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.
Block 20. Enter the names and phone numbers of witnesses and anyone who can provide additional
firsthand information.
Block 21. Enter the name, signature, and phone number of the person who compiles the information
for the report. Make sure the person who compiles the report signs it. Enter the date of the
report.
Preparing the DA Form 4379-1-R
When the malfunction involves GMLR, report the incident using DA Form 4379-1-R. Prepare this form
according to the instructions below.
Note: Study the examples given in Figure 1-6 and Figure 1-7 as you read the explanation of each
entry.
Block 1.
Self-explanatory.
Block 2.
Enter the unit's DODAAC, the report number, and the 2-digit calendar year.
Block 3.
Self-explanatory.
Block 4.
Enter the battery, battalion, division, or other organization that experienced the malfunction.
Block 5.
Enter the location where the malfunction occurred (for example, McGregor Range, Fort
Bliss, TX).
Block 6.
On Line 6a, enter the type of firing (for example, troop training, fire demonstration,
standardization flight, or annual service practice). On Line 6b, enter the method of firing,
such as surface-to-surface or surface-to-air.
Block 7.
Enter the missile's flight time in seconds. This is the length of time from the launch until the
malfunction occurred.
Block 8.
Enter the missile type and model number (for example, SHILLELAGH-MTM-51A).
Block 9.
Enter the missile's serial number, lot number, and NSN.
Get this information from the
missile body.
Block 10. Enter the warhead type, serial and lot numbers from DD Form 1650 (Ammunition Data
Card).
Block 11. Enter the rocket motor model designation, serial, and lot numbers from the DD Form 1650.
MM0159
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