JUDUL PROSES

TANGGAL DIMULAI
TANGGAL SELESAI

LANGKAH 1
PEMBENTUKAN TIM
KETUA
ANGGOTA

FASILITATOR
NOTULEN

SASARAN

Project Status
Status COMPLETE
TOTAL FAILURE MODE.

ALUR PROSES

PROSES
1 2 3 4 5
 SUB PROSES

f
LANGKAH 3,4,5,6

MODUS KEGAGALAN DAN DAMPAK

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

Likelihood

Detection

Likelihood

Detection
Reassessment Date
Potential Potential Potential Current

RPN

Severity
Recommended

New RPN
Severity
Failure Mode Causes for Effects of Controls Action
Failure Failure
MODUS KEGAGALAN DAN DAMPAK

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

Likelihood

Detection

Likelihood

Detection
Severity

Reassessment Date
Potential Potential Potential Current

RPN

Severity
Recommended

New RPN
Failure Mode Causes for Effects of Controls Action
Failure Failure
MODUS KEGAGALAN DAN DAMPAK

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

Likelihood

Detection

Likelihood

Detection
Severity

Reassessment Date
Potential Potential Potential Current

RPN

Severity
Recommended

New RPN
Failure Mode Causes for Effects of Controls Action
Failure Failure
MODUS KEGAGALAN DAN DAMPAK

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

Likelihood

Detection

Likelihood

Detection
Severity

Reassessment Date
Potential Potential Potential Current

RPN

Severity
Recommended

New RPN
Failure Mode Causes for Effects of Controls Action
Failure Failure
MODUS KEGAGALAN DAN DAMPAK

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

Likelihood

Detection

Likelihood

Detection
Severity

Reassessment Date
Potential Potential Potential Current

RPN

Severity
Recommended

New RPN
Failure Mode Causes for Effects of Controls Action
Failure Failure
Potential Failure Potential Potential Current

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

Reassessment Date
Likelihood
Severity

Detection

New RPN
 Action Plan :
Failure Mode CAUSE Recommendation(s) Action(s) to Implementation
achieve by Whom
recommendations
(How)

ACTION PLAN:

Failure Mode CAUSE Recommendation(s) Action(s) to Implementation

achieve by Whom
recommendations
(How)
 Implementation Implementation Resource Resource Evidence of Monitoring &
by when of the place required required completion evaluation
(Where) (Time) (Money) arrangements

ACTION PLAN:

Implementation Implementation Resource Resource Evidence of Monitoring &

by when of the place required required completion evaluation
(Where) (Time) (Money) arrangements
Sign-off by Sign-off
Date

Sign-off by Sign-off
Date