PERSONNEL STATEMENT

FEDERAL AVIATION ADMTH1STRATION

NEW YORK TRACON
1515 Stewart Ave.. Westbury.NY 11590

BACKGROUND' Much of the information concerning the circumstances of this accident/incident can be retrieved
via recorded daia sources. However, some of the facts concerning what you sew and what you did may not have
been completely captured. The purpose of this statement is to provide any facts within your personal knowledge that
you believe will provide a more complete understanding of the circumstances surrounding this accident/incident.
Therefore, speculations, hearsay, opinions, conclusions, and/or other extraneous data arc not to be included in this
statement. This statement may be released to the public through FOlA or litigation activities including pretrial
discover)', depositions, and actual court testimony..

INSTRUCTIONS: This statement is to be printed and signed by you and your signature below certifies ixs accuracy.
It will neither be edited nor typed and. once signed, will constitute your original statement.

This statement concerns the IrrM^ent/Accident involving (JnL- I (j\i CAJ / C ^/ _

on 7////IA
7 ////£}.,at UTC. My name is f^O^/^L^l> fitl <*Pr(v |/€<O. } am employed
inanr) I op mitt
as an (ATCS} (5ATCS) by the FA.^ at New York TRACON. 1 was working the.

position from UTC to ___ UTC.

i time i

Complete this section ONLY for accidents: Operational equipment configuration was: Radar Channel: (A) or
Beacon Channel: (1) or (2). MTI set at miles. Polarization in use: (LP) or (CP\o Map in use: (1

Text of statement (continue on reverse if needed):

ge and recollection, ihis Statemeni is correct

e."

Form 7210.:- Cl'J

 &&i5ft#£'& firfZS^Q

ti&u i/otot , Jc &UL /y^'fl^r^^y

•v-^-O

r
I
 Interview Statement
Tbs iafonnaaon pivcn by you will become put of urad/autf s *ud rcccnunrad ATC
ifa= records in iht Privicy Act System, imptovcmcnt. Inronaarion provided
OFM/GOVT-L bs H'^^1""^ xs 2 rooxme nxc in acemd wiih tfae
The FAA's antboriry to oboin the information is syxam dcsntjpoon of OPM/GOVT-L Uoda
comzined in 49 US.C Sccnon 13A*. 49 UJS.C this authority, discioium HUT be mad: to union
Scoion 1348. and 5 U^.C. Sraion 301. reprcscmarivcs and to tb± NTSB. Failure ID
Pruviomg of this information is mandatory. Tbe provide tfae inlmmanon lEtjurficd -wDl remit in
principal uie of the iafonmwion provided ii to disciplinary action under FAA

TOTRL P.14