The Outcome-Oriented Academy

Aviation Accident Analysis - A Systems Approach

6-Week Instructor-Led Online Course

In-house Presentation and Blended Learning Options for Organizations


A new view, a holistic systems view, that sees individuals in systems, is growing. It is a view which recognizes human error as a symptom rather than cause of trouble inside the system.

Led by Capt. Paul S. Nelson, Senior Human Factors Consultant

paul-nelsonPaul Nelson has been involved in aviation and safety for over 25 years. His experience includes general aviation flying, owning and maintaining a personal single engine aircraft, air carrier experience as a First Officer and Captain of Canadair Regional Jets, and various leadership positions in both Airline and Pilot Union safety structures. In 2008, he completed a Master Degree in Human Factors and System Safety from Lund University, Sweden. Presently, Captain Nelson is president and Human Factors safety consultant in his company Nelson HF Safety Consulting, LLC. Under NHFS he is a sub contractor to the FAA’s AFS-440 in Oklahoma City, as an Aviation Human Factors Psychologist to NextGen Human-in-the-Loop research projects. His presentation and education style has been characterized as “energetic”, “practical”, “dynamic” and “useful”. When not involved with these professional pursuits, Paul and his wife take care of their 25-acre alpaca farm in eastern Oregon, USA.

Top 5 Reasons Why You Should Attend This Unique Course.

  • Get up to 2 hours of Personal Instructor feedback / interaction over 6 weeks

  • Online, In-house and Blended Learning Delivery Options

  • Proven course with High Ratings from past participants

  • Gain Hard Copy Certificate of Completion by Courier

  • Weekly Activities, Q&A Forums and Exercises for Maximum Retention of Knowledge

This course is based on cutting edge Systems and Human Factors theory. Course materials draw from STAMP (System Theoretic Accident Modeling Process) developed by Dr. Nancy Leveson, Professor at MIT and Dr. Sidney Dekker’s Local Rationality and the New View of Human Error. This course and materials focus on relational connections and interactions intrinsic to any system. Emphasis is placed on real world application exercises which can bring resiliency and safety to your workplace.

Week 1: Presentation

Presentation 1 – Human Factors: A historical context

  • Deconstructionism-Linearism-Chain of events
  • Cause & Effect-Root Cause
  • Newtonian-Cartesian Logic
  • The Sum of the Parts-“mechanical” interactions

Week 2: Presentation

Presentation 2 – Systems Theory

  • Competing Goals-Goal Conflict-A balancing act
  • Relational influences-Nonlinear Interactions
  • Multiple Factors to incidents and accidents
  • Complexity vs. Complicated

Week 3: Presentation

Presentation 3 – Local Rationality and the “New View” of Human Factors

  • Actions make sense at the time!
  • Emergent Properties-Greater than the sum of the parts
  • Human Error as a symptom
  • System Drift
  • Change the System not the Human

Week 4: Exercises

Presentation 4 – Theory meets Practice Part 1

  • NTSB Report: Attempted Takeoff From Wrong Runway-Comair Flight 5191
  • STAMP analysis: A STAMP Analysis of the LEX Comair 5191 Accident

Case Study – Morning Tragedy-Comair 5191 Accident

Week 5: Exercises

Presentation 5 – Theory meets Practice Part 2

  • Medication Error: Case Incident description

Week 6: Exercises

Presentation 6 – Theory meets Practice Part 3

Case Study – Bring your Incident or Accident for analysis

Group Discounts and Early Bird Discounts are Available!

What the Past Participants Say About Our Courses?

The new ideologies brought up and applicability. Many Thanks to Paul for his great work!
Stephane Landry
Seaplane Pilot / Jet Ops, Dubai
It was nice to see some other perspectives and refresh some concepts.
Caio Rosante Garcia
Captain / Azul Brazilian Airlines, Brazil
I would like to thank Outcomy team for maintaining a cordial relationship with the participants.
Raman Giridhar
Licensed Aircraft Engineer / Air Canada Jazz, Canada
I liked the interaction between the participants since it allows to draw from others’ experiences.
Erika LaCour-Loyd
Lead Engineer – Reliability Engineering / American Airlines, USA
The course got me thinking and it was nice to see how others do things around the world.
Jo-Anne Fletcher
Airworthiness Assistant / Flybe, United Kingdom
I like the way in which the course was organized and I could participate at my convenience.
Boril Yonchev
Planning & Engineering Department / Lufthansa Technik Sofia Ltd., Bulgaria
Very good "Case Studies", since they helped directly apply the learning.
Maurizio Tomassi
Planning & Continuous Airworthiness Surveillance Manager / INAER Aviation Italia

24x7 Learning Anywhere. Anytime. Flexible and Convenient. No time off from work.

Thousands of Learners representing 300 Clients in 100 Countries have Attended these Courses.

Leslie Munnings, Bahamas Air, Past Participant

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