nearmiss reporting
that company should adopt aʹjust cultureʹ to
encouragereporting
(IMOMSCMEPC.7/Circ.7,2008).
The first principle to create aʹjust cultureʹ is to
accept that the human error is inevitable. Therefore,
policies, processes and interfaces in an organization
mustbemonitoredandimprovedallthetime.Inthe
sameguidance open communication,discussionand
team management issues are also addressed
which
arebelievedtohaveaneffectonaʹjustculture’.
Creating a safety culture, in the most effective
way, has always been an issue for the maritime
industry. Not only the duty of the ship is to create
safety culture on board and maintain it but also so
many
otherorganizationssuchasportstates,owners,
operators, national and international organizations
among many others are included in the creation,
reviewandfeedbackprocess.TheISMCodewasthe
attempt to form the safety culture in the maritime
industry. After ISM Code was introduced, studies
havebeencarriedouttosee
howmuchsuccessfullyit
has been implemented and what criticisms it has
gained. Near miss reporting has seen as the failing
part of ISM code’s implementation and received
resistancefromtheusers(Lappalainen,2011).
Safety culture definition of IMO Maritime Safety
Committee is that “it is a culture in which
there is
considerableinformedendeavortoreduceriskstothe
individual, ships and the marine environment to a
levelthatisaslowasisreasonablypracticable”(IMO
MSCMEPC.7/Circ.7,2008).
Under this approach near miss reporting
consideredasthemostimportanttoolinlinkbackthe
error chains before drifting
into failure. The main
points of reporting near misses are learning from
others’ experiences and avoid accidents. It can be
said, in other words, that it is big resource for the
companies especially for the small ones to have a
bigger pool of occurrences on board and their
preventiveactions.
Then,itbecomeseasiertomanage
safety related issues on board, such as technical
failuresamongmanyothers.Nearmissandaccident
reporting systems are the ways of sharing
experiences. Reporting nearmisses is the factor that
canlead tobettersafety level as a resultof learning
fromsmall mistakes
andavoiding them to turninto
majoraccidents.
3 METHODOLOGY
In this section data collection together with the
interview content (The profile of the companies and
people participated in the interviews questions and
analysisoftheanswerswasgiven)arepresented.
660
Themethodusedfordatacollectionwaspersonal
interviews in a semi structured way. Question was
presentedinacloseform(wasansweredbyaYESor
NO)butdependingontheanswertherewasasecond
open requirement granted by the interviewer. This
methodwasusedbothforcompanies’
representatives
andseafarers.
3.1 Interviewers’profile
Totally 39 people were interviewed which includes
one(1)DPA,one(1)crewmanagerandtwo(2)safety
departmentemployees,fromshoreside,7masters,4
chiefengineers,6chiefofficers,5second engineers,7
second officers and 6 third engineers. All the
participants
were Greek. Ages were approximately
between 24 and 55. The companies chosen to
participate are considered (according their quality
systems)tobeinahighlevelofsafetybothonboard
and at the office. Interviews were confidential.
Therefore,theyappearasletters.
CompanyAisaGreekcompanyrunning 17
ships
(5bulkcarrierspanamaxandsupramaxsize,and12
tankers of various sizes). The DPA of the company
participatedintheinterview.
CompanyBisaGreekcompanyrunning32ships
(allbulkcarriersofcapsize,postpanamax,panamax
sizes). The safety department subdirector of the
companyparticipatedintheinterview.
Company C is a Greek company operating 28
ships(alltankersofvarioussizes). Amemberofthe
safetydepartmentparticipatedintheinterview
CompanyDisaGreekcompanyrunning52ships
(bulkcarriersandtankersofvarioussizes).Thecrew
managerofthecompanywasinterviewed.
36 Seafarers were participated in the interview
while they were attended courses of special schools
according STCW requirements. The interview was
conducted during the intervals of the classes.
Seafarers were served on various types of ships
of
variouscompanies.
4 FINDINGSOFTHEINTERVIEWS
In this part findings from the interviews are to be
listed, separately from the shorebased and onboard
organizationsʹperspectives,respectively.
4.1 Companies’representatives’answers
In these interviews were participated one DPA, one
crewmanagerandtwocompanies’safetydepartment
members. They
were all Greeks and the Greek
language was used. Ages of the company’s
representativeswere between4555 years old.All of
themwere servingtheircompanies for15 years and
more. Participants answered the interview questions
asfollowing:
1 Do you think that reporting of near misses is a
matter
ofcompliancetoregulatoryframeworkora
factor to increase overall safety within the
company?
All of them answered that “it is a factor of
increasing safety, but it still on the evaluation
process regarding the number and nature of
reports.
2 How many near miss reports are received
approximately
pership/peryear?
Table1.Nearmissreported
_______________________________________________
Numberofvessels Numberofnearmisses
_______________________________________________
CompanyA 1712pershipperyear
CompanyB 327pershipperyear
CompanyC 2810pershipperyear
CompanyD 529pershipperyear
_______________________________________________
The52shipsowningcompanywasreceived9per
shipperyear, the32 shipsowning companywas
received7pershipperyearThe28shipsowning
company was received 10 per ship per year and
finally17shipsowningcompanywasreceived12
pershipperyear
3 What
kindofnearmissesarereported?
Allthe tankerowning shipscompanies’
representatives claimed that they are receiving
mostlyequipmentfailurenearmissesreportsthan
the human error near misses in a percentage of
70% against 30% respectively. The bulk carrier
company’s representative claimed that near
misses’ reports are more
or less the same in
number either regarding equipment failure or
humanerror.
4 Is your reporting system revised since ISM
implementation?
The answer was the same for all companies. The
systemisusedfornearmissreportingistheSMS
format and is the same from 1/7/1998 when ISM
was
implemented.
5 Isincreasing ofnear missesreportedreallya key
factorforimprovingoverallsafetyonboardships?
All of the representatives believe that if they are
advised to report every small detail, reporting
losesitsimportanceandreality.Theyallthinkthat
number of near misses is not
an indication of
safetylevelonboard.Theysaythatthenumberof
accidentscanbeanindicationbecausetheycannot
behidden,andtheymustbereported.Sincenotall
the near misses are reported, there are hidden
ones,theycannotbeanindicationofanything.
6 Is your company
motivating its employees on
boardforincreasingreporting?
Only two of the interviewed representatives
answered positively in the above question and
motives are not related to money, but as
contributing factor to promotion of the crew
members. All four of them say that awarding
systemsdo not increasethe number
of nearmiss
reportingbutcontributetoenhancesafetyculture
environmentonboard.
7 Is your company implementing the “no bla me
culture?”
All the representatives say that no blame culture
shallnotbeconsideredasincompetencytolerance
bythecompanyandwhenanearmissoccursdue
tohuman error only
at thevery first time the no
blameculturewillapply
8 Inyouropinionthesafetycultureonboardships
inanacceptablelevel?
Allthe tankerowning shipscompanies’
661
representatives believe that safety is in a higher
than an acceptable level but when it comes to
safetycultureenvironment,theythinkthatthereis
a lot of work to be done starting with the
newcomers in the job (mostly seafarers). Instead,
thebulkcarriercompanyrepresentativesaysthat
the
safetyculturelevelinhiscompanyisaslowly
increasingprocedure.
9 Is there a system within your company of
analyzing reported near misses to support
feedbackandfollowupprocedures?
Feedback process works quite similar in all the
companies with small differences. The reports
come to the responsible person
for the reporting
system,DPAorsafety departmentmanager,then
distributedtotechnicalormarinesuperintendents
dependingonthenatureofthenearmiss.Afterall,
DPAgetsthereport,addshisideasandforwards
ittotheship. Regardingfollowupsystemtheonly
procedure to check if the proactive
measures are
implementedonboardisinternalauditsonboard
bycompany’srepresentative.
10 Whatkindof barriersare therefor reportingand
forthedevelopmentofsafetyculture?
All the participants agreed that barriers to near
miss reporting are considered the excessive
workload and the paperwork, the seafarers’
perception
onreportingespeciallythemasters’
11 Are you in favor or against to report companies
nearmissesdirectlytoanexternaldatabase?They
all agree that a common database for all Greek
companies is a very power tool by sharing other
companies’ experiences and improving feedback
tothe ships.Butthe
first stepis to usecomputer
systemsforreportinginauserfriendlyandsimple
way.
4.2 Seafarers’answers
Inseafarers’interviews7masters,4chiefengineers,6
chief officers, 5 second engineers, 8 second officers
and 6 third engineers participated. All the
participants were Greek. Ages were approximately
between
24 and 50. They answered the questions as
following:
1 Do you think that reporting of near misses is a
matterofcompliancetoregulatoryframeworkora
factortoincreaseoverallsafetyonboard?
Answersherearequitesurprising.Inapercentage
of 60% they think that reports are a
regulatory
complianceandonly 40% of them think that is a
safetyimprovingfactor.Thesurprisingpartisthat
junior officers and engineers believe the second,
whilemasters, chief engineers and senior officers
believethatnearmissreportingseparatelyisonly
addingpaperwork,buttheyhavetocomplywith
the
company’swrittenprocedures
Figure2. Near miss: Regulatory obligation or safety level
factor
2 How many near miss reports are reported
approximatelypership/peryear?
Mastersintheirvastmajority(5outof7)claimed
thattheyreport12monthlyintheformalwaybut
they discuss more than67 internally with their
crew.
3 What kind of near misses are reported? Are
shipping companies providing ships with
guidelines on what kind of near miss will be
reported?
Masters(4outof7)andchiefengineers(3outof5)
say that they report near misses which are not
expandedtothelackofsafetyculture.“Theseare
notthesignificantones” they say.
A chief officer
gaveanexampleofacloseencounterinopensea,
but he did not report the fact as a near miss
becausesuchareportmightcosthisjob.
4 Isincreasing ofnear missesreportedreallya key
factorforimprovingoverallsafetyonboardships?
Many
of the participants (28 to 35) agree on that
numberofreportsisnotakeyfactorofsafetylevel
onboard.Mostofthemsaythattheyoftendiscuss
the happeningsand take the actions immediately
however,theydonʹtmakeanyreport.They believe
thatsafetymeetingson
boardareastrongertoolto
improve the ship’s safety level than near miss
reporting and by including near misses in the
agenda of safety meetings the job is done in a
simplerandmoreeffectivemanner.
5 Are in your experience shipping companies
motivating seafarers on board for increasing
reporting?
Many(20out of 35) of the interviewed
saythattheyhaveheardaboutpromotionmotives
fromsomecompanies(mostlytankeroperating)
6 Are in your experience shipping companies
implementingthe“noblameculture?”
They all are familiar with the expression but in
theirmindnoblameculturesometimesespecially
to
junior officer and engineers is perceived as
tolerance from their superiors. Masters (all of
them) claimed that “no blame culture” is a
dangerouspolicywhenitcomestosafety.
7 Inyouropinionissafetycultureonboardshipsin
anacceptablelevel?
Seafarerssaythatsafetyculturehastobe
fittedin
the minds of the seafarers prior to joining a ship
fortheveryfirsttime.Oneofthemasterssaythat
whenheconductedtrainingonboardonaspecific
issue,hehadtorevertonthetrainingissueaweek
later and participants are not still aware
of the
trainingissue. “If fora simple matter alertness is
662
very poor who is talking about increasing near
missreporting?”
8 Is there a system within shipping companies of
analyzing reported near misses to support
feedbackandfollowupprocedures?
According to the seafarers’ statements nowadays
allshippingcompaniesareimplementingfeedback
procedures either from other company’s ships
reportsor
accidentsoccurredonothercompanies’
ships.Butforthefollowupprocedurethereisnot
a proof of decided proactive measures
implementationonboard
9 Whatkindof barriersarethereforreportingand
forthedevelopmentofsafetyculture?
Masters and chief engineers say that the most
important barrier
is the resistance of seafarers to
comply, the excessive workload in an already
heavyschedule and the “weknow how things is
done”philosophy
10 Are you in favor or against to report companies
near misses directly to an external database?
Seafarersin theirvastmajority (30 out of 35) say
that the first step is the use of a computer
reporting system in a simple manner between
shore and ship. Shipping companies have to
cooperateonthesubjectandconcludeinacreation
of such a database in a national or international
level.
5 CONCLUSIONS
The objective of this research
was to find out best
practices about nearmiss reporting from the
companies considered to have high level of
commitment to safety within their organization.
Inside the safety departments of these companies’
efforts are made to create on board a safety culture
environment and although increasing of near miss
reporting gain
a strong resistance by seafarers the
numberofreportingisquiteimpressive.
Companies’representatives believethatnearmiss
reportingisanindicatortosafetybutisstillunder
evaluation.Onthecontrary,seafarersbelievethat
near miss reporting is more an obligation to
regulatory framework than a commitment to
safety.
Both the participants seafarers and companies’
representativesagreeonusingasimplemannerof
reporting through a computerbased system
insteadtheISMhardcopyformat.
Increasing the numbers of reporting is not
necessarilyanincreasinginsafetyculturelevelon
board a ship. According to the majority of the
participants from both onboard and shore
organization, providing more significant and
rarely happening near misses to the company is
moreimportantwithregardtotheactual
purpose
ofthenearmissreporting.
Financial motivation is not preferred by the
companies. Promotional is most likely but the
resultsarestillunderevaluation.
Noblameculturealthoughisrecommendedbythe
companies, seafarers especially the superior
officershavereasonstobelievethatresultswillbe
worse.
All participants agree to the use of an external
common database for reporting near misses as
they consider that pool of experiences is
dramatically increasing giving the chance to
companies’representativesandseafarersto“learn
fromothers”
Forcompaniesandseafarersthereisalotofwork
to be done
in the aspect of training courses aiming
firsttochangethecultureonboardinthedirectionof
safety.ProgramsofstudiesintheMaritimeacademies
and inhouse training courses for the companies
shouldbeadjustedto“plant”thesafetyintheminds
oftheofficers.
Finally, regarding near miss
there is no clear
evidence which shows that safety culture on board
andwithinthecompanieswillincreasebyincreasing
thenumberofreportingorcompanies.
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