Area: FMEA Number :

Processs: Safety Prepared By:

Responsible person: Failure Mode and Effects Analysis FMEA Date (Orig.) :
Team members:
Current Process Action Results

Classification

Known cost

Severity

Occurrence
Regulatory

Deterrence

Deterrence
Hazard
Responsibility &

Occurence
Potential

RPN

Severity
Task description Hazard description Requirement/ Hazard Hazard Recommended Action Target Completion

RPN
injury Actions Taken &
OSHA Code Controls Controls Date Completion Date
(prevention) (detection)

1 $ -
2 $ -
3 $ -
4 $ -
5 $ -
6 $ -
7 $ -
8 $ -
9 $ -
10 $ -
11 $ -
12 $ -
13 $ -
14 $ -
15 $ -
16 $ -
17 $ -
18 $ -
19 $ -
20 $ -
21 $ -
22 $ -
23 $ -
24 $ -
25 $ -
26 $ -
27 $ -
28 $ -
29 $ -
30 $ -
31 $ -
32 $ -
33 $ -
34 $ -
35 $ -
36 $ -
37 $ -
38 $ -
39 $ -
40 $ -
41 $ -
42 $ -
43 $ -
44 $ -
45 $ -
46 $ -
47 $ -
48 $ -
49 $ -
50 $ -
51 $ -
52 $ -
53 $ -
54 $ -
55 $ -
56 $ -
57 $ -
58 $ -
59 $ -
60 $ -
61 $ -

Injury Type Risk type Severity - trauma injury

Asphyxiation Chem 0 No identified hazard
Cave in Ergo 1 Long term hazard.
Chemical burn Trauma 2 Immediate extremity hazard.
Crush - mechanical 3 Immediate serious injury hazard
Crush - cave in 4 Immediate disability or death hazard
Cut/Stab
Drown Severity - ergonomic injury Source: Cornell University http://ergo.human.cornell.edu/ahRULA.html
Electric shock 1 Person is working in the best posture with no risk of injury from their work posture.

1 of 4
 Current Process Action Results

Classification

Known cost

Severity

Occurrence
Regulatory

Deterrence

Deterrence
Hazard
Responsibility &

Occurence
Potential

RPN

Severity
Task description Hazard description Requirement/ Hazard Hazard Recommended Action Target Completion

RPN
injury Actions Taken &
OSHA Code Controls Controls Date Completion Date
(prevention) (detection)

Person is working in a posture that could present some risk of injury from their work posture, and this score most likely is the result of one part of the body being in a deviated and awkward
Ergonomic 2 position, so this should be investigated and corrected.
Explosion 3 Person is working in a poor posture with a risk of injury from their work posture. The reasons for this need to be investigated and changed in the near future to prevent an injury.
Fall 4 Person is working in the worst posture with an immediate risk of injury from their work posture. The reasons for this need to be investigated and changed immediately to prevent an injury.
Freezing/hypothermia
Heat burn Occurrence
Impact: Strike by object 0 None: process is automated or designed to eliminate repetition
Noise - hearing loss 1 Slight: task is performed 2 to 3 times per day.
Poisoning 2 Moderate: task is performed 4 to 8 times per day.
3 Severe: task is performed 9 to 20 times per day.
4 Critical: task is repeated over 20 times per day

Deterrence
0 Risk is completely eliminated by process automation or task design
1 Risk is slight based on mechanical guards or process controls
2 Risk is moderate based on limiting exposure to the hazard
3 Risk is severe enough to need supervision, e.g fire watch or buddy system for confined space entry
4 Not controlled.

2 of 4
 Table 1: Evaluating Severity for chemicals and substance
Severity: defining chemical or substance risk levels using DO
Refer to the Material Safety Data Sheet.
0 1 2

Flash Point above

Will not burn Flash Point above 200° F 100° F, not
exceeding 200° F

Violent chemical
Stable Unstable if heated
change
Normal Material Slightly Hazardous Hazardous
White: Specific OX or OXY: Oxidizer
Hazard (No number values are assigned)

Table 2: Evaluating Severity for physical ris

Severity: defining physical hazard (risk) lev
0 1
Trauma injury Remote or isolated
No identified hazard
hazard hazard.

Ergonomic injury RULA Score

No identified hazard
hazard 1 or 2
Source for RULA risk evaluation (XL worksheet): http://ergo.human

Table 3: Evaluating Occurrence: accumulated exposure ri

Occurrence: defining accumulated risk exposure levels
0 1 2
None: process is
Moderate: task is
automated or Slight: task is performed 2
performed 4 to 8
designed to to 3 times per day.
times per day.
eliminate repetition

Table 4: Evaluating Deterrence levels: risk mitigation

Deterrence (used instead of Detection): defining existing contr
0 1 2
Risk is completely Risk is moderate
Risk is slight based on
eliminated by based on limiting
mechanical guards or
process automation exposure to the
process controls
or task design hazard
y for chemicals and substances
bstance risk levels using DOT criteria
rial Safety Data Sheet.
3 4
Flash Point below 73° F Flash Point below
(Boiling point at/above 100° 73° F (Boiling
F) and/or at/above 73° F, Point below 100°
not exceeding 100° F F)
Shock and heat may
May detonate
detonate
Extreme Danger Deadly
W (with line through it) Use no water
(No number values are assigned)

uating Severity for physical risks

ning physical hazard (risk) levels
2 3 4
Immediate
Immediate extremity Immediate serious
disability or
hazard. injury hazard
death hazard
RULA Score RULA Score RULA Score
3 or 4 5 or 6 7
worksheet): http://ergo.human.cornell.edu/ahRULA.html

nce: accumulated exposure risk

umulated risk exposure levels
3 4
Critical: task is
Severe: task is performed 9
repeated over 20
to 20 times per day.
times per day

errence levels: risk mitigation

ction): defining existing control levels
3 4
Risk is severe enough to
need supervision, e.g fire
Not controlled.
watch or buddy system for
confined space entry