De Menezes didn't run from police

According to leaked documents from the official investigation into the shooting death of Jean Charles de Menezes on 22 July. The Guardian also reports here. It's outrageous: de Menezes calmly walked through the turnstiles, picked up a free newspaper, and only ran once he heard the train approaching. The officers weren't sure he was really a suspect because one of them was "relieving" himself when de Menezes left his flat. He wasn't even wearing a heavy coat. And so on.

I hope the outcome of the inquiry is not limited to punishing the police officers responsible. Errors like this reveal systemic problems with the whole system that have to be - and can be - fixed.

I've just been reading about wrongful police shootings in Malcolm Gladwell's book Blink. He suggests that when you chase someone and your heartrate goes above 175, your cognitive capacities are sharply diminished, and you become "temporarily autistic" as he puts it - unable to read someone's intentions. The mind just doesn't work as it should. Police departments have started to realize this, in banning high speed chases, having patrol officers work alone (so you don't feel the need to be brave in front of your partner), and following strict procedures when approaching a car, like standing slightly behind the driver and shining a flashlight onto the driver's lap (so there's no possibility for wrongly thinking the driver's about to shoot you). You cannot rely on human agency in these situations - you need to set up circumstances to reduce the chances of human error to as low as reasonably possible.

It's the same story with medical errors. Doctors try their hardest, but there is a limit to human ability, and at that limit, tiny modifications in the environment can make a difference. Following systematic study of fatal errors in anesthesiology, doctors cut the death rate from general anesthesia from 1 in 10,000 to less than 1 in 200,000 by seemingly trivial things like making all dials turn in the same direction and making it impossible to turn oxygen delivery down to zero.

We'll know more when the full report on the wrongful shooting of de Menezes comes out. The police officers are surely guilty of incompetence, but that isn't the whole story - I don't doubt that the "system" is guilty of incompetence too.