JUDUL PROSES

TANGGAL DIMULAI
TANGGAL SELESAI
LATAR BELAKANG

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

SUB PROSES

f
6 8 9
LANGKAH 3,4,5,6

MODUS KEGAGALAN DAN DAMPAK

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

Likelihoo
d
Detection

Likelihoo
d
Detection
Severity
Potential Failure Potential Causes Potential Effects Current

RPN
Recommended

New RPN
Severity
Mode for Failure of Failure Controls Action
LANGKAH 3,4,5,6

MODUS KEGAGALAN DAN DAMPAK

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

Likelihoo
d
Detection

Likelihoo
d
Detection
Severity
Potential Failure Potential Causes Potential Effects Current

RPN
Recommended

New RPN
Severity
Mode for Failure of Failure Controls Action
PRIORITAS

Potential Failure Potential Causes Potential Effects Current Controls

Severity
Recommended Action

Severity

New RPN
Detection

RPN

Detection
Reassessment
Date
Likelihood

Likelihood
Mode of Failure of Failure
 Action Plan :………………………
Failure Mode CAUSE Recommendatio Action(s) to Implementat Implemen Implementatio Resourc Resource Evidence of Monitoring Sign- Sign-
n(s) achieve ion by tation by n of the place e required completion & off by off
recommendati Whom when (Where) required (Money) evaluation Date
ons (How) (Time) arrangemen
ts
PDSA

PLAN :

TINDAKAN :

DO :

STUDY :

ACTION :