Professional Documents
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Interview Statement
The aifonuadoa given by yon wfli become part of determine trcnd/ctusts and rccaauamu} ATC
ibe records in Uw Priv»cy Act System syitcm Jzaprovtmeni, fafonnaiian pjnvidcd will
be disclosed u a ncronne use in accord with Uic
The FAA's authority 10 obraln the intomatian is system dcscriptioa of O?MA3OV*T-1. Under
contained in 49 U.S.C. Section 1344, 49 U.S.C. this imhoriiy, disdoawes any be made ro union
Scctian 134$^ and 5 U-S.C Section 3QL rrprcieniatives 2nd to the NTSB. Ftilure to
Providing of this mformarion is mandatory. The provide the Infonnnion requested will rtsult in
priftripal use Of tbc bfonnaiion provided is to scricin tin
DEC. 15. 2003 3:56PM 9-1 1 COMMISSION 0^ NO. 0596 P. 5
rrjvSONNEL STATEMENT
FEDERAL AVIATION ADMINISTRATE^
NEW YORK TRACON
1515 Stewart Ave., Westbury, NY 11 590
BACKGROUND; Much of the information concerning the circumstances of this accident/incident can be retrieved
via recorded data sources. However, some of the facts concerning "What you saw and what you did may not have
been completely captured. The purpose of this statement is to provide any frets within yo'ur personal knowledge that
you believe will provide a more complete understanding of the circumstances surrounding this accident/moid ent.
Therefore, speculations, hearsay, opinions* conclusions, and/or other extraneous data are not to be included in this
gcaicraent This statement may be released to flie public through FOIA or Litigation activities including pretrial
discovery, depositions, and actual court testimony.
INSTRUCTIONS: This statement is to be printed and signed by you and your signature below certifies its accuracy.
It wil] neither be edited nor typed and, once signed, wil] constitute your original statement
Complete This section ONLY for accidents: Operational equipment configuration was: Radar Ctanbel: (A) or (B).
Beacon ChanneJ: (i)or(2). MHsetnl miles. PoJamadon in use: (LP)or(CP),
Video Map iti use; (?) (2) (3) (4) (5). or £] Equipment configuration unknown.
Signarure
Interview Statement
^infen^tipt.givcr.byyDiiwiUbecomcpanof detennini irend/owes tod ncnmmcad ATC
OwJooVTl" ** ?liV1Cy ACt SyttCni> system improvcmoiL Infatmwteo provided will
~ * be disclosed u B routine usa in accord with Ihe
The FAA's authority to obrain ihft informiriM is syn;m description of OfM/GOVT-1. Unicr
mottined in 49 U.S.Q Section 1344, 49 U.S,C *is twhoriiy. ductosures may be made to Union
jeaion 1348, aad 5 UJS.C. Sc^tin 301. represenarivts «id to the NTSB. Faflure 10
Frovidtag of ihis infamurioD is mandamr/. "Hit provide ihc Woraadon rtqocs»d win result in
principal use of the information provided is to disciplinary action under FAA regnlxiioiis.
9-
DEC.15.2003 3:56PM 9-11 COMMISSION A NO. 0596
PERSONNEL STATEMENT
FEDERAL A V1ATIOH ADMINISTRATION
NEW YORK TRACON
1515 Stewart Ave.. Wcsibuty. NY 11590
BACKGROLMD: Much of the information concerning the circumstances of this accident/incident can be retrieved
via recorded dad sourctt. However, some of the facts coDcEnnng what you saw mid what you did may not riave
been completely captured. The purpose of this statement is to provide any racrs within your personal know/ledge that
you believe will provide a more complete understanding of the circumstances surrounding this accident/incident.
Therefore, speculations, hearsay, opinions, conclusions, and/ar other extraneous data arc not to be included in this
statement. This statement may be released to the public through FOlA or iitigatior> activities including prttrial
discovery, depositions, and actual conn testimony.
INSTRUCTIONS: This statement is to be printed end signed by you and your signature beiuw certifies its accuracy,
h will neither be edited nor typed and, once signed, will constitute your original statement.
this section ONLY for accidents; Operational equipment configuralion was: fUdar Channel: (A) or (B).
Beacon Channel; (l)ot(2). MTIsetat miks. Pollrization in use: (LP)onCP).
Video Map in usa: (1) (1) (3) (4) (5\r Q Equipment configuTEtion
irv ihe best of my kno« ledge and recollection, ihis sutemsnt (i correct.
PERSONNEL STATEMENT
FEDERAL AVIATION ADMINISTRATION
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 data sources. However, some of the facts concerning what you saw and what you did may not have
been compieteiy 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 are not to be included in this
statement. This statement may be released to the public through FOIA or litigation activities including pretrial
discovery, depositions, and actual court testimony.
INSTRUCTIONS: This statement is to be printed and signed by you and your signature below certifies its accuracy.
It will neither be edited nor typed and. once signed, will constitute your original statement.
Complete this section ONLY for accidents: Operational equipment configuration was: Radar Channel: (A) or (B).
Beacon Channel: (l)or(2). MTIsetat miles. Polarization in use: (LP)or(CP).
Video Map in use: (1") (2) (3) (4) (5X or Q Equipment configuration unknown.
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I certify, to the best of my /knowledge and recollection, this statement is correct.
Date
Interview Statement
The information given by you will become part Of determine tread/causes a»d recommend AXC
the records in tbc Privacy Act Sysism, system improvemen:. iBfonnariDQ provided will
OPM/OOVT-1. b'e disclosed as a routine osc in accord •with Ujt
The FAA's autfioriiy to obtain the information IB sysicm descripdon of OPM/GOVT-l, UnJ=r
cooained in 49 U.S.C Section 1344, 49 U.S.C. ibis Liithoricy, disciosurca may bo made to union
Section 1348, and 5 U-S.C. Section 3DI- representatives ind to the NTSB. FaDure to
Providing of this Information is mandatory, The provide ihc infonnadon requested will result ir>
principal use of ihc information provided is ID disciplinary action under KAA
Date
DEC. 15. 2003 3:56PM 9-1 COMMISSION NO. 0596 P. 9
PERSONNEL STATEMENT
FEDERAL AVLAHON ADMINISTRATION
N£\ YORK TRACON
1515 Stewart Ave.. WestUiry, NY 1 1 590
Much of the information concerning the circumstances of this accident/incident can be retrieved
via recorded data sources. However, some of the facts concerning what you saw and what you did may not have
been completely caprm«d. The purpose of this stareiDcm 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 are not to be included in this
statement. This statement may be released to the public through FOlA or litigation activities including pietrial
discovery, depositions, and actual court testimony.
INSTRUCTIONS: This statement is To be printed and signed by you and your signature below certifies its accuracy.
It will neither be edited nor typed and. once signed, will cojjstiiutc your original
Complete this section ONLY for accidents: Operational equipment configuration was: Rsdar Channel; (A) or (B).
Beacon Cbafiael: (]) or (2). MTI set at miJ«. Polarizfttiob in use: (LP) or(CP1.
^ Video Map in use: (I) (2) (3) (4) (5X or Q^Ecpiipment confiEuraxion unknown.
laterYiew Statement
The information given by ymi will become part ef determine trmd'eaujes ituJ reeemmcnd ATC
the records in the ftiviey Act System system impmvcnlEm. Information provided will
OPM/GOVT-l. bo disclosed as a ronaQo ttsc in accord wiib the
Tb« FAA1* authority to obtain ihe inromurion is sysnan description pf OPM/GOVT-1. Under
eoouiaed in 49 US.C. Scoion 1144, 49 U.S.C thii authority, disdosotca m&y be nude to union
Swtion IMS. and 5 US.C. Section 3QL represcntairvcs and to the N"TSB. Failure to
rnjvidmg of tins infonniriDn is ffluidatDty, The provide the inforniMirin rcqoesied will result in
principal use of ihe infomwrion provided is to disciplinary letjon under FAA regulations.
Sign*, cure
DEC.15.2003 3:55PM 9-1 1 COMMISSION • NO 0596 F2
PERSONNEL STATEMENT « • •
' FEDERAL AVIATION ADMINISTRATE
NE"WYORK.TRACON
1515 Siewart Ave., Westbury. NY 11 590
B ACKgROUND; Much of the information concerning the cirrmnsiflnces of this accident/incident can be retrieved
via recorded data sources. However- some of the facts concerning what you saw and What you did may not have
been completely captured. The purpose af This statement is to provide any facts within your personal knowledge that
you believe will provide a. more complete understanding of the circumstancw surrounding this a.ccidenl/iiicidcm.
Therefore, speculations. bearsoy, opinions, conclusions, and/or other extraneous data are nor lo be included in this
statement. This statement may bt rfrkastd to the public through F01A or litigation activities including preo-ial
discovery, depositions, and actual court testimony.
INSTRUCTIONS: This statement U to be printed and signed by you and your signature below certifies iis accuracv,
Ii will neither be edited nor typed and. once stenecL ^vill constitute your original statement.
Complete this section ONLY for accidents: Operational equipment configuration was: Radar Channel; (A) or (B).
Beacon Channel: (l)or(2). MTlsetat ^miles. Polarization m use: (LPWr (CPV
.. Video Map jo ysc: (]) (2) (5) W (51 or Q Equipment configuration unknown.
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I certify. 10 the b<rsi of my knowledge and recollection, this scatcnjent is correct
P. 3,
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