Success does not depend on a single event, just as a catastrophe does not depend on a single failure.1 —Dr. Steven J. Spearnned maintenance and casualty control typically, however, are written to deal with a singular task or problem and assume a sailor’s actions will affect only that particular piece of equipment. These procedures often fail to account for other issues within that subsystem or the networked shipboard environment as a whole. As a result, crewmembers must think critically and anticipate the second- and third-order effects of their intended actions, which is often difficult.
The challenges associated with mentally navigating multiple layers of complexity are compounded when systems are not fully operational. Sailors must rely on combinations of procedures to control the situation and prevent the possibility of a cascading casualty. Furthermore, sailors must contend with documentation that frequently is out of date, conflicting, or missing altogether. To deal with these problems, the Navy must answer two questions: