Documents
Transcription
Documents
R -D TM TI Marine & Pollution Incident Investigation Report er Collision between the Domestic Commercial vessel Jet X 29086QE and the windsurfer on his sailboard in the South Wave Break Island Channel resulting in minor injuries and damage. un d Title: se d Incident date: 10/04/2015 Category 3 lea Category: CaseMan no: GC40968 (N/A for TOMPA incidents) Stephen Knowles Position Marine Officer Grade 3 - MSI 104550 Division Maritime Safety Queensland Regional office Gold Coast Address 40 - 44 Sea World Drive, Main Beach 4217 Contact number 07 55851816 Email [email protected] Report date 15 June 2015 Re Investigator Marine incident investigation report 135 -04257 Form Released Copy.pdf - Page Number: 1 of 22 F3072 ES v04 Sep 2013 Page 1 of 13 Summary Regional office: Gold Coast DMS File No: 230/00609 Incident date: 10/04/2015 Time of incident: 11:32hrs Category: Category 3 Date reported: 13/04/2015 Incident type: Collision Between Ships Officers attending: Contact No: QPS attended: Officers attending: Contact No: QAS attended: Officers attending: QBFP attended: Officers attending: Aquatic event: (copy of permit attached) DT M R MSQ attended: Contact No: Contact No: I- Evidence Add evidence RT Restitution Remove evidence Example: costs of oil response, damage to beacons, total cost of repairs and so on (attach quotes / invoices to report) er Location Latitude: un d Body of water / landmark: MA 12 - South Wave Break Island Channel, Labrador -27.9461 Longitude: 153.4164 Latitude & longitude must be recorded in decimal format for entry into the CaseMan system. All coordinates in deg/min or deg/min/sec format must be converted to decimal degree format for entry. For example 16°30'S would become -16.5000 degrees. Conditions Weather: Clear Calm Tide: Incoming Visibility: Good Wind: Re lea Water: d Smooth waters (incl. tidal rivers & creeks) se Waters: Moderate (force 3-4 / 7-15 knts) Pollution Source Pollutant Ship: Sheen: Land: Diesel: Unknown: Bilge: HFO: Extent Other: or Size of slick (length and width in metres) Marine incident investigation report Litres 135 -04257 Form Released Copy.pdf - Page Number: 2 of 22 F3072 ES v04 Sep 2013 Page 2 of 13 Ships involved Add ship Remove last ship Ship 1. Ship name : Jet X Owners name: Jetboat Extreme Commercial Ship class: Class 1 Ship description: 6.69 alloy monohull jet boat Reg no: 29086QE DT M Ship type: R Owners address: Boat mark: Port of registry: GOLD Registration expiry: 23/09/2015 Length (in metres): 6.69 Engine type: Inboard (diesel) I- Registering authority: AMSA Construction: Aluminium RT Beam (in metres): 2.38 No. of engines: 1 Last monitoring date: Total power (kW): 308.9 Written direction: er Previous incidents: nd Master of ship 1. Masters name: Masters address: Place of birth: Home phone: d Mobile phone: se Personal Information Date of birth: Personal Information Personal Information Email address: RUF: Personal Information Work phone: Coercive powers used: Statement/ROI: lea Marine licences: Coxswain & MED 2 Add deceased or injured persons on ship 1. Re Add crew on ship 1. Add offence details for person on ship 1. Marine incident investigation report Add inj. person Remove inj. person Add crew Remove crew Add offence Remove offence 135 -04257 Form Released Copy.pdf - Page Number: 3 of 22 F3072 ES v04 Sep 2013 Page 3 of 13 Legislation: National Law DCV Section: 18(4) Suspect interviewed: MIN issued: MIN details: Transcription: MIN #: Elements proven: Issuing officer: Breach duty to take reasonable care for safety of persons (master) Section 17(2) Address: R Name: DT M Personal Information Date of birth: Personal Information Role: Master Licence number: Expiry date: 31/07/2018 Offence recorded for ship 1. Add witness Personal Information Address: known by MSQ Home phone: Remove witness RT Name: I- Add witness er Mobile phone: Coercive powers used: un d Email address: Work phone: Statement provided: Evidence adopted: Name: Address: d Personal Information se known by MSQ Home phone: lea Email address: Mobile phone: Work phone: Coercive powers used: Statement provided: Re Evidence adopted: Marine incident investigation report 135 -04257 Form Released Copy.pdf - Page Number: 4 of 22 F3072 ES v04 Sep 2013 Page 4 of 13 Name: Address: Personal Information Known by MSQ Home phone: Mobile phone: Work phone: Email address: Coercive powers used: R Statement provided: -D TM Evidence adopted: Ship 2. Ship name : unnamed sailboard Owners name: Owners address: Ship class: Recreational Ship description: 2.4 metre fibreglass sailboard Reg no: unregistered RUF: Boat mark: Port of registry: de Registering authority: Registration expiry: Engine type: Last monitoring date: Previous incidents: Master of ship 2. Beam (in metres): 0.6 un 2.4 Construction: Fibreglass No. of engines: 0 Total power (kW): Written direction: ed Length (in metres): TI Recreational rR Ship type: Masters name: Place of birth: Masters address: Home phone: Email address: Date of birth: Work phone: Mobile phone: Statement/ROI: Coercive powers used: Marine licences: Add deceased or injured persons on ship 2. Marine incident investigation report Add inj. person 135 -04257 Form Released Copy.pdf - Page Number: 5 of 22 F3072 ES v04 Sep 2013 Remove inj. person Page 5 of 13 Name: Phone: Address: Email address: Fatality: Statement: Admitted to hospital: Hospital: Coercive powers used: Doctor: R Nature of injuries: 2 fractured ribs. soft tissue damage and vertigo Role: Master DT M Deceased or injured person related to ship 2. Add crew on ship 2. Remove crew Add offence Remove offence I- Add offence details for person on ship 2. Add crew Add witness Remove witness Re lea se d un d er RT Add witness Marine incident investigation report 135 -04257 Form Released Copy.pdf - Page Number: 6 of 22 F3072 ES v04 Sep 2013 Page 6 of 13 Summary of facts—explain incident & investigations conducted On Friday the 10th day of April 2015, the DCV Jet X 29084QE and a sailboard were operating in The Incident the South Wave Break Island channel when they collided. The Jet X, a 6.69 metre alloy constructed thrill ride boat powered by a inboard diesel engine through a jet propulsion unit, was on the return leg of a 55 minute cruise/joyride of the Broadwater when it negotiated a shallow narrow channel known as the "shortcut" emerging in the South Wavebreak Island Channel. R Include full particulars of vessels, voyage and location of incident. At the helm as master was a commercially qualified Coxswain. Onboard were a total of 11 passengers made up of 8 adults and 3 children. -D As the Jet X entered the channel, a windsurfer owned and operated by commenced a south westerly run from Wave Break Island after turning in the shallows at the island. TI At 11.32am, navigated across the channel and performed a spin in the water adjacent to the sandbank. The spin brought the Jet X to a stationary position with its head pointing in a north westerly direction then accelerated away from the stopped position and applied port helm to achieve a large port sweeping turn before entering the 6 knot area near the Grand Hotel. He failed to observe the windsurfer. un de rR watched the Jet X arrive in the channel at speed, spin, stop and accelerate again. He continued to watch the progress of the jet-boat as the gap between himself and the jet-boat decreased and on deciding that the jet-boat was not going to take action to avoid the collision, assessed that if he altered to starboard, the jet-boat would go behind him. He was unaware that had neither seen him or that the jet-boat was not navigating a straight course. He altered between 10 and 15 degrees to starboard and continued some 50 to 60 metres before realising a collision was imminent. Immediately before impact, let go of his boom and covered his head. He was then struck by the starboard stern quarter of the jet-boat, knocked from his upright position and went under the stern of the jet-boat. se came to the surface and clung to his board. slowed and returned to and stopped alongside him before engaging in a conversation. Another windsurfer arrived a short time later and provided some assistance to determined that was uninjured and was being assisted by a friend. He exchanged details and departed the scene made his way ashore. lea The above incident was reported to Maritime Safety Queensland on Monday the 13th day of The April 2015 by both the master of Jet X and the windsurfer. As a consequence, it was detailed to Investigation the investigating Marine Safety Inspector on the 15/4/2015. Re The incident was subsequently categorised as a cat 3 Marine Incident. Both persons involved reported the incident as occurring on the 10th of April 2015 at approximately 11.32am. The I/O has confirmed that ship 1, Jet X - 29086QE was issued with a Certificate of Operation for an existing vessel. It is a alloy constructed 6.69 metre mono hull jet boat powered by a 308.9kW main engine. At the time of the incident, it was operating within its permitted smooth water (E) limits and being operated by Jet Boat Extreme Pty Ltd. The master of ship 1 is identified as DOB Personal Affairs and was found to be the holder of both a Certificate of Competency as a Restricted (Sheltered Waters) Coxswain Grade 1 and a Marine Engine Driver Grade 2. Marine incident investigation report 135 -04257 Form Released Copy.pdf - Page Number: 7 of 22 F3072 ES v04 Sep 2013 Page 7 of 13 Ship 2 is a sailing vessel without any mechanical propulsion. It is described as a JP slalom 66 sailboard, 2.4 metres in length and rigged with a Severne Reflex 6 sail. The master of ship 2 is identified as and whilst not requiring any license, holds both a Recreational Marine Drivers License and a Personal Watercraft License. R The tide was flooding with an expected high tide at the Gold Coast Seaway at 11.55am of 1.1metres. The wind speed was an estimated 15 to 18 knots from the south east. RT I- DT M A statement was obtained from on the 17th of April 2015. In his statement he describes the lead up to the incident and his activity that included sailing a circuit at speeds between 15 and 20 knots within the South Wave Break Island channel between the Labrador channel and the south western end of Wave Break Island. He recalls the jet boat first performing a spin on the southern side of the channel before accelerating again. At this time, he was sailing a south westerly course and the jet boat was off to his port side. The jet boat continued increasing speed from his spin and stopped position and who now thought he was aiming at him performed an assessment of the risk of collision if he continued and deemed that if he did nothing a collision would result. He then describes veering off to the west to give the jet boat room to go under his stern. He continued to watch the jet boat over his shoulder and determined that the master of ship 1had done nothing and a collision was imminent. He believed he was going to be killed and immediately brought both hands up to protect his head. The starboard stern quarter of the jet boat impacted and knocked him from the board and he then went under the stern before coming to the surface. He further describes the masters actions and his recovery to shore. er provided overlays of his track recorded on a GPS worn whilst sailing. It provides a history of tracks undertaken that morning, the alteration of course and the point of impact. un d The I/O attended the office of Jetboat Extreme on the 17th of April and was provided with a document entitled Supporting Evidence of Marine Incident and on request, a copy of the passenger manifest and logbook for the day in question. The supporting evidence provided by was drafted after he had read information about the incident on a windsurfer forum found on the Seabreeze website. ed Statements were obtained from a passenger and witnesses on the foreshore at Labrador. ele as On the 16th day of July 2015, in company with his Solicitor attended the Maritime Safety Queensland office on the Gold Coast and willingly took part in an electronically recorded record of interview. This interview focused on the failure by in relation to his duty as a master of a DCV to take reasonable care for the safety of persons who may be affected by his acts or omissions. [Section 17(1)(b)]. During this interview, he attempted to claim privilege as a stand on vessel but later reluctantly admitted not seeing the windsurfer until after impact. whilst able to recite specific rules from the International Regulations for the Prevention of Collisions at Sea, clearly had little understanding of the application of those rules. readily answered all questions and admitted not being distracted or reacting to any onboard emergency. He was familiar with the area and knew that on windy days, windsurfers operated in the area. He had not previously assessed or mitigated the risks associated with operating in close proximity to windsurfers and on the 10th of April, saw 2 windsurfers He could offer no reason or excuse for failing to take reasonable care for the safety of persons in relation to his duty as a master. Marine incident investigation report 135 -04257 Form Released Copy.pdf - Page Number: 8 of 22 F3072 ES v04 Sep 2013 Page 8 of 13 The I/O determined that had failed in his obligation to maintain a proper lookout (Rule 5) and in doing so did not determine by any means if risk of collision existed (Rule 7) nor did he take action to avoid a collision. (Rule 8) There is no evidence to suggest that fatigue, drugs or alcohol contributed in any way to this incident. Re lea se d un d er RT I- DT M R acted appropriately post-incident and offered all reasonable assistance, completed incident reports and provided additional information as requested. Marine incident investigation report 135 -04257 Form Released Copy.pdf - Page Number: 9 of 22 F3072 ES v04 Sep 2013 Page 9 of 13 Contributing factors Contributing factors are not the cause of the marine incident but rather factors that may have contributed to the incident taking place or it's severity. All factors that potentially contributed to the incident should be recorded here. Human contributing factors Insecure mooring Commercial pressure Insufficient crew numbers Excessive speed Insufficient fuel Failure to wear engine kill switch lanyard Insufficient maintenance Failure to wear PFD Insufficient planning Fatigue Navigation error—failure to keep proper lookout Inadequate training of crew Navigation error—other Inappropriate advice to ship—Harbour Control/Port Authority Navigation error—violation of Colregs Inappropriate advice to ship—Pilot Operational error—other Inappropriate advice to ship—Vessel Traffic System Overloading Inappropriate instructions to crew—other Poor communications Inappropriate instructions to crew—poor communications Poor ship to shore communications Inattention Violation of standard procedures DT M I- RT Violation of statutory rules or standards Inexperience or lack of knowledge er Other (human): un d Material contributing factors Bridge or navigation failure Electrical failure Equipment failure - other Fuel or gas leak d Hull failure Inadequate stability—other se Inadequate stability—overloading lea Other (material): R Alcohol or drugs Inadequate stability—shifting cargo Inappropriate hull or equipment—construction fault Inappropriate hull or equipment—design fault Inappropriate hull or equipment—insufficient maintenance Insufficient safety equipment Machinery failure Shore structure badly designed built or maintained Environmental contributing factors Re Abnormal tidal conditions Hazardous waters—uncharted hazards Bar conditions Heavy traffic area Floating or submerged object Poor visibility Hazardous season (cyclones etc) Sea state Hazardous waters—coral reefs Wash of passing vessel Hazardous waters—lack navigation aids Wind Hazardous waters—shifting channel Other (environmental): Marine incident investigation report 135 -04257 Released Copy.pdf - Page Number: 10 of 22 Form F3072 ES v04 Sep 2013 Page 10 of 13 Findings Add findings Remove last finding 1. DCV Jet X involved in Marine Incident at time, date and place 2. DCV Jet X appropriately registered and crewed 3. Windsurfer undertaking both permitted and lawful activity in area frequented by similar craft R 4. Master DCV Jet X familiar with area and activities undertaken in area DT M 5. Master DCV admitted not seeing windsurfer - failed to keep proper lookout 6. Master DCV failed to assess risk of collision 7. Master DCV failed to take action to avoid a collision I- Conclusions RT The incident has been investigated as a Cat 3 Marine Incident and involved both a DCV and an unregistered and unregulated sailing vessel. er The I/O has determined that the master failed to take reasonable care for the safety of persons in relation to his duty as a master. In arriving at the determination, the I/O considered that his failure to comply with the International Regulations for the Prevention of Collisions at Sea significantly contributed to the resultant collision and injuries to the windsurfer. Re lea se d un d A Breach Report was submitted to AMSA and it is recommended that it is progressed to an infringement notice for the specified offence. Marine incident investigation report 135 -04257 Released Copy.pdf - Page Number: 11 of 22 Form F3072 ES v04 Sep 2013 Page 11 of 13 Completed actions Acknowledgement letter sent Attached CaseMan file closed or reassigned Attached Marine incident categorised Attached (Not applicable to TOMPA incidents) R (Not applicable to TOMPA incidents) Attached DT M Ship inspection report (monitoring inspection completed) Written direction issued Photographic evidence taken I- Exhibits seized RT Witness statements MIN issued er Evidence un d Other POLREP form sent Attached Attached Attached Copy attached Attached Attached Copy attached S Knowles By whom (enter name) Re lea se d CaseMan incident, ship and person records updated and validated Attached Marine incident investigation report 135 -04257 Released Copy.pdf - Page Number: 12 of 22 Form F3072 ES v04 Sep 2013 Page 12 of 13 For consideration by Compliance Section DT M R Further action required—copy of file forwarded for review and prosecution for specified offences. Stephen Knowles er Name: RT I- Report completed by un d Position: Marine Officer Grade 3 Name: Greg Turner se d Report endorsed by lea Position: Area Manager (Gold Coast) Re CaseMan updated by Name: Stephen Knowles Position: Marine Officer Grade 3 Marine incident investigation report 135 -04257 Released Copy.pdf - Page Number: 13 of 22 Form F3072 ES v04 Sep 2013 Page 13 of 13 Maritime Safety Queensland Statement of Witness Statement Number Date 1 17 April 2015 Statement of Date of birth Age DT M Occupation R Name of witness Shipping Inspector/Authorised Officer taking statement Position (insert position title, for example, marine officer) Stephen Knowles Marine Officer (Marine Safety Inspector 104550) Region (for example, Cairns) Base office (for example, Weipa) Brisbane Gold Coast I- Name of Inspector (full name) Registered Number RT T 212 eside at an address known to Maritime Safety Que d 2. Since the age craft in various forms including dinghies, ocean Personal Watercraft Licence. un racing yachts and sailboards. I have a Queensland issued Recreational Marine Driver’s License and a d 3. I took up the sport of windsurfing some 4 years ago and sail regularly on the Broadwater and lower Moreton Bay area. The area I frequent on the Broadwater includes the waters on the western side of se the waterway bounded by the end of North Street in the south to Shearwater Esplanade in the north. This area provides consistent calm water in strong winds and is surrounded by numerous low-lying lea sand banks. Re 4. I remember Friday the 10th of April 2015. On that day I took some time away from work to go windsurfing in the area adjacent to the Grand Hotel Labrador. The wind on the day was southeast and had an estimated speed of no more than 15 knots. As a consequence, I chose to use my JP slalom 66 board that is described as a board 2.4 metres long, 0.66 metre wide and has 108 litres of buoyancy. I rigged it with a Severne Reflex 6 sail measuring 7.8 metres. I was wearing a red rashie and shorts underneath a black purpose built harness and thick padded Prolimit life jacket. Page 1 of 4 Corporate Forms Area Form F5009 CFD V01 Aug 2013 135 -04257 Released Copy.pdf - Page Number: 14 of 22 Maritime Safety Queensland Statement of Witness 5. Whilst windsurfing on that day, I had attached a GPS, a highly accurate, speed windsurfing racing approved Locosys GT-3 that enables me to record both my track and speed at one second update R interval. I have a programme on my computer that enables downloading of the day’s activities and I -D TM am able to review, print or share through social media with others. I was using the GPS device on this day. 6. About 11.32am, according to my GPS data, on that day I navigated a north easterly course towards the south western corner of Wavebreak Island before turning downwind and commencing an almost reciprocal course towards the Grand Hotel. I believe there was one other windsurfer in the area at TI this time. I was tracking at a speed of between 15 and 20 knots in the light winds when I saw that a yellow and red commercial jet boat was now off to my approximately 45 degrees front/left site and rR also operating within the same channel. I watched him over my shoulder and saw him do a spin about 100 meters away followed by a freestyle, swinging the jet boat’s back left and right before de taking off again in straight line in my general direction. 7. I continued on my course whilst I monitored the jet boats’ movements and soon after determined un that he appeared to be accelerating towards me. I kept watching as the distance between us decreased from about 90 to 50 meters and I then made a deliberate minor course change to my right to give the jet boat more space and at that time remember thinking he should now be pointing d behind me as I was constantly moving forward. He didn’t and I felt as if he was aiming right at me se and constantly adjusting his course to achieve that. As the distance between us decreased rapidly to about 10-15 meters I knew, having many years of boating and competition water skiers towing lea experience, that there is no way collision can be avoided at that speed, estimated to be around 50 km/h. As the boat’s front was perfectly lined up with my head there was no chance to escape and at that moment I thought it was all over and I was going to be killed. Immediately before the collision I Re brought both my hands and arms up to protect my head and turned my side and buttock towards the boat in order to position my head as far as possible from the impact. 8. On impact with my body and board, I remember going under the right rear of the vessel before re- surfacing. The jet boat I now know as Gold Coast Jet X was now stopped and had approached me in the water. I was disorientated, shocked and could not believe what had just happened. I saw a Page 2 of 4 Corporate Forms Area Form F5009 CFD V01 Aug 2013 135 -04257 Released Copy.pdf - Page Number: 15 of 22 Maritime Safety Queensland Statement of Witness number of people in the jet boat and the skipper, a person I now know as then arrived and was also assisting. I provided he could go. He kept asking if I was OK and I sa s feeling glad to be he other windsurfer with my details and told him that I was OK and s. I then said to him, “I was watching you the R alright. I could move all my limbs and at that p was asking if I was -D TM whole time and you didn’t see me?” A fellow windsurfer who came to help also asked him why he is doing this? (He recognized this driver who came so close to him in the similar manner just week prior to this accident. When my follow windsurfer lost the balance due to a large spray and water, this driver came back and laughed together with the passengers and then took off.) He didn’t respond but asked again if I was OK and if I’m ok to get to shore. I said that I was ok and being only hundred meters from shore and surrounded by many sand banks I said I was ok to manage to get back with my TI fellow windsurfer’s help if needed. rR 9. I was then assisted ashore by the other windsurfer. I inspected my gear once ashore and saw that I had a crack in my board, the boom was damaged and I had a tear in my harness. Friends ashore had seen the incident and over the next 2 hours supported me before eventually convincing me to get de back on the windsurfer in an effort to face my fears or “get back on the horse” to help get over the physiological aspect of the collision. I then fitted a new, smaller sail and spare boom to a different, un much larger board and went out on the water for one slow run towards the Wave Break Island and back. I started to feel the pain so I finished. During that period a jet boat from the same company again appeared however this time stayed well away from the area and drove through the deep d South-North channel towards the Gold Coast Seaway. se 10. I then recovered my gear and went home. I was now feeling the effects of the collision and had a very sore chest, left ankle and wrist and also neck muscles. I thought may have broken a rib. My left lea ankle and arm had now swollen, I noted the onset of bruising to my left hip, legs and felt as though I had strained neck muscles. Over the weekend I regularly applied an ice pack in order to reduce the Re swelling and pain. 11. I downloaded the data from my GPS and was able to clearly see my course and speed. The recorded track for my last leg sailed pre-incident clearly showed the alteration of course to starboard and the north. Page 3 of 4 Corporate Forms Area Form F5009 CFD V01 Aug 2013 135 -04257 Released Copy.pdf - Page Number: 16 of 22 Maritime Safety Queensland Statement of Witness 12. On the following Monday (13/4/15), I attended my family doctor who examined me and recorded his findings. It was decided to wait a few days to x-ray my chest. I reported that I was suffering some dizzy spells throughout my day. The x-ray results later confirmed some soft tissue swelling and R undisplaced fractures. I was prescribed the medication in order to deal with my vertigo symptoms -D TM and I’m still receiving medical treatment. 13. As a consequence of a phone call with Maritime safety Queensland, I downloaded and completed a marine incident report. In this report I provided my version of events and to the best of my recollection, drew a diagram depicting my course and location together with the course of the jet boat prior to impact. I over-laid the downloaded GPS data with Google earth and printed this out on TI an A4 sheet of paper before drawing in what I believed was the approximate location and course of rR the jet boat. The downloaded GPS data is a true and accurate record and has not been altered. 14. Later that week I attended the office of Maritime Safety Queensland where I made this statement de and lodged my Marine Incident report. un 15. On returning home after this meeting, I unpacked and laid out the equipment that I used on the day of the day of the incident. I took nine (9) photos of the gear with a focus on the damage. I later Justices Act 1886 lea se d email to the investigating Marine Officer. I acknowledge by virtue of section 110A of the Justices Act that: Re 1. This written statement by me dated 17 April 2015 and contained in the pages numbered 1 to 4 is true to the best of my knowledge and belief, and 2. I make this statement knowing that, if it were admitted as evidence, I may be liable to prosecution for stating in it anything that I know is false. Signature …………………………………………………………………………………. Signed at Main Beach this 3rd day of June 2015. Page 4 of 4 Corporate Forms Area Form F5009 CFD V01 Aug 2013 135 -04257 Released Copy.pdf - Page Number: 17 of 22 R DT M IRT er un d d se lea Re 135 -04257 Released Copy.pdf - Page Number: 18 of 22 R M I r e d e T R d n u s a e l e R 135 -04257 Released Copy.pdf - Page Number: 19 of 22 T D R M I r e d e T R d n u s a e l e R 135 -04257 Released Copy.pdf - Page Number: 20 of 22 T D R M I r e d e T R d n u s a e l e R 135 -04257 Released Copy.pdf - Page Number: 21 of 22 T D R M I r e d e T R d n u s a e l e R 135 -04257 Released Copy.pdf - Page Number: 22 of 22 T D