Maintenance FMEA Checklist Form
Use this form to systematically identify and analyze failure modes, effects, causes, controls, and recommended actions for maintenance tasks.
Equipment or Maintenance Task
*
Failure Mode (Describe the way the equipment or process could fail)
*
Effect of Failure (What happens if the failure occurs?)
*
Potential Causes of Failure
*
Current Controls (Existing measures to detect or prevent the failure)
*
Recommended Actions (Steps to reduce risk or improve controls)
*
Action Status
*
Please Select
Not Started
In Progress
Completed
Deferred
Responsible Person or Team
*
Date Identified
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Checklist (Select all that apply)
Failure mode clearly defined
Effects analyzed
Causes identified
Controls reviewed
Actions assigned
Follow-up scheduled
Submit Checklist
Should be Empty: