BloOk La
b±ock 2a
En²er your uni² and ±oOa²ion p±us zip or AP³ num´r. Add
your unit's DepaRmµnt of DefµNsµ Activity Address
Code (D³DAAC)¶ Your P·¸c±erk w¹l± know²hµ D³DAACº
Put in thµ address of the itµm»s man-
age¼sº You½±l find the addresses on
pages 1¾ and ¾2 of !his Hand¿ookÀ
SECTION i
2a. To
(Screening poiNt)
la± From
(OrIGinating point)
SVC CO, IST SF
F
BLANK± USA
01234
DOdAAc:
Wl8R4R
Comman²er³ US ARmy. TACOM
ATTN´ AMSTA-QµD
WaRren Ml
48397-5000
1
b² typed Name, DuLy Phone and SignaLure
WILlIAM J. FAUlKNER, aV 623-5446
2b² typed Name, DULy Phone³ and SignaLUre
1t-fF
,.
block ¾¿
Your name aNd phone. Áo²e AV if for AUT³V³Á, FTS orCommerc¹a±º
b±ock 3
Make ²he Âepoà Con²roÄ Áumż wi²h your uni²½s ƳDAAC, ²he calµndar year, and ²heN wi²h
four places, ²Çe Num¿er of SÈ 368És you Çave senÊ IN du¼iNg ²he calenda¼ yearº D³ÆAAC (6
places)
+
calµNdar yµar (2 places)
±
numËer of SÈ 36ÌÉs
(4
places)Í
3.
Repo´ Conµro¶ No±
±²
DaLe DefIciency
².
Na·iona¶ S·Ack No² (NSN)
Discovered
W± 8R4R870001
i DEC 87
5365-01-²6²-4055
block
4
The calendar da²e you found ²He defec² or go
³ ³
hµ ideaº
BLock ´
Entµr
the Commµrcial and GoveÎment Ïntity
(CAGE) codµ oÐ the manuÑac²urµ¼ who made !he itemº
Enter the name of tHe goverNmµnt or contracting
agency that ¼epaired or overhaulÒ the i²em when
the CAGE Is not availa¿leÓ
H
tÔe shipÕ¼ is diÖerent
f¼om the×e actØvÙ²Ùe×, INclude thµ shØpÕ s addre×sº
Q
blocks 5
&
Ú
The itemÉs ÁSÁ aNd NameÛ
b±ock 9
ÏNter the serialÜ lot or ¿atch
Num¿er of the ¿ad itµms.
bloOk ¾0
Ýist the coNt¼act o¼ pu¼chase
orde¼ Num¿er aNd the ¼equiÞ
sitioN numÅ¼ß ³n GSà items,
±ist alÄ th¼á Num¿ersº Conâ
tract Num¿ers may Å found
on thµ ¿ad item»s data platµº
µ¶
ManU¸acLurer
/
Mfg
²
Code
¹
Sh
i
pper
1³862
8º Mfg± Par» No²
9²
Ser¼a¶½¾aVBa¿ch NoÀ
10³
Con¿rac
V
PO
¹
Do
c
umenL NoÁ
11²
¿em
´
New
Repaired¹
D
Overhau¶ed
block 11
ãs the ätem New? åas
It ËeeN overhauled?
474309
DAAD-05-C´86´0001
12²
Da¿e ManufacLuredÃ
Repaired/OverhauÄed
Block 12
I
fit appliµs and you know
ItÜ the datµ of maNufacæ
ture or last overhauĺ
13± OperaLing time aL Fai¶Ure
8609µ1 MILES
block 13
åow loNg had the equipment ¿een
ruN wHen the pro¿lem was fçundè
milesé cycles, hoursÜ rounds?
µ¶
1±²
GovernmenL Åurnished Ma¿er¼a¶
d
Yes
·
No
±6
bloOk ¾4
CêNtractors mark yeëì
every¿oíy µlse marks
²he No ¿ox.
JAN 8¸
block ¾Úa
Give the name or NouN of the majo¼ end itemÜ and its typeÜ modµ±, seriesî and ÁSÁº
q
a² End ¶Lem
¹1)
type¹Mode¶ÆSeries
¹2)
Seria¶ No²
·6¸
Deficieǿ
(
Aircraf,
TRUCK¶ CARGO· TACT¸CAL Mi008
3²7626
ank± ship±
¶·em
howiTer² etc. )
Works
b.
Nex·
¹1)
NaLIonaÄ S¿ock NoÀ (NSN)
I
º»¼
Nomenc¶a·Ure
i
½3¾
Par¿ NoÈ
¹±)
Seria¶ NoÉʾoL NoÀ
OÇËiLh
HIgher
ÌssemͶy
b±ock ¾6¿
Entµr the ÁSÁ, Name or NouN aNd ïyÕ/modelðseriesÜ part numñer, and serial nuò¿er of tHe next Highµr
assem¿ly that the ¿ad Itµm is paà oó. For ammo ätems usµ thµ lot num¿er iNstµad of seria± Num¿erº
block ¾7
Enter the estimated cost of thµ item (use
the AMDF price)ô
·µ¸
Do¶¶ar Îa¶ue
18² EsLÏ CorrecLion Cos!
19²
пem Ñnder Òarran¿y
¿
Yes
No
¿
ÓnknoÔn
block 2¾
Check the ¿ox that
sHows
the
actioN
you½ve taken or are
asking forß
21À
ÕcLioÖÃD×sposiµion
õlock ¾8
Give tHe actual cost iNcurrµd or
estimated cost (äncluding overö
head if you know it) for ¼epairing
deficient Itµms ±¹s²ed iN ¿lock ¾5c÷
Á
Ho¶ding ExhibiL Øor
_ÂÃ
d_ys
Re¶eased for
d
¶nvesLIgaLion
block 22
bÄock 19
øs the item uùder
warranty? úf uNû
kNowNÜ cheük thµ
UnknowN ¿ox¶
Re¿Urned ¿o
D
SLAcKDisposed of
20³
Òork ÑniL Code
Ù
EÚC
(³av andAir
Force only)
block 20
ENter the codµ for tHµ maintenance lµvel
of the activity where the ¿ad item was
discove¼µd and repoÃed:
¹
ýorganizaû
²ion; È þdirect suppoÿĀ åāgµNeral supû
portĂ
º»
specia± repair activityĂ ăýdepot¶
Ä
Repaired
OÛher
(Explain
´in ltem22 )
THis is the ¿±ock wHµre you explain wHat happµnµd and givµ tHe information needµd to evaluate thµ pro¿±emº Áeµd
more space? Add another shát hµaded ¿y your Ąeport CoNtrol Áum¿erą åµre arµ the ïypes of Information nµededĆ
ć. U²iliza²ioN Code for your unit¶ DA Pam 73Ĉæ750 lists ÊHose codes.
·
2º Fai±u¼e detected durinĉ (whµn was the failurµ found?)
J¼
Fi¼st indicatioN of trou¿lµ (What was happening when you noticed the t¼ou¿lµ?)
4Å
TM Numñeré da²eĊ aNd Äatest cċaNge NuČ¿ečĎ
ďº ĐđĒces ērioĔ to diĕĖiculėĘ (WHęt dµtai±s do you have?)
ÚĚ DµscriētioN of děfficul
Ĝ
7º ĝause (What do yĞu thğNk caused tHµ pro¿lem or need for improvemµnt?)
:
Ġ
±²
a
³
did you do or suggµst ¿e doNµ ²o fix or improve the eQuipmen²?)
¾0ġ µcommµndatioNs
22²
DeL
À
aiÜs
(Describe± t
.
o best abiLµ± what i¶ Wrong± hoW and Why± circum¶tances prior to di·icul¸± descr¹Ption oº di·icul¸² cau¶e±
ac/10 taken McludMg »pos1¼½on± recommendations. ¾denti¿ With related item numberÀ ¾nclude and Lst supporÁing document¶Â
ContÃnue on separate sheet 1Ä necessaRÂ)
¹º
Æ
b»
F¹¼±ure Detected D½¾¼ng: ¿orm¹± Oper¹t¼on
c.
F¼¾st Ànd¼c¹Á¼on of Tro½b±e Re¹r whee±
½
h½b ¹ssy c¹me off
dà ÄM 9Å2320´289-20PÆ J½n 85Ç F¼gà 86È Item 20· P¹ge 2-194
e.
R¼ght re¹r whee± be¹¾¼ngs we¾e ch¹nged on 22 Sep 87/8ɲ2 ʼ±esË
fÌ
When ret¹¼n¼ng r¼ng d¼sp±¹cedÍ be¹¾¼ngs bec¹me ±oose ¼n hub ¹nd the hub c¹Êe off the sp¼nd±eº
g.
C¹½seÎ Poss¼b±e d¹Ê¹ged ret¹
.
¼n
.
¼ng r¼ng d½¾¼ng m¹¼nten¹nceÇ poss¼b±e defect¼ve ¾¼ngÇ poss¼b±e
Ïncorrect±y Ïnst¹±±ed Ðng» Ret¹ÑnÒng rÒng h¹d been ¾eÊoved/re-¼nst¹±±ed d½¾¼ng be¹r¼ng rep±¹ceÊentº
For Category I equipmenT Çeficiencies, senÇ in a messaGe that inclUÇes alL
the infORmation in Section I of an SF È6ÉÊ
JAN 8¸
µµ