Attachment 23
Criticality Assessment
PROJECT NAME PROJECT REFERENCE NUMBER:
SYSTEM/EQUIPMENT DESCRIPTION:
SECTION 1: IDENTIFICATION OF CRITICALITY ASSESSMENT TEAM
Role/Area Job Title Name Responsibilities
Process Owner
Engineering
Quality Assurance
Other
SECTION 2: DESCRIPTION OF SYSTEM AND DEFINITION OF SCOPE OF ASSESSMENT
Identification of Sub-Components Function(s) of Sub-component Determination of Impact on Either Product, Process, or
Environment based on Function
Direct / Indirect / No Impact
Direct / Indirect / No Impact
Direct / Indirect / No Impact
SECTION 3: INSTRUMENT CRITICALITY ASSESSMENT FOR DIRECT AND IN-DIRECT SUBCOMPONENTS ONLY
Sub-Component 1:
Instrument Id Function of Sub- Effect of Failure on Product Effect of Failure on Effect of Failure on Safety Criticality
Component Process
Critical/ Non-critical
Critical/ Non-critical
Critical/ Non-critical
Sub-Component 2:
Instrument Id Function Effect of Failure on Product Effect of Failure on Effect of Failure on Safety Criticality
Process
Critical/ Non-critical
Critical/ Non-critical
Critical/ Non-critical
SECTION 4: DEFINITION OF CALIBRATION RANGE, TOLERANCE AND FREQUENCY FOR CRITICAL INSTRUMENTION ONLY
Instrument Id Manufacturer Model Instrument Specification Process Requirements Periodicity/ Acceptance of
Frequency of Instrument
Operating Tolerance Process Process Calibration
Range Range Tolerance
Accept/Reject
Accept/Reject
Accept/Reject
SECTION 5: APPROVAL OF ASSESSMENT
Role/Area Name Signature Date
Process Owner
Engineering
Quality Assurance
Other