NOTE: Study the examples given in Figure 1-2 and Figure 1-3 as you read the following description of
each block.
Block 1.
Enter the report number. It consists of the unit DODAAC, the number of reports submitted,
and the two-digit calendar year. In the example, the unit DODAAC is W1EAA, this is the first
malfunction of the year, and the year is 1991. The report number is "W1EAA-1-91." Use
this report number in all correspondence on this malfunction.
Block 2.
Enter the complete nomenclature for the item that malfunctioned. Include as applicable the
caliber, type, model, NSN, DODIC, lot number, and serial number (if available).
Block 3.
Provide the following information, as appropriate. If necessary, continue on the back of the
form or on a separate sheet of paper:
For small arms and both fixed and semifixed conventional ammunition (including mortar
rounds), enter the fuze type, model, and lot number. Also enter the headstamp of the
cartridge case (the manufacturer's symbol and the year of manufacture). See Figure 1-4.
For separate-loading conventional ammunition, enter the projectile caliber, type, model,
NSN, DODIC, lot number, and kind of filler. Enter the type and lot number of the booster
or burster. Enter the propelling charge caliber, type, model, NSN, DODIC, lot number,
and weight, including the number of increments used with the round that malfunctioned.
Note the physical condition of the propelling charge bag or bags and the wrappings.
Provide the pressure and velocity of the round that malfunctioned, if available. Enter the
fuze type, model, NSN, DODIC, and lot number. State whether the fuze was properly
assembled and seated with a fuze wrench prior to loading. Finally, list the primer type,
model, NSN, DODIC, and lot number. See Figure 1-5.
For all other conventional munitions (such as grenades, rockets, mines, smoke pots,
pyrotechnics, demolition items, cartridge-actuated devices, and propellant-actuated
devices), enter the type, model, NSN, DODIC, and lot number of the end item and any
components, such as fuzes, rocket motors, and bursters. Also, provide the type of filler
present in chemical munitions.
For conventional or chemical-filled warheads and warhead sections that are not
assembled to GMLR, enter the type of filler present in chemical munitions; the type,
model, and lot number of the fuze; and the type, model, and lot number of the propulsion
system. Also, give the type, model, and lot number of the adaption kit or adaption kit
component involved in the malfunction.
Block 4.
Enter a brief description of the malfunction.
Block 5.
Enter the geographic location where the malfunction occurred.
Block 6.
Enter the activity and address of the person to contact to gain access to the malfunction site.
Block 7.
Enter the unit that was firing at the time of the malfunction.
Block 8.
Enter the date and the local military time of the malfunction.
Block 9.
Enter any casualties (killed, hospitalized, other injuries) that resulted from the malfunction.
MM0159
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