Block 12. Enter the rocket motor cluster, model identification (when applicable), serial, and lot
numbers from DD Form 1650. If you need additional space, continue in block 27.
Block 13. Enter igniter model identification, serial, and lot numbers from DD Form 1650.
Block 14. Enter the fuze model, serial, and lot numbers from the DD Form 1650.
Block 15. Enter the safe and arming device model, serial, and lot numbers from the DD Form 1650.
Block 16. For missiles using liquid propellants, include the name of the fuel and the oxidizer (for
example, IRFNA and UDMH).
Block 17. Enter the model and the serial number of the launcher.
Block 18. Provide the wind speed and direction, visibility (for example, clear, fog, or rain), and the
Fahrenheit temperature at the time of the malfunction.
Blocks 19 through 22. Self-explanatory.
Block 23. Enter model number of telemetry, where appropriate.
Block 24. Describe the storage conditions of the ammunition before the malfunction occurred,
including whether the items were received in original sealed containers. Identify the length
of time the items were exposed to climatic conditions and whether they were stored in
uncovered open storage.
Block 25. Describe any damage to the launcher or to other property. Include photographs, sketches,
and measurements of important features.
Block 26. Enter the number of fatalities or injuries resulting from the malfunction. Classify the injuries
as major only if hospitalization is required.
Classify injuries that do not require
hospitalization as minor.
Block 27. Describe the missile or rocket malfunction. If the flight was abnormal or erratic, give details;
for example, "the missile flew a normal trajectory for about 100 meters. At that time, it made
a sharp downward turn to the right and detonated on impact with the ground."
Block 28. Enter the number of missiles fired from the lot on the day the malfunction occurred. Give
quantity of rounds of that lot remaining on hand.
Block 29. Enter the estimated or actual distance from the launcher, in yards or meters, where the
Block 30. State whether or not the involved lot was temporarily suspended from further issue and use.
Block 31. Check applicable blocks, showing whether fragments or other components of interest are
available. Also, indicate whether technical assistance is needed from the commodity
command (AMC or MICOM).
Block 32. Give other pertinent information for personnel evaluating the report (data helpful in determining
the reason for the unsatisfactory performance). Include photographs or sketches of