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It seems to be a few years since I last moaned about my Apple kit (eg iPod, Spotlight, iCal, Pages, iCloud).

A few weeks ago my iMac (21.5-inch, late 2012, 2.7GHz Core i5, 8GB memory, then OS X 10.12.3) started seizing up, sometimes so badly that I had to do a hard reboot, other times just slowing a a crawl. I tried all kinds of things but could not afford the time to get systematic about pinning it down, I was desperate to churn out various memos etc.

Yesterday, I finally got more serious and found the main problem was that an Apple process called “suggestd” was taking up nearly 100% of the CPU time, presumably locked in some kind of endless loop. The forums suggested this problem first appeared a few years ago and was apparently sorted – after a while. Then it re-appeared under v10.12.3. The second suggested fix I tried worked.

But removing that bottleneck revealed another. Looking at the log files I traced that to Snapz. The utilities that Apple provided used to be fairly hopeless for taking an image of an area of the screen or recording a video, so like many people I purchased Snapz. It proved useful for several years. I had to uninstall it when I moved to El Capitan (OS X v10.11), but I discovered that Apple had caught up and I no longer needed it.

However, it turned out that it was much trickier to uninstall than I had realized and I had not completely got rid of it. That bit me when I moved to Sierra (OS X v10.12). It turned out that launchd was trying to launch a LaunchAgent for it every 10 seconds, mostly this just slowed things down slightly but sometimes it glitched iTunes or froze for a minute if the TimeMachine backup was starting. I like TimeMachine, but there is not enough control over it to stop the wretched thing starting an unnecessary backup just as you have unsleeped the machine.

I cannot really fault Apple for the Snapz mess which was primarily due to poor uninstall instructions from its authors, but sorting it out is not made any easier by the lack of convenient Apple documentation for the key Apple process launchctl. I reckon to be reasonably competent at software – I know in broad terms what to do, but I am not that fast at it, because I try to limit my time on playing software to a few per cent of my time. To get really good you have to do it full-time, then you remember the thousands of tiny details and do not need to look them up. Be that as it may, the whole mess (suggestd and Snapz) has wasted many hours of my time at a particularly busy period. Grrrrr!

I never quite know the answer to the complexity of modern desktops. Most people only want fairly limited functionality, and delivering that could be really cheap – £50-100 for a smartphone or tablet and £100-200 for a laptop or desktop. But that does not suit Apple, Intel or Microsoft.

The hardware guys are stuck with Moore’s Law, they every year or two the capability of hardware improves by a factor two. So in principle they could halve their prices and deliver the same – which obviously has little appeal to them – or they can deliver more for the same price. The “more” sometimes involves new things that are genuinely useful to the user: displaying good quality video; good touch screens. Indeed, after decades of failure, good voice control is finally starting to emerge (using extensive server software via the internet). But much of the time the “more” is of limited use or a positive nuisance.

What about the massive, bloated operating systems? To be fair to Apple, it realised that we had to move away from the idea of a single machine the PC, albeit sometimes clothed as a desktop and sometimes as a laptop. It introduced the smartphone and later the tablet. It is now struggling, via Swift, to tie iOS and OS X together better.

But it remains true that most people would be happy with much simpler cheaper desktop machines with a small set of standard apps and no ability to install new apps off the internet. Unfortunately no one has a financial interest in providing that, and it has proved possible to sway consumers with advertising focussing on fashion and snake-oil rather than functionality, reliability and ease-of-use.

Snowflakes and all that

A small plug for the really useful online OED:


I am thinking about the derogatory meaning. I first noticed it in connection with “safe spaces”:


I have written several times before about the ludicrous expansion of university education in the UK (here, here, here, and here). The inevitable result has been the creation of a large number of almost entirely useless universities which do almost no worthwhile research and which provide undergraduates with little useful education or training.

The cost is substantial, but hard to estimate at all accurately. Partly the statistics are confusing, partly there is a difficult judgment issue over how much of the student loans will eventually be repaid. If we look back before tuition fees became significant the cost of tertiary education seems to have been about £10 billion a year, of which at least half must have been for useless universities.

However, the snowflake issue is about how it is actually worse than that because many universities are rapidly becoming positively harmful rather than merely useless. For years much university teaching in the humanities has been degenerating into the absurd with modernist theories which preach a bizarre “post-truth” message, but this is now starting to move towards its logical conclusion with efforts to ban speakers whose views might upset students whose views are different – “no-platforming” and “safe spaces” (where students can be sure their prejudices will not be challenged). In other words, universities are becoming complicit in encouraging students to give up altogether on the painful business of thinking and analysing.

Of course, the “post-truth ”


tsunami is not confined to universities. The news that prompted this post was the latest development in Ken Livingstone saga. Naz Shah (43) is the Labour MP for Bradford West.


She was born in Bradford, although her parents came from Pakistan. She was elected as an MP for the first time in the last general election in May 2015. In 2014 she posted this on Facebook at a time when Israeli atrocities in Gaza were in the news:


and added a couple of comments shortly afterwards


In 2016 a blogger discovered the post (or maybe a reposting, I have not checked FB because Shah’s account has a vast number of posts) and publicised it. There was a row. On 26 April 2016 she stepped down as PPS to John McDonnell (shadow Chancellor), but retained her seat on the Home Affairs Select Committee. The following day she was suspended by the Labour Party, then re-instated on 5 July 2016. She made all kinds of fulsome apologies and the Left forgave her.

On 28 April 2016 Livinsgstone was interviewed by Vanessa Feltz (55). The Independent later published a transcript:

KL: She’s a deep critic of Israel and its policies. Her remarks were over-the-top but she’s not antisemitic. I’ve been in the Labour party for 47 years; I’ve never heard anyone say anything antisemitic. I’ve heard a lot of criticism of the state of Israel and its abuse of Palestinians but I’ve never heard anyone say anything antisemitic.

It’s completely over the top but it’s not antisemitism. Let’s remember when Hitler won his election in 1932, his policy then was that Jews should be moved to Israel. He was supporting Zionism – this before he went mad and ended up killing six million Jews.

The simple fact in all of this is that Naz made these comments at a time when there was another brutal Israeli attack on the Palestinians; and there’s one stark fact that virtually no one in the British media ever reports, in almost all these conflicts the death toll is usually between 60 and 100 Palestinians killed for every Israeli. Now, any other country doing that would be accused of war crimes but it’s like we have a double standard about the policies of the Israeli government …

I’m not an apologist for anyone who makes antisemitic statements. What I’m saying is don’t confuse antisemitism with criticism of the Israeli government policy.

I have not even begun to look into the history of exactly what Hitler did before WW2, but my general experience of Livingstone is that he does his homework. But even if his opinions could be criticised as historically dodgy, they are certainly not anti-semitic. Of course, large numbers of Jews (and others) have taken offence, but that is entirely another matter.

The whole point about free speech is that one must be free to offend and upset. A freedom restricted to a freedom to flatter is hardly of much value.

Needless to say, however, his remarks did not go down well with some sections of the Labour Party. John Mann in particular – a politician who has said some sensible things on other issues, such as the banking crisis – was filmed wagging his finger and accusing Livingstone of being a Nazi apologist. Later in the day Jeremy Corbyn suspended Livingstone from the Labour Party for bringing the Party into disrepute, pending an investigation.

The investigation eventually concluded earlier this week that Livingstone should be suspended from the Party for two years (one of which has already passed). His critics were outraged that he had not been expelled.

Yesterday Michael Levy (72) a long-standing friend of Tony Blair and his chief fundraiser for the Labour Party was interviewed on the Today programme (R4):

ML: … I do not believe that the punishment [of Livingstone] was correct … many of the comments … particularly from our Chief Rabbi have endorsed that opinion.

He agonised for a while about whether he should leave the Labour Party, and then came out with this bizarre snowflakery, muddled up with nostalgia for the days when he had the ear of the prime minister:

ML: … I am very upset … I do not believe there has been a zero tolerance policy towards anti-Semitism … The lack of sensitivity [shown by Ken Livingstone] towards the Jewish community has been outrageous …

John Humphrys: You will be aware that some Jewish members of the Labour Party do not believe Mr Livingstone was guilty of anti-Semitism …

ML: Well those members are I would guess such a distinct minority, there can be very very few of them and they, to me, are not what I call serious members of the Labour Party, and they are not the future of the Labour Party. Nearly 10M people, John, voted for this Party in the last election. A handful of members, if they are of the Jewish faith, so be it, their problem. That does not mean that we cannot make this Party into a serious party for the future … Let us not forget how Tony Blair behaved towards the Jewish community, how Gordon Brown behaved towards the Jewish community. Let us not forget that the current Mayor of London instead of celebrating with his family literally two days after his election victory, he was at the Holocaust Memorial Day showing solidarity. There is still much good in the party …

JH: What they [the Labour dissenters] say is that for a political party to adopt the principle that causing offence to some part of the population is a reason for expulsion, that would be to deny freedom of expression for what are legitimate political opinions …

ML: who signed off on that?

JH: a group of people, 30 of them … they say that they represent Jewish Labour Party members, many of them anyway.

ML: Well, I don’t think so at all. As far as I am concerned my Jewish colleagues within the Labour Party and my non-Jewish colleagues in the Labour Party, many many hundreds, thousands of them, would be absolutely in total disagreement with that statement … quite frankly to me our leader is our Chief Rabbi and not this group of 30 people, and I think that they need to refer to what he has said, which is unequivocal in terms of his criticism both of Livingstone and of the Labour Party on how it has behaved on this issue.

Evidently Michael Levy considers that the Jews are a special case. No one should say anything that might offend them.

Added 11 Apr 17

Presumably Levy’s reference to the Chief Rabbi condemning Livingstone refer to remarks by Ephraim Mirvis reported in the Jewish News on 7 Apr:

This was a chance for the Labour Party to show that it would not tolerate wilful and unapologetic baiting of the Jewish community, by shamefully using the Holocaust as a tool with which to inflict the maximum amount of offence. Worryingly, the party has yet again failed to show that it is sufficiently serious about tackling the scourge of anti-Semitism. The Labour Party has failed the Jewish community, it has failed its members and it has failed all those who believe in zero tolerance of anti-Semitism.

I guess Mirvis chose his words carefully. He does not actually say that Livingstone was being anti-semitic. He just says that he offended those who believe in zero tolerance of anti-Semitism.

Going back to Livingstone’s remarks, the Jewish Virtual Library has:


So it is clear that, however insensitive his remarks, Livingstone was speaking the truth. We have to get better at listening to unwelcome truths and at standing up to minorities who are unwilling to do that. Or put more broadly, the UK must wake up and defend its core values, which took us centuries to implement.

Child porn (2)

My first post on this topic was more than eight years ago. For most of that time the situation has got worse. Much worse. But today I saw the first glimmer of light:


All major disasters have multiple causes and the great child abuse overreaction is no exception. Why grown men – and occasionally women – should want to kiddie-fiddle, I have no idea. Some sexual misbehaviour I can understand, even find tempting. Usually men my age (60s) getting romantically or sexually entangled with 18 year old girls are figures of fun. I remember that when I was young I had difficulty appreciating fine differences (or a decade or so) in the ages of those much older than me. Basically there were just two categories: the old, like my parents or the teachers at school, and the incredibly old, like my grandparents. So that stunning, sexy 18 year old girl sees me as incredibly old, like her grandfather. Maybe her grandfather is a lovable old stick, in which case she might not mind talking to me. Or maybe is a bad-tempered bore, in which case she might not. But in no case would she have any romantic or sexual interest. Or maybe that kind of analysis comes more naturally to mathematicians (like me) who are programmed to generalise, abstract, recurse etc more easily than breathing.

There are clearly exceptions. The sufficiently famous and the sufficiently rich often attract at least simulated interest from much younger members of the opposite sex. A minority of girls also seem to enjoy trying to attract much older men either for amusement or as part of discovering their sexuality, but with no intention of ever consummating the relationship, such as it is. Also men seem to be genetically inclined to make fools of themselves even when their rational selves know that a relationship won’t work. But after a number of misadventures most men, over say 50, have grasped that relations with much younger girls are unlikely to work well, however tempting they may be.

So far I have skirted around an inevitable difficulty. The law uses fixed ages, which are set cautiously high. But some people mature sexually, if not emotionally, far earlier than others. Some girls have substantial sexual experience by the age of 14 or younger. Others have none by the age of 21. The American use “jailbait” to describe a girl under the statutory age who behaves like an extremely flirtatious and apparently sexually available girl in her twenties. Appearances can be deceptive, she may not actually expect or want things to go further than suggestive talk, but it makes little difference, responding to her overtures if you are significantly older (say over 25) is to risk being jailed, and we all have, or should have, sufficient self-control not to respond.

Arbitrary boundaries arise all over the law and basically one just has to accept them. But consider the case of someone manifestly young enough to have little idea of what sex is about, say age 9 or 4 or 2. Why are some people sexually aroused by such children? If you do not feel any such arousal yourself, you are likely to feel absolutely appalled by the behaviour of someone who apparently does.

In passing, it is unfortunate that the word “child” has two meanings in this context. On the one hand it means “under-age human being”, on the other it means what most people think of as a child – someone pre-puberty, probably under 10 and maybe under 4. So the horror which we naturally associate with someone buggering a 3-year old child tends to get carried across to someone having conventional sex with a highly sexually experienced girl of 15 who took the initiative all the way along.

So far I have been talking about “child abuse”. At first sight, it would seem that “child porn” is a far less serious matter. After all, if I spend all day watching unpleasant videos, no one else is apparently hurt, although there it is at least arguable that I am. Interestingly, this point is rarely made. When it is, the response is that the watcher is increasing the demand for such movies and hence indirectly increasing the supply of such movies. Assuming there is no clever fakery, each movie involves actual child abuse.

We can forget clever fakery. The only cheap fakery is for an actress in her early 20s to dress, make up and act as if she was 15. The video equivalent of “photoshopping” images is still far too expensive (in time and equipment) to be much used.

But it is hard to see that (say) 100 views of a video would justify the trouble and expense of making it. So yes an individual watching a video of a child being buggered is adding to the total number of real-world incidents, but his contribution is small, far smaller than the contribution of the person carrying out the buggery. You may object that an individual may watch thousands of hours of such videos, but I still find the whole argument flimsy.

If you try to discuss it, or look at the way the topic is treated, it is quite clear that this issue does not get careful consideration. People just emote. They are horrified by the idea of their 2 year old child being abused by some “monster” and anyone involved in that kind of thing (such as someone caught with downloaded child porn) is clearly a monster. Lock him up and throw away the key.

That brings us back to the elephant in the room. The overwhelming majority of child abuse is by family and close friends. Usually, family members not directly involved in the abuse cannot bring themselves to believe it is happening, even when there is clear evidence that it is. All that is exceedingly uncomfortable. Much easier to blame a gang of evil strangers going around kidnapping or grooming innocent children and then abusing and filming them, so their sicko friends and contacts can watch what they did.


Even professionals can get wildly over-excited – see my earlier article, although Jim Gamble has now left CEOP, which is now part of the National Crime Agency.

But curiously, Simon Bailey has now come out to say we should stop prosecuting people for watching child porn. He is the chief constable of Norfolk and the NPCC lead on child protection. The NPCC, for those lagging behind, is effectively the April 2015 replacement for ACPO. Its role is to coordinate policing between the various forces. Partly that is about boring issues like purchasing policy, and partly about trying to get an agreed approach to tricky issues.


Doing something about online child porn is one of its “digital” objectives in its 2016 plan:


Bailey is clearly aware that the public will emote wildly about the idea of not jailing those looking at child porn. He bases he recommendations simply on practicality.

Hounding Hogan-Howe

Do we really want a succession of Ian Blairs as Met Commissioners (see here, here, and here)? His attention seemed to be largely focussed on pleasing politicians. He spent inordinate amounts of time on cases/issues that he thought might interest them. Hogan-Howe on the other hand is a proper policeman. I believe him when he starts quoting the number of major cases he has to keep an eye on, with Operation Midland just one of them. He is interested in all of them, so making his life miserable and pushing for him to resign because of mistakes in one (Operation Midland) is completely unreasonable.

A brief recap. As the full horror of Jimmy Savile’s activities gradually became apparent, everyone started to worry what other paedophiles had been operating decades ago. In passing, I my view is that we need a statute of limitations on criminal cases except perhaps for the most serious – murder and maybe a tiny handful of others. Sex with girls aged 15 would not come into that category for me. Sure, it is illegal, but the limit of 16 is something of a cultural matter, it is hard to see it as an objective standard. Sex with children under the age of say 10, I would have no difficulty in making an exception. Where the dividing line should come I am not sure.

But whatever the category of exceptions, the other problem is that it is hard to get a reliable conviction for anything that happened decades ago. All sex crimes pose evidential problems at the best of times, but it becomes really difficult for a sex crime alleged to have happened long ago. It is easy to forget that convicting the innocent is worse than failing to convict the guilty.

Inevitably the pendulum swung too far. The police decided that traditional approaches to dealing with complaints of sexual abuse of children were wrong, because they were too off-putting for the complainant. As often happens in such cases, ACPO appointed someone to take the lead on policy, in this case Simon Bailey, chief constable of Norfolk. He set up a “coordination hub” called Hydrant and produced the “Operation Hydrant SIO Guidance” for dealing with historic cases where well-known public figures were suspected of abuse (SIO is police jargon for the senior investigating officer on a particular case).

The full guidance is not publicly available, but it later emerged that it required SIOs to believe complainants, which (if followed) was more or less guaranteed to end in disaster.

Meanwhile several historical investigations were launched. Operation Fairbank focussed on claims that boys were sexually abused and groomed during parties of gay men at the Elm Guest House. It was about 7 miles from Parliament in a row of terraced houses in Rocks Lane, which runs North from Barnes station through Barnes Common. In the early 1980s it was raided by police following complaints that it had become a gay brothel, and it closed in 1982. The manager, Carole Kasir, was convicted of running a disorderly house. Later in 1990 she died aged 47; the inquest verdict was suicide by an overdose of insulin.

The precise story at this point is getting difficult to follow, because all sorts of documents once on the internet seem to have been taken down and I lack the inclination to search diligently for them on wayback etc. But a key player seems to have been Chris Fay (now 70), a former Labour councillor and social worker who worked for (and set up?) NAYPIC (National Association for Young People in Care, a child welfare charity). He appeared to claim that all kinds of photos and other documents had been shown to him by Kasir which proved that 4 MPs, led by Leon Brittan, the former home secretary, had been involved in abusing children at Elm House. All these (alleged) photos and documents had subsequently disappeared.

[a lengthy interview with Chris Fay by a sympathetic anti-child abuse activist and filmmaker]

He tried to interest a freelance journalist, who lost interest when he was unable to get any corroborating evidence. But all the allegations seem to have been passed to the Met, who also dropped them after failing to find anything to make them sufficiently credible.

The really curious can spend an hour watching the video above (from Oct 2013). Initially, at least, Fay comes across as low-key and credible. But at 28m (and 31m etc) we have the interviewer ranting on about how terrible child abuse by top people is. He is right, child abuse is terrible. But the questions are: did these particular individuals abuse children; and is there enough evidence to convict in court? Halfway through that video I began to see clearly that we could be in either of two situations: some powerful people covered up some terrible things, or we are in danger of re-running a modern version of the Salem witch trials.

The problem is that the internet is full of material by people who have not looked at the evidence available to them at all carefully, or even at all, but instantly react with violent emotion and want vengeance. Worse, it soon gets tangled up with all kinds of other agendas, like a visceral dislike of Tory politicians and policies.

Chris Fay tried to interest various people in his allegations, including Tom Watson (currently the elected deputy leader of the Labour Party). On 24 Oct 2012 (Hansard col 923) he asked at Prime Minister’s Questions:

The evidence file used to convict paedophile Peter Righton, if it still exists, contains clear intelligence of a widespread paedophile ring. One of its members boasts of his links to a senior aide of a former Prime Minister, who says he could smuggle indecent images of children from abroad. The leads were not followed up, but if the file still exists I want to ensure that the Metropolitan police secure the evidence, re-examine it and investigate clear intelligence suggesting a powerful paedophile network linked to Parliament and No. 10.

He got a fairly non-committal reply from Cameron:

The hon. Gentleman raises a very difficult and complex case, and I am not entirely sure which former Prime Minister he is referring to. What I would like to do is look carefully in Hansard at the allegations he has made and the case he has raised, and look carefully at what the Government can do to help give him the assurances he seeks.

But, of course, the question was broadcast live and attracted a good deal of attention, including presumably in the Metropolitan Police who were apparently being accused of grossly failing in their duty. Some years later in 2015, Fay was interviewed as part of a BBC Panorama programme.


[last shown just over a year ago, no longer on BBC iPlayer, but still unofficially on youtube]

I wasted a good deal of time failing to make up my mind. On the one hand, Fay is claiming a large-scale cover-up, apparently masterminded by the security services. He also has a fraud conviction. On the other hand, he is not an obvious fantasist. So has there been a careful and successful cover-up, which has left little hard evidence beyond the odd witness whose uncorroborated evidence would be unlikely to stand up in court, or is he a fantasist?

My meanderings through various links quickly led me to things like Chris Spivey‘s blog. He is an angry campaigner who finds it really hard to attribute anything but bad motivation at every turn to senior Tory politicians. Eminently sane, he has a strong and powerfully-expressed point of view. Then I ran into Brian Heap who claims persecution over a period of several years by a substantial cast of characters (including the police) all because he sacked a teacher for child abuse when he was a headmaster.

As I read through the pages of his “Chronology” I started thinking what an awful time he had had. Then we moved on to his sectioning under Mental Health legislation. Most stories of paranoia are indeed induced by mental health problems, but occasionally they are true. Few people (including consultant psychiatrists) bother to look into such stories carefully, they just take a few salient features of such stories as clear hallmarks of mental illness.

Neither of those two individuals turned out to be relevant (as far as I could see, despite being only a link or two away from the Operation Midland case), but I began to grasp the real difficulty of investigating these “historical cases”. Many of the witnesses who come forward are clearly most unlikely to appear sufficiently credible – for a variety of reasons – in a court case where guilt for a specific crime by a specific person has to be proved beyond reasonable doubt.

The real trouble came when Nick put forward his claims:

Operation Midland arose from claims by “Nick”, a man aged in his 40s who was a child at the time of the alleged incidents. Having written of his abuse, Nick was contacted by Exaro, a short-lived investigative journalism website funded by Jerome Booth. Exaro sold stories to newspapers about the alleged incidents, and a reporter from Exaro accompanied “Nick” to meetings with police.

Nick claimed the VIPs had not stopped at child abuse, they had murdered three children.

Operation Midland’s investigations into these allegations resulted in several VIPs being effectively named and shamed, despite the fact that the Met were unable to find any solid evidence to support the allegations, which later appeared to have been made by a wild fantasist.

Realising that Operation Midland had had a bad outcome, Hogan-Howe commissioned Richard Henriques, a retired High Court judge, to look into it. At the end of October Henriques submitted a lengthy 500 page report. Earlier this month, Hogan-Howe made public the 68 page summary.

The summary is hard-hitting and spells out clearly and forcefully why Simon Bailey’s Hydrant guidance is seriously flawed. Similarly, he spelt out that not only is “believing victims” wrong, so is calling them “victims”. They should remain “complainants” until the allegations are proved. He then went into detail about the Met’s policy on releasing information to the press prior to suspects being charged, and explained clearly why this policy did not work for well-known public figures, whom the press could easily identify from the limited information released.

The summary is clearly and forcefully written and closely argued. I imagine it will be persuasive in changing police practice.

But poor Hogan-Howe is now being criticised for not releasing the full report. This is ridiculous. Some of those under his command quite properly followed ACPO guidance on how to conduct a particular type of case. Hogan-Howe noticed that the case had had a bad outcome and commissioned an enquiry. He published the hard-hitting (and fairly lengthy) summary a few days after he received it. All that seems exactly what we should hope for in a Met commissioner. We really must stop treating highly competent professionals unfairly. Do we want a politicised police force?

Tram crash


The crash was between Lloyd Park and Sandilands. The schematic map above is confusing. The map below is clearer for orientation but less detailed. The shape of the track from Sandilands to Lloyd Park is like a Z:


The Google aerial map is:


Lloyd Park tramstop is the tiny blue and white symbol in the centre bottom. The track goes West a short way and then North-North-East up the dark gap between the two green lines. Near the top right it turns sharply left. The blue and white symbol a little further on is Sandilands Station. At the sharp left another track comes from Sandilands and takes a sharp left to Addiscombe tramstop way out of the picture to the NNE. A larger scale of the crash area is:


The speed limit on the long straight run up from Lloyd Park, much of which is in a tunnel, is 50mph. The speed limit on the sharp bend is 12mph. Apparently, the tram was going far too fast around the bend, derailed and killed 7 people, injuring many more. The driver was arrested.

We now have the classic media protest. Heart-rending sob stories from the injured and relatives of the deceased and demands that something be done. That translates, of course, into someone must be found to take the blame for the tragedy. The unfortunate driver looks like the fall guy.

When will people learn?

Blame enquiries are not the way to improve things. We know that. The paradigm is the air accident investigation. Because aircrashes tend to kill many people at once, they attract totally disproportionate attention. But at least we focus that in a constructive way. The investigations are usually extremely thorough. They are not about blame. You find that the pilot pressed the wrong button, say. Instead of demanding that he suffer for his terrible crime, the investigators ask what can be done to stop pilots doing that in future. Maybe the button is in the wrong place, or easily confused with another button, or needs some kind of interlock, so you have to twist it first. So you get carefully nested systems where several things have to go wrong before a tragedy can happen, instead of just one.

Medicine and the police tend to be different. There it is usually about blame. So what happens? Progress in eliminating bad behaviour is extremely slow. Those involved close ranks. Evidence mysteriously goes missing, and so on. But there are the occasional notable exceptions. When I was young it was common for patients to die in operating theatres as a result of errors in anaesthesia. The anaesthetists got together and started no-blame inquiries. Instead of blaming the harassed anaesthetist for pressing the wrong button, they redesigned the buttons. Today almost no one dies from anaesthesia.

I remember a few years ago falling into conversation with someone in Dillons (now Waterstones) near University College London and saying that. He turned out to be an anaesthetist/researcher. Yes, he said sadly, unfortunately we seem to have solved the problems! [Meaning that research was now less exciting.]