JUDUL PROSES

TANGGAL DIMULAI
TANGGAL SELESAI

LANGKAH 1
PEMBENTUKAN TIM
KETUA
ANGGOTA

FASILITATOR
NOTULEN

SASARAN / GOAL

Project Status
Status COMPLETE
TOTAL FAILURE MODE……….

ALUR PROSES

PROSES
1 2 3 4 5 6
a

f
8 9
LANGKAH 3,4,5,6

MODUS KEGAGALAN DAN DAMPAK

Process/Product: 1. ………………………….. ; Tim leader : ………………….. ; Date : ……………..

Potential Potential Potential Current Recommended

Likelihood
Detection

Likelihood
Detection
RPN

Severity

New RPN
Severity
Failure Mode Causes for Effects of Controls Action
Failure Failure

3 2 4 24 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
LANGKAH 3,4,5,6

MODUS KEGAGALAN DAN DAMPAK

Process/Product: 1. ………………………….. ; Tim leader : ………………….. ; Date : ……………..

Potential Potential Potential Current Recommended

Likelihood
Detection

Likelihood
Detection
RPN

Severity

New RPN
Severity
Failure Mode Causes for Effects of Controls Action
Failure Failure

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 Severity

Detection
RPN
Likelihood
Potential Failure Potential Potential Current
Mode Effects for Causes of Controls
Failure Failure
 Recommended Action

Reassessment
Date
Likelihood
Severity

Detection

New RPN
 Action Plan :………………………
Failure CAUSE Recommen Action(s) to Implement Implemen Implementatio Resourc Resource Evidence Monitoring Sign- Sign-
Mode dation(s) achieve ation by tation by n of the place e required of & off by off
recommendati Whom when (Where) required (Money) completio evaluation Date
ons (How) (Time) n arrangemen
ts