Title Page
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Date of Issue Occurrence
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Person Reporting the Issue
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Specific Location of Issue
Issue Description
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Describe the Issue (If necessary, attach additional info below):
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What is the potential cause or causes of the issue?
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What are the potential effects on the system or subsystem?
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Who is the responsible party?
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What is the initial Hazard Severity rating?
- 1 - Catastrophic / May cause death, system loss, or severe disruption of service system wide.
- 2 - Critical / May cause severe injury, severe occupational illness, major system damage, or major system wide disruption of service.
- 3 - Marginal / May cause minor injury, minor occupational illness, minor system damage, or minor system disruption.
- 4 - Negligible / Less than minor injury, occupational illness, system damage, or less than minor system disruption of service.
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What is the initial Hazard Probability rating?
- A - Frequent / Likely to occur frequently to an individual item. Continuously experienced in the system.
- B - Probable / May Occur several time in the life of an item. may occur frequently in the system.
- C - Occasional / Likely to occur sometime in the life of an item. May occur several times in the system.
- D - Remote /Unlikely, but possible to occur in the lifetime of an item. Unlikely but expected to occur expected to occur at some time in the system.
- E - Improbable / So unlikely to occur, it can be assumed an occurrence may not be experienced. Unlikely, but possible to occur in system.
- F - Eliminated / Incapable of Occurrence. This level is used when potential hazards are identified and later eliminated.
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What is the proposed corrective action?
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