JUDUL PROSESTANGGAL DIMULAI TANGGAL SELESAI

LANGKAH 1PEMBENTUKAN TIMKETUA ANGGOTA

FASILITATORNOTULEN

SASARAN

Status COMPLETE

TOTAL FAILURE MODE ……….

ALUR PROSES

PROSES1 2 3 4 5

Project Status

SUB PROSES

a

b

c

d

e

f

LANGKAH 3,4,5,6

MODUS KEGAGALAN DAN DAMPAK

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

Se

veri

ty

Lik

elih

oo

d

Det

ect

ion

RP

N

Rea

sse

ssm

ent

Da

te

Lik

elih

oo

d

Se

veri

ty

Det

ect

ion

New

RP

NPotential Failure Mode

Potential Causes for

Failure

Potential Effects of

Failure

Current Controls

Recommended Action

MODUS KEGAGALAN DAN DAMPAK

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

Lik

elih

oo

d

Se

veri

ty

Det

ect

ion

RP

N

Rea

sse

ssm

ent

Da

te

Lik

elih

oo

d

Se

veri

ty

Det

ect

ion

New

RP

NPotential Failure Mode

Potential Causes for

Failure

Potential Effects of

Failure

Current Controls

Recommended Action

MODUS KEGAGALAN DAN DAMPAK

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

Lik

elih

oo

d

Se

veri

ty

Det

ect

ion

RP

N

Rea

sse

ssm

ent

Da

te

Lik

elih

oo

d

Se

veri

ty

Det

ect

ion

New

RP

NPotential Failure Mode

Potential Causes for

Failure

Potential Effects of

Failure

Current Controls

Recommended Action

MODUS KEGAGALAN DAN DAMPAK

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

Lik

elih

oo

d

Se

veri

ty

Det

ect

ion

RP

N

Rea

sse

ssm

ent

Da

te

Lik

elih

oo

d

Se

veri

ty

Det

ect

ion

New

RP

NPotential Failure Mode

Potential Causes for

Failure

Potential Effects of

Failure

Current Controls

Recommended Action

MODUS KEGAGALAN DAN DAMPAK

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

Lik

elih

oo

d

Se

veri

ty

Det

ect

ion

RP

N

Rea

sse

ssm

ent

Da

te

Lik

elih

oo

d

Se

veri

ty

Det

ect

ion

New

RP

NPotential Failure Mode

Potential Causes for

Failure

Potential Effects of

Failure

Current Controls

Recommended Action

Severi

ty

Lik

elih

ood

Dete

cti

on

RP

NPotential Failure Mode

Potential Effects for

Failure

Potential Causes of

Failure

Current Controls

Recommended Action

Lik

elih

ood

Severi

ty

Dete

cti

on

New

RP

N

Reassessm

en

t D

ate

Action Plan :………………………

Failure Mode CAUSE Recommendation(s)

ACTION PLAN: …………………………

Failure Mode CAUSE Recommendation(s)

Action(s) to achieve

recommendations (How)

Implementation by Whom

Action(s) to achieve

recommendations (How)

Implementation by Whom

ACTION PLAN: …………………………

Implementation by when

Implementation of the place

(Where)

Resource required (Time)

Resource required (Money)

Evidence of completion

Monitoring & evaluation

arrangements

Implementation by when

Implementation of the place

(Where)

Resource required

(Time)

Resource required (Money)

Evidence of completion

Monitoring & evaluation

arrangements

Sign-off by

ACTION PLAN: …………………………

Sign-off by

Sign-off Date

Sign-off Date