Mark the appropriate blocks. If the package was inadequate or damaged, describe the problem on the back of the
Provide the following information on the back of the form:
Describe the events immediately before the malfunction and the actions taken following the malfunction.
Indicate the locations of casualties with respect to the weapon and the malfunctioning item.
Describe the most probable path of fragments, the distance fragments were found from the malfunction
site, and their weight and appearance. Attach photographs, if available.
For chemical items, describe the extent and type of contamination resulting from the malfunction.
Indicate whether the weapon was operating normally just before the malfunction, and describe the action
of the weapon at the time of the malfunction.
Indicate whether there is evidence or other reason to believe that foreign objects (such as pebbles, gravel,
or stones) could have been blown into the bore when previous rounds were fired.
Indicate whether there was any evidence of unburned powder or residue in the tube.
If the round detonated in the gun tube, indicate where in the tube the detonation occurred-that is, at the
breech, at the muzzle, or in the middle of the tube.
Indicate whether the projectile reached the anticipated point of impact or intercept.
If the malfunction was a premature detonation, indicate whether it was a high-order or low-order
Indicate the setting of the dual-purpose or time fuze.
For electrically initiated ammunition or explosives, describe any nearby sources of electrical or
electromagnetic energy (such as power lines, generators, microwave towers, or radar antennas). Include
the power rating of the source and its distance from the ammunition at the time of the malfunction.
Describe any nonstandard conditions (such as the use of more propellant than specified for the weapon
and round). Include any deviations from the instructions given in the appropriate technical manuals.
Indicate whether any unauthorized modifications to the weapon or the ammunition had been made. If so,
indicate whether the modification may have contributed to the malfunction.
Provide a copy of the press release, if any.
For a 2.75-inch rocket hangfire, include the tube number in which the hangfire occurred, the type of
aircraft involved, the location of the launcher on the aircraft, and the number of rockets fired through the
tube before the hangfire.
For malfunctions of rifle grenades, indicate whether bulleted ammunition was in use.