Block 10
Describe the damage to the weapon, the level of repairs required, and any damage to other materiel. Continue this
item on the back of the form, if necessary. Attach any appropriate photographs, sketches, and measurements.
Block 11
Self-explanatory.
Block 12
Enter the quantity of affected ammunition on hand. Also, enter any local suspension data.
Block 13
Self-explanatory.
Block 14
In Block 14a, enter the abbreviated nomenclature, the NSN, and the serial number of the weapon or launcher in
which the malfunctioning item was fired. Complete Blocks 14b through 14m as appropriate. When appropriate,
provide the following information on the back of the form:
The name of the manufacturer (plant or arsenal).
The number of propellant increments fired (for mortar rounds).
Length recoil.
The condition of the weapon or launcher prior to the malfunction. Include (as applicable) the date of the
last overhaul, the overhauling installation, the timing and headspace dimensions of the weapon (by actual
gauge check), the date of the last cleaning, and the date of the last boresight.
For 37mm or larger weapons, enter the total number of rounds fired through the tube before the
malfunction. Read and report the pullover gauge reading of the damaged gun tube according to the
guidance contained in TM 9-4933-200-35. If the tube has been destroyed or if the gauge is not available,
extract the most recent pullover gauge reading from the log book and list the total number of rounds fired
subsequent to that reading.
Block 15
Briefly describe the general conditions, such as marsh, jungle, woods, dry grassy plain, or muddy hillside, at the
firing site and along the flight path of the item. Describe any natural or artificial barriers, such as overhanging
trees or heavy camouflage, that may have obstructed the line of fire. Enter the distance for which witnesses to the
malfunction had an unobstructed view of the flight path.
Block 16
Enter the estimated visibility limit due to atmospheric conditions, such as haze, smoke, rain, or fog. Briefly
describe the nature and quantity of any precipitation, such as rain, sleet, or snow, either at the time of, or shortly
before, the malfunction. Enter the temperature and the relative humidity.
Block 17
Self-explanatory.
2-5
MM0167
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