Block 12
Enter the rocket motor cluster model identification (when applicable), the serial number, and the lot number from
the DD Form 1650. If you need additional space, continue in Block 27.
Block 13
Enter the igniter model identification, the serial number, and the lot number from the DD Form 1650.
Block 14
Enter the fuze model, the serial number, and the lot number from the DD Form 1650.
Block 15
Enter the safe and arming device model, the serial number, and the lot number 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 the model number of the telemetry system, if 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 not requiring hospitalization as minor.
Block 27
Describe the missile or rocket. If the flight was abnormal or erratic, give details, such as, "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."
MM0167
2-10
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