. . l?l??lltba .lf y} I II .. ?Hmw?mw??a?>Lm2mm21cozmmnozu>z< .iv' ., 2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH: AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31, 2019 # In Memoriam On May 31, 2019, the City of Virginia Beach lost 12 of its own. Their lives were taken in a place where they should have been safe, where they worked every day as dedicated civil servants. They passed suddenly and left family, friends and colleagues – and their entire community – to face the unthinkable, begin to grieve and find ways to forge ahead without them. Each of these 12 individuals had unique passions and backgrounds, families and friends, hardships and successes. Let’s continue to honor them, share their stories and remember their lives. www.hillardheintze.com $ LaQuita C. Brown Ryan Keith Cox Tara Welch Gallagher 39 years old 50 years old 39 years old LaQuita “Quita” had a warm smile and a contagious laugh that brightened everyone’s mood. She was admired and respected by all. The thoughtfulness and joy on her face will never be forgotten. At the age of 16, she symbolized her dedication to Jehovah by undergoing water baptism. She took her dedication to God seriously and chose the ministry as her vocation. She enjoyed many privileges of service and performed all with zeal and humility. Her experience in the real estate field, particularly as a Right-of-Way Technician, proved to be an invaluable service. LaQuita also loved spending time with children, having a profound effect on the spiritual development of many. Ryan Keith Cox served 12½ years as an Accounting Clerk for the City of Virginia Beach. He was a member of the New Hope Baptist Church, Anointed Voices, Men of Hope, the Male Chorus, and the Men’s Ministry. Ryan loved sports, reading, and studying the Bible. He leaves to cherish his memory his parents, Pastor E. Ray Cox, Sr. and Maxine Mills Cox; two brothers, Tony F. Mills and Erin Ray Cox, Jr., and a host of other relatives and friends. Tara Welch Gallagher was a devoted wife and mother. She was a beautiful person both inside and out. Tara's life centered around her family. She was most proud of her role as a mother to Patrick III. Tara touched many lives both personally and professionally and her absence will continue to be felt as an empty loss. Tara will always be missed and will never leave her family’s thoughts. © 2019 HILLARD HEINTZE > THE CITY OF VIRGINIA BEACH: AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31, 2019 Mary Lou Gayle Alexander Mikhail Gusev Joshua O. Hardy 65 years old 35 years old 52 years old Mary Louise "Mary Lou" Crutsinger Gayle was a self-made woman from a strong and loving family. She raised two children as a single mother and after proudly seeing them through college, returned to school herself and earned both a Bachelor’s and a Master's. Mary Lou was a dedicated public servant who proudly worked for the City of Virginia Beach for 24 years, advancing to become a Senior Right-of-Way Agent in the Public Works Department where her focus was on supporting projects to improve and beautify the city that was her lifelong home. She was a dedicated and beloved mother, grandmother, sister, aunt, daughter and friend who enriched the lives of all with her generosity, infectious zest for life, quick wit, kindness, and unshakeable faith. Alexander Mikhail Gusev was born in Mogilev, Belarus. He came to the United States on May 31, 2003, looking for the American dream. He graduated from ODU with a BS in Science and Business Management, and eventually became a Right-of-Way agent for the Virginia Beach Public Works Department, allowing him the opportunity to bring his mother from Belarus to join him in America. Alex was an easy-going person with a great sense of humor, made many faithful friends and touched the lives of many others. He is survived by his parents, Mikhail and Alena, his twin brother Aliaksei, his sister-in-law Olga, and his niece Arina. Joshua Orion “Dennis” Hardy is remembered by his family as having the attributes of love residing in him, accompanied with the natural God-giving instinct to protect and serve. He is remembered as a Godfearing man whose life spoke out to family, friends, the coworkers that he loved, and the world in these few words: “This is my commandment, That ye love one another, as I have loved you. Greater love hath no man than this, that a man lay down his life for his friends” (John 15:12-13). www.hillardheintze.com H Michelle “Missy” Langer Richard H. Nettleton Katherine A. Lusich-Nixon 60 years old 65 years old 42 years old Michelle Marie “Missy” Langer lived in Virginia Beach for the past 20 years, loving the beach life and serving her church, the Good Shepherd Lutheran Church. She loved Paul McCartney and was an avid fan of the Michigan Wolverines, having been born in Michigan, as well as the Pittsburgh Steelers. Left to cherish her memory are her sister, Deborah Borato and her husband, Ron; her brother, Herman “Fred” Langer and his wife Kim; as well as several nieces, nephews, cousins, and extended family. She touched the lives of many people in the City of Virginia Beach and leaves many close friends behind. Richard Nettleton was a 10-year veteran of the U.S. Army before becoming a dedicated Virginia Beach Design and Construction Manager in Public Utilities and loved being an Engineer, with coworkers holding him in high regard as one who enjoyed mentoring other engineers and who put himself last on the list when others had a need. Richard was proud of his Chinese heritage on his mother’s side, and was a strong supporter of the Minority Business Expo and believed in professionalism, diversity, and reaching out to all in the community. Remembered by his family as a strong, steady presence during every family challenge, he leaves behind his wife, Sarah; his sons Richard Jr. and Robert; step-children Byron and Mary Elizabeth; his mother Teresa Nettleton; and his siblings and their spouses: Diana and Bill, May and Mike, Sue and Carl, Eric and Donna, Mary and Marc, Dora and Don, and Peter and Cheryl. Katherine Lusich-Nixon is remembered by her husband as his best friend and one of the most loving, intelligent woman he has ever met. A loving wife and mother, Kate loved her daughters and her family more than anything in the world. She loved volunteering in the community and believed that everyone should be part of the solutions in life, not part of the problems in life. She touched many lives in both her personal and professional life. The world will not be the same without Kate Nixon in it. © 2019 HILLARD HEINTZE M THE CITY OF VIRGINIA BEACH: AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31, 2019 Christopher Kelly Rapp Herbert “Bert” Snelling Robert “Bobby” Williams 54 years old 57 years old 72 years old Christopher Kelly Rapp held an illustrious and varied career in public service for public utilities, most recently as Stormwater Management Regulatory Engineer for the City of Virginia Beach. Chris was gifted musically and loved playing the bagpipes, learning to play the piano, and dancing, including line dancing, ballroom dancing, and Filipino Cultural dances. He is survived by his loving wife, Bessie M. Rapp; his parents, Michael D. and Patricia K. Rapp; and his brother, Timothy A. Rapp. His brother, Eric M. Rapp, preceded him in death. Herbert Ray “Bert” Snelling, Jr. loved to create custom gates and custom cabinetry with his master carpentry skills. He was a humble and self-sacrificing man with an infectious laugh who found humor in every opportunity and helped others find joy in all things. He served the Lord and others his whole life, most recently as a member of Crosswalk Church in Virginia Beach. He is survived by his wife, Sonja; his mother, Veronica “Roni” Sharrett; his father, Herbert Ray Snelling, Sr.; his brother Micah Snelling; and his children, Melissa “Missy” Fay Hart and Herbert Ray “BJ” Snelling III. Robert Thomas “Bobby” Williams was a veteran of the U.S. Navy before becoming an employee of the City of Virginia Beach, most recently as a Special Projects Coordinator in the Public Utilities Department. His family remembers him as the most loving, extraordinary husband, dad, and “Pop-Pop” who considered family his first priority. He is survived by his wife, Sharon Williams; his son, Robert T. Williams, Jr. and his wife Rachel; his daughter, Sarah Hodges and her husband Rob; his siblings Janice Sandlin, Kathy Murden, Timothy Williams, and Ronald Williams, and many grandchildren, nieces, and nephews. Four additional City of Virginia Beach employees and one VBPD officer were wounded during the May 31, 2019 attack. We respect their privacy and hope for their full recovery. www.hillardheintze.com ] The Crucial Need to Learn – and Prevent Another Tragedy To the families and colleagues of the people who lost their lives on May 31, 2019 as well as the Virginia Beach Community, Mayor and City Council During our review of the terrible acts that shattered many lives on May 31, 2019, we learned a great deal about your family members, friends and coworkers who are no longer with us – and about the four employees and one police officer who survived the attack and are fighting their way back toward health. We learned about the many acts of heroism and selflessness by the brave employees of Building 2, police officers and other first responders who placed their own security aside to protect and shelter others. And we learned about the many employees who escaped physical harm but continue to struggle with the aftereffects of the event. With compassion for your community and respect for your resilience, we present the results of Hillard Heintze’s review of the tragic events of May 31, 2019. We have worked to identify as much as possible about what happened that awful day and why. On your behalf and that of other communities like yours, we have been driven by the desire to identify insights and analysis that can help the City of Virginia Beach and other communities intervene in comparable circumstances and learn to prevent many such acts of violence in the future. When you engaged us 119 days ago, we acknowledged the urgency driving your assignment – and immediately mobilized our team and structured our approach to conform to the City’s priorities, requirements and expectations as memorialized in the City Council’s Resolution to engage an independent consultant. Please find the results of our work here in the form of six key findings and 58 recommendations, supported by the insights and observations we believe are most important. It has been an honor to do this work on your behalf. Thank you for allowing us into your community and for helping us ask and try to answer the hard questions. The light you have helped shine on the difficult facts here will help you and your community – and others – prepare to save lives in the future. Sincerely, HILLARD HEINTZE LLC Arnette F. Heintze Chief Executive Officer © 2019 HILLARD HEINTZE _ THE CITY OF VIRGINIA BEACH: AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31, 2019 Overview Objectives: What We Set Out to Accomplish In alignment with the City of Virginia Beach City Council resolution authorizing this review, this examination was undertaken to help the City: 1 Understand: Determine and confirm what happened and why on May 31, 2019, including the creation of a timeline leading up to the shooting that highlights the perpetrator's employment history and workplace interactions. 2 Improve: Review relevant City policies, procedures and practices, including, without limitation, those related to facility security, prevention of workplace violence and employee alerting and response to active shooter notifications. 3 Learn: Identify actions that might have helped prevent the tragedy or mitigate its consequences. 4 Prepare and Prevent: Recommend strategies, tactics and countermeasures that the City needs to implement to help ensure such an act or any similar one does not occur again. A NOTE ON HOW WE REFER TO THE ATTACKER THROUGHOUT THIS REPORT Consistent with the initial practice of the City, we have intentionally chosen to avoid identifying the attacker by name, wherever possible, throughout the report. www.hillardheintze.com ef Actions Taken: What We Did Hillard Heintze undertook an intensive approach in this review. Our team of experts evaluated critical areas with a direct bearing on the attack, including physical security, human resources management, threat and violence risk management, law enforcement, command and control and forensic psychology. This review included: • A continuous on-site presence and contact in Virginia Beach from the initiation of the project on July 22 through November 4, 2019, during which time the team conducted interviews, collected observations and reviewed evidence. • Direct engagement with stakeholders through interviews, group discussions and public forums for employees and community members to ensure those affected by the May 31, 2019 tragedy had a voice in our process. • The fielding of two surveys, one for the entire workforce, which was implemented by a thirdparty survey company, People Element, and the other specifically for employees within Building 2. • A physical assessment and walk-through of Building 2 as well as the overall municipal campus. • Refinement of the timeline based on data related to the police response, 9-1-1 calls and Virginia Beach Police Department (VBPD) and emergency medical services (EMS) radio dispatch recordings during the attack. • Review and analysis of a wide range of policies, crime reports, evidence, data and electronic records. • Indexing, analysis and assessment of all data received, including 335,000 emails (115.75 gigabytes) and 6,500 documents (2.62 gigabytes). This data came primarily from the attacker’s work-related electronics and additional personal data that was provided. • Searches of social media sites and public records for information relating to the attacker and possible motives. • A retrospective threat assessment of the subject, given the data amassed and known at the time of this report. © 2019 HILLARD HEINTZE ee THE CITY OF VIRGINIA BEACH: AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31, 2019 Interviews and Listening Sessions: Who We Tapped for Insights We held two Employee Listening Sessions and two Community Listening Sessions to explore community concerns, explain the assessment process and incorporate feedback into the review and this final report. We established and processed inquiries made through our direct access lines including approximately 187 emails to our public-facing email address – virginiabeach@hillardheintze.com – and 85 calls to our toll-free phone number, (877) 208-5650. We conducted more than 230 interviews with stakeholders including witnesses, City employees, and family members of the victims and of the subject as well as responding officers and supervisors who were on the scene. We engaged other City and County employees, including representatives from the City HR Department, the VBPD, the City Auditor’s Office, the Magistrate’s Office, the Virginia Beach Fire Department (VBFD), the Office of Emergency Management (OEM), Virginia Beach Emergency Medical Services and the Facilities Management Office. We met with most of the victims’ families, 10 of 12 of them, and reached out many times through liaisons provided by the City and the Catholic Charity to schedule interviews with the remaining families to ensure their voices were heard. www.hillardheintze.com e" Key Findings ACTION IN THE FACE OF DANGER 1 The City of Virginia Beach employees, police and first responders acted courageously in the face of life-threatening danger, and their actions prevented further casualties. City personnel acted heroically. Building 2 employees placed themselves in peril to save their coworkers and prevent further loss of life. The Virginia Beach Police Department’s response was swift and effective. Officers entering Building 2 followed best practices, demonstrated highly professional tactics and used their knowledge and capabilities to isolate the attacker and take him into custody, prior to his death due to injuries. Members of the Virginia Beach Fire Department and emergency medical services (EMS) who responded to bring wounded evacuees to care and others to safety saved the lives of many and protected others who were traumatized. These responders are to be commended for their courage, selflessness and service to others. © 2019 HILLARD HEINTZE e# THE CITY OF VIRGINIA BEACH: AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31, 2019 THE ATTACKER 2 The attacker did not display warning signs or prohibited behaviors associated with a pathway to violence that could have provided the City of Virginia Beach or expert threat assessors with an opportunity to intervene ahead of the violence on May 31, 2019. The subject’s actions, behaviors and communications before the attack did not include many known pre-incident risk factors for targeted workplace violence. While the post-incident review uncovered previously unidentified personal risk factors, these did not rise to an elevated level of risk that would have warranted intervention and do not provide a definitive motive for his attack. We found no evidence that the subject communicated his violent intentions to others before the attack. This communication of intent is sometimes referred to as “leakage warning behaviors.” The attacker did not appear preoccupied with violence nor did he openly exhibit homicidal thoughts or fantasies. Though our analysis indicated that the subject may have been interested in past masscasualty and other active shooter events, the evidence collected is not conclusive on this point and we cannot say with confidence that he expressed observable interest in others who have perpetrated acts of general or workplace violence. The subject legally acquired several firearms over the past three years. He had recently purchased a gun suppressor and body armor and had reviewed Building 2 floor plans in the days before the shooting. He also used his identification card to access doorways other than those in his area in Building 2. None of these behaviors were known to the City before the attack. The subject had no known history of mental health care and treatment. The subject left no clear evidence of a plan or manifesto detailing his intent and rationale or revealing any observable pre-attack behaviors. For the past two years, the subject received formal feedback from his supervisors and managers regarding deficiencies in his performance. Shortly before the attack, he was informed of another potentially significant error in his work performance that may have caused him increased stress and anxiety, possibly exacerbated by insomnia. Some of the subject’s coworkers described him as reserved, with little emotional affect and socially withdrawn. No one, however, described him, his behaviors or his communications as overtly aggressive or violent. None of the coworkers interviewed thought the subject posed a threat or would commit such a violent act. www.hillardheintze.com e$ WORKPLACE VIOLENCE PREVENTION 3 Improving the City of Virginia Beach’s workplace violence prevention programs and policies represents a key step towards establishing a new culture of workplace safety across City facilities. The City needs to establish a comprehensive program that holistically enables and advances workplace violence prevention. While the City has a policy against workplace violence, it is not sufficiently robust and its requirements were not sufficiently embraced by leaders, managers and employees before May 31, 2019. The City’s commitment to workplace violence prevention before the shooting was largely restricted to its violence prevention policy and civilian response to active shooter training, which was a voluntary program with limited availability. In order to establish a comprehensive program capable of identifying, assessing and mitigating risks associated with workplace violence, the City needs to formulate a clear policy with guidance for supervisors, managers and employees. This guidance should include how, what and when to report regarding suspicious behaviors; how to manage policy violations on matters such as weapons in the workplace; and how to handle domestic violence matters at work. The policy should also include intervention strategies and resources to help struggling employees exhibiting early warning signs and prohibited behaviors. The City should institute mandatory workplace violence prevention training. Workplace violence prevention training needs to be mandatory and ongoing for all personnel as well as customized for specific internal audiences. This training is not solely to evaluate whether a threat has been made; training should also be focused on education about the issues surrounding workplace violence – how to engage and what to do should an active threat occur in the workplace. Managers and supervisors should be trained on how to recognize early warning behaviors. The City HR Department needs to work with supervisors and managers to manage difficult employees and situations quickly and proactively. All employees should be trained on violence prevention basics and recognizing warning signs to ensure they understand their reporting responsibility and what will happen once they report. Employees also need to be trained routinely on response procedures (e.g., shelter-in-place, evacuation) to different kinds of events (e.g., fires, chemical spills, active assailant incidents). The © 2019 HILLARD HEINTZE e> THE CITY OF VIRGINIA BEACH: AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31, 2019 City HR Department must play a vital leadership role, providing early intervention assistance and ongoing training. Establishing a formal behavioral threat assessment capability or an interdisciplinary Threat Assessment Team (TAT) would greatly advance the City’s ability to identify and prevent workplace violence. The City of Virginia Beach does not have a formalized behavioral threat assessment capability for collecting and analyzing relevant information about subjects who may pose a threat to their personnel, assets or services. Threat assessment is recognized as a best practice for organizations to reduce their risk of targeted violence. Establishing, documenting and following a formal process when investigating and assessing potential threats is strongly advised. The tragedy of May 31, 2019 and others across the U.S. have highlighted the significant advantages of establishing an interdisciplinary Threat Assessment Team. A TAT’s main purpose is to assess behavior before it becomes violent and to manage cases of concerning behavior to hopefully prevent violence from occurring. Team members should include individuals representing Human Resources, Legal Counsel and Security who possess the requisite experience, training, judgment, authority, temperament and credibility within the organization to carry out the required duties. Although the costs associated with these prevention programs are relatively low, plans should be made to ensure they are reflected in the City’s annual budget. www.hillardheintze.com eH THE CITY HR DEPARTMENT 4 The City of Virginia Beach needs to restructure its highly decentralized Human Resources function, particularly with respect to establishing roles, reporting channels, policies and protocols, data management and training. Additional professional HR staff aligned to the HR mission are needed to engage with employees and managers and bring greater consistency to the HR functions in the various City departments and units to best nurture, engage and support employees. Establishing an HR organization that includes consistently trained and impartial experts will help supervisors and managers champion and cultivate a vibrant employee corps. The HR training and experience of the HR Liaisons and unit managers – who are tasked with most HR issues within individual units – varies significantly, as does the HR training and capacity of the unit managers. Professional HR staff, with the appropriate training and skills, needs to direct the HR functions of the City, including at the unit level where HR issues originate. At a minimum, HR Liaisons and managers need to be trained at a baseline proficiency level with readily available and engaged HR resources in place to support their needs. City leaders need to strengthen the alignment of duties between unit-level HR functions and the City Human Resources Department (City HR Department) to improve engagement and reporting as well as facilitate information sharing and data management critical to workplace violence prevention. The City relies on a decentralized HR structure in which HR Liaisons within the specific units direct and control most employee engagement. A certain level of decentralization is expected when addressing employee performance, particularly given the size of the City’s workforce. However, the standards, procedures and support for employees, managers and HR Liaisons vary across the units. HR Liaisons are simultaneously tasked with other primary work duties and report to unit managers. Many employees, including managers and HR Liaisons, with whom we engaged do not feel fully supported by the City HR Department. Some employees felt that HR Liaisons have insufficient experience. Others pointed out that they are not independent enough from the local managers. This results in a structure that is challenging for both employees and managers – and could create future challenges for workplace violence prevention. © 2019 HILLARD HEINTZE eM THE CITY OF VIRGINIA BEACH: AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31, 2019 Establishing a centralized database of all employee performance and workplace issues would increase the City’s visibility into and knowledge about employee resources, skills and issues, including those directly impacting the risk of workplace violence. The City does not have a centralized repository of information regarding employees. Records are kept in various formats, both digital and paper. The digital records are not integrated, and little coordination occurs regarding employees – even when performance concerns arise. This results in an incomplete organizational view of employees and does not allow the City to foster the most effective and efficient use of the extensive skills, knowledge and abilities of its workforce. Complete records would also help City HR Department professionals identify and develop protocols involving warning signs and prohibited behaviors, and give the City earlier opportunities to intervene before a harmful act occurs. The City’s focus on and use of the Employee Assistance Program (EAP) should be strengthened and its role, availability and value communicated more fully to employees. The City offers an EAP program, established by policy, in which engagement is voluntary for all employees and mandatory for some in certain circumstances. However, before this attack, the City did not commit enough resources to educating employees confronting stressful personal or workplace challenges about the resources available to them. Adopting a wellness-centric approach, including a stronger focus on EAP policies and education for supervisors and managers, will allow the City to intervene earlier in many cases – when individuals first exhibit warning behaviors rather than later when these behaviors become more serious. Creating a Public Advocate’s Office would create an independent channel for employees to voice their concern and, over time, improve employee morale and job satisfaction while helping the City to identify and resolve a range of employee issues earlier and more effectively. The City’s employee population includes a small but significant group of employees who feel that they have no voice and cannot fairly report or be heard on critical issues regarding employment, promotions, supervisory mistreatment and racism within the work environment. Establishing an independent public advocate or ombud would help this group and all other employees gain confidence that they can report complaints without fear of reprisal. www.hillardheintze.com e] CRITICAL INCIDENT RESPONSE 5 Improvements in the City’s critical incident response protocols are warranted in areas such as mass-notification alerting, training and compliance, first responder communications and allhazards response planning. The City’s mass communication capabilities were not robust enough to address communication requirements on May 31, 2019. During the attack, key notification alerts did not reach all at-risk stakeholders. While the City has mass-notification systems in place, employee enrollment in them is voluntary and, as of the day of the attack, enrollment was not high enough to give Emergency Communication & Citizen Services (ECCS) supervisors confidence in using this communication channel. Establishing user groups and providing consistent messaging and outreach during emergencies is a key function of these systems. Ensuring appropriate pre-recorded messaging and focus on timely messaging is a key benefit of such systems and would have supported the exchange of information during this attack. The City’s critical incident response protocols were not fully followed during the event on May 31, 2019. The City’s investment in Incident Command System (ICS) training and protocols helped first responders engage, isolate and stop the shooter – and victims were assisted in evacuation and provided medical aid. However, not all first responders engaged in establishing a shared environment and key personnel did not fulfill their command leadership and oversight roles in important functions, including the Emergency Operations Center (EOC) and as part of Incident Command. In any crisis or emergency, centralizing command and control operations supporting first responders is crucial to ensuring timely and appropriate resourcing and making effective and efficient decisions about critical security and safety issues. The role and function of the City’s main communications center are not clearly established. Although the City’s Emergency Communication & Citizen Services Center has been modernized and updated to serve as the communications hub for emergency services, ECCS continues to rely © 2019 HILLARD HEINTZE e_ THE CITY OF VIRGINIA BEACH: AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31, 2019 upon legacy response protocols and policies for communications left over from its days as a function owned and managed by the VBPD. For example, responsibility for notifications still lies with the operational units, instead of being centralized in ECCS. Key management issues around use of communications channels, dispatch of resources and communications for critical incidents are best centered with ECCS. Comprehensive response protocols that address a range of critical incidents are needed to facilitate a seamless response under an all-hazards approach, ranging from severe weather to active assailants. The City has a response framework but not a comprehensive protocol supported by distinct guidelines based upon a range of threats, including an active assailant. A response to a hurricane predicted several days in advance is different from a response to a no-notice event such as an active assailant. The City was better prepared for the former rather than the latter. Developing a baseline response protocol and supplementing it with the specific requirements of many types of critical incidents will allow the City to respond, intervene, mitigate and recover from many types of incidents with better resource visibility, faster engagement and better outcomes. An all-hazards approach will allow for rapid escalation in allocation of resources based upon need, with roles and tasks for all responders identified at each stage of a critical incident. The City should expand its training approach to include key post-event issues and ensure a range of training exercises that test response across the spectrum of City services. The City has dedicated resources to training for critical incidents and, in fact, recently trained appropriate personnel on the role and function of the Family Reunification Center (FRC). Training could be enhanced by incorporating post-incident learning and analysis into exercises and course content as well as ensuring that the scope of the curriculum addresses all critical functions of an emergency response and also tests known vulnerabilities. The City needs to designate and provide authority to a lead agency for formal tasking and followthrough regarding issues identified in after-actions and reviews of training exercises. The City follows good practice in that a single city unit – the Office of Emergency Management – is tasked with coordinating City-wide exercises. However, the OEM should also be granted authority to ensure a continuous improvement loop. Each participating unit should be responsible for engaging in training, conducting a post-exercise review and reporting to the City Manager and www.hillardheintze.com "f Deputy City Manager regarding actions taken to address any deficiencies uncovered during training. By establishing a single chain-of-command and vision for emergency response preparedness, the City can ensure that the multiple agencies that respond are working collectively toward a single plan and shared outcomes. © 2019 HILLARD HEINTZE "e THE CITY OF VIRGINIA BEACH: AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31, 2019 PHYSICAL AND TECHNICAL SECURITY 6 Improvements to various physical and technical security capabilities will help support the City’s workplace violence prevention goals and capabilities in the months and years ahead. No single City department or individual is responsible for overall physical and technical security. Different departments or subdivisions handle discrete portions of the Virginia Beach security program applicable to Building 2. The City should develop an enterprise-wide physical and technical security plan, including a formal written minimum-security standard for all Cityowned or operated buildings. Such a plan should include minimum standards on the level of physical and technical security requirements for buildings and workgroups based upon whether they (1) require public access, (2) can be secured office environments or (3) require even higher levels of security measures. The City should discontinue the practice of have Department heads responsible for requesting, planning and funding security improvements as they do not have the security expertise to manage this function. First responders did not have access to critical areas in Building 2 when they were pursuing the shooter. The City Access Control Systems (ACS) should be assessed to determine the best remoted control oversight. The VBPD did not have approved access to the interior floors of Building 2, based upon existing protocols for employee access. ECCS could not remotely operate the doors to support the police pursuit of the active shooter. Ensuring oversight controls, either through electronic access at ECCS or through methods such as providing first responders with master ACS, should be considered. The City of Virginia Beach does not have a robust camera network that provides visibility across the municipal campus. Most of the City’s security technology systems are not integrated for automatic video display of an active alarm or system activity alert. Security cameras on most City-controlled buildings are not actively monitored. www.hillardheintze.com "" Should an incident occur in an area with security camera coverage, stored images are reviewed after the event, as needed, by City personnel. Surveillance cameras in Building 2 were limited to the IT section and did not capture the attack, as no cameras are on the upper floors. Use of physical security, random law enforcement checks and surveillance cameras to facilitate security monitoring are options used by some government entities to monitor safety in public buildings. Developing a layered security approach to potential security risks would improve security in City government facilities. © 2019 HILLARD HEINTZE "# THE CITY OF VIRGINIA BEACH: AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31, 2019 The Timeline Below is a timeline that details key events in the subject’s life prior to the attack, and what happened and when on May 31, 2019. Hillard Heintze interviewed stakeholders, reviewed law enforcement and Building 2 records, evaluated the subject’s work and personal devices and their contents, and leveraged other sources to construct this timeline to the best of our ability. Note: Unless otherwise specified, the subject is conducting the actions described. Accepts offer of position as Engineer at Lewis and White May 2003 Resigns from Lewis and White. Accepts offer of position as Project Engineer at MSA Engineering. February 2008 Gets laid-off from MSA Engineering. An individual close to the subject said he complained about the lack of a promotion and perceived racism. Marries. Accepts offer of position as Project Engineer III at Draper Aden Associates. July 2008 Resigns from Draper Aden Associates. November 2008 Accepts offer of position as Engineer II for the City of Newport News, Virginia. January 2010 Resigns from Newport News. Subject’s History Relevant to the Attack From 1996 to 2010 April 1996 - April 2002 Serves in the Virginia Army National Guard. Assigned to Army National Guard units in Norfolk and Hampton, Virginia. April 2002 Receives honorable discharge from the National Guard. May 2002 Graduates from Old Dominion University. From 2011 to 2015 February 2010 Accepts offer of position as Engineer II at City of Virginia Beach. 2011 -2017 Receives annual evaluation and is rated “Meets Standards.” January 2012 Purchases home in Virginia Beach. September 2012 Receives “Thumbs Up” Award. www.hillardheintze.com "$ April 2014 Receives Excellence in Service Award. May 2015 Receives Team Participation Award. Emails supervisor attesting that his work was above average, but that his salary did not reflect that. June 2017 Wife moves out. December 2015 Receives Excellence in Service Award. Emails supervisor complaining he is assigned a project above his expertise and paygrade. 2016 Management places subject on Performance Improvement Plan for deficiencies in project management skills. April 2016 Applies for and obtains Concealed Handgun Permit. July 2016 Purchases H&K USP45C 45 ACP pistol. Purchases JRC JRCV067138 45 ACP carbine rifle. Subject states he feels “singled out” for his unsatisfactory work performance. August 2017 Directs attorney to proceed with filing divorce. Completes his Performance Improvement Plan successfully. August 2016 Begins regularly visiting gun websites via his phone. September 2016 Separates from wife. Suppressor registration completed. September 2017 Divorce is finalized. First images of weapons appear on his phone. Texts somebody close to him that he “finally got my suppressor today.” Purchases Glock 21 45 ACP pistol. October 2016 Submits Suppressor Transference Certification. December 2016 Issue occurs regarding missing contractor checks on subject’s project. 2017 January 2017 Management letter documents subject’s mishandling of these checks. December 2017 Purchases Bond Arms Backup Derringer 45 ACP pistol. The frequency of the subject’s communications with his mother begin to decrease. 2018 February 2018 Subject’s communications with ex-wife increase. © 2019 HILLARD HEINTZE "> THE CITY OF VIRGINIA BEACH: AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31, 2019 April 2018 Receives “Thumbs Up” Award. June 2018 Purchases second Glock 21 45 ACP pistol. July 2018 Receives written reprimand for poor performance as well as Letter of Performance Expectations. Submits verbal grievance to supervisor about written reprimand. Stops communicating with ex-wife. 2019 January 2019 Uses Smart TV Guide to visit a news report about the Orland Square Mall shooting. March 2019 Visits gun conversion kit websites. April 2019 3 Drafts work email on his perceptions of his professional relationships and stressors. Supervisor verbally responds to grievance. August 2018 Receives “Improvement Required – PIP Required” annual evaluation due to poor performance. Submits written grievance to supervisor. Submits written grievance to Department Head to remove reprimand. Complains in response to annual evaluation that he is discriminated against by being assigned critical projects above his paygrade. Drafts work email expressing concerns about being “sandbagged.” September 2018 Emails Department Head after the meeting. States that he is clearly discriminated through project assignments. Requests again that the reprimand be removed. Is informed that the reprimand will remain. Elects to end his grievance and not to appeal it to the Personnel Board. November 2018 Stops communicating with mother. Drafts but never sends emails that reflect irrational and suspicious beliefs. 7 Browses Premier Body Armor website and views body armor and ballistic plates. 8 Views Level 3A ballistic body armor panels via his mobile telephone. 10 Receives email confirming delivery of purchased body armor. 12 Purchases Ruger rifle. May 2019 20 Searches on computer for maps of Building 2 and the Municipal Center. 23 Sets message on computer that he will be out of office from May 24 to 28. 24 Purchases three rifle gun magazines and rifle case. 28 Emails Contracts Unit asking to expedite payment for $3,027.48 contractor invoice, for which funds have not been properly obligated. 29 Contracts Specialist emails back requiring justification for and additional information about the purchase order and directs subject www.hillardheintze.com "H to email City Procurement Officer with this request. Emails Procurement Officer seeking assistance to resolve purchase order issue. Procurement Officer leaves voicemail for subject about the purchase order issue, telling him that he has made an unauthorized purchase and violated a City ordinance. Procurement Officer informs subject that she will send him an email as well and asks him to call her back. Procurement Officer emails subject that fiscal policies have not been adhered to and procurement procedures have not been properly followed on the matter, and that full documentation will be required. Replays the voicemail for supervisors. Emails supervisor on how he will respond to Procurement Officer’s email. Another employee receives pre-dismissal letter from supervisors. A Virginia Beach Police Department (VBPD) officer is posted to Building 2 as a precaution. 30 The other employee receives a termination letter and a supervisor escorts him out of building. Subject states he is too upset to meet with the Procurement Officer and will pay $3,027.48 from his personal checking account to correct the error. In the evening, places 54-second call from his mobile phone to his desk phone. In the evening, makes two personal calls – one to his ex-wife, in which he is apologetic in nature; the other to his mother, in which he refers to his insomnia and problems with supervisors at work but is otherwise upbeat in tone. The Day of the Attack: May 31, 2019 Note: The timeline items in this section are based on employee interviews, 9-1-1 calls and crime-scene details. Final determination of the chronology of shootings and locations cannot be made until the results of the forensics examinations and scene reconstructions are available. 6:58 a.m. Leaves residence. 7:16 a.m. Arrives at City’s municipal complex. 7:21:30 a.m. Swipes card for entry into Building 2 Ops/PU 2nd Floor Engineering North Hall. 7:23 a.m. Starts up his work computer and checks his Outlook mail. 10:00 – 10:30 a.m. Conducts internet searches for Building 2 maps, the ECCS and the Municipal Center Building Map. 10:31 a.m. Emails supervisor his resignation and refers to personal reasons. 10:46 a.m. Supervisor responds saying he hopes that the subject resolves his personal reasons and asks for confirmation that his last day will be June 14. 10:49 a.m. Supervisor forwards subject’s resignation email to other managers and copies the subject. © 2019 HILLARD HEINTZE "M THE CITY OF VIRGINIA BEACH: AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31, 2019 10:52 a.m. Subject swipes card for entry into Building 2 PU 2nd Floor East Engineering South. 11:25 a.m. Responds to supervisor’s email with email, “Thank you. Yes, that is correct.” 11:23 – 11:33 a.m. Sends routine work-related emails. 11:58 a.m. Swipes card for entry into Building 2 Ops/PU 2nd Floor Engineering North Hall. 12:08 p.m. Swipes card for entry into Building 2 Ops/PU 2nd Floor Engineering South. 1:00 p.m. Swipes card for entry into Building 2 Ops/PU 2nd Floor Engineering South. 1:04 p.m. Subject and two co-workers leave Building 2 to travel in car for routine inspection of three project sites. 1:06 – 3:06 p.m. Subject is at project sites with co-workers and in transit. 3:11:49 p.m. Swipes card for entry into Building 2 Ops/PU 2nd Floor Engineering South. 3:55 p.m. Sends routine work-related email. 3:57 p.m. Subject is observed brushing teeth in 2nd Floor bathroom. 4:00 – 4:05 p.m. Enters South Building 2 entrance. Witness hears gunshots, sees subject with a gun in his hand walk into the building. Sees a man bleeding on the ground. 4:00 p.m. – 4:16 p.m. Shoots Mary Louise Gayle, Alexander Mikhail Gusev, Katherine Nixon, Michelle Langer, Ryan Cox, Robert Williams, Christopher Rapp, Tara Gallagher, Laquita Brown, Richard Nettleton, Herbert Snelling, Joshua Hardy, Melanie Coffey, Kayode Aransiola, Stephen Motley and Carl Britt. 4:05:56 p.m. Swipes card for entry into Building 2/PU 2nd Floor East Engineering South. 4:06:32 p.m. First 9-1-1 call is received (call duration is 4:59). Caller reports seeing body on ground with blood, hears shots, sees black man in blue shirt running into building, hears more shots near his office and ends call. 4:08 p.m. Call is dispatched regarding man in front of Building 2 who is possibly shot. First suspect description is dispatched. Refers to Hispanic man on 2nd floor. Dispatcher hears gunshots on the call in the background. 4:08:13 p.m. Swipes card for entry into Building 2 Ops/PU 2nd Floor/West Side Business Unit. 4:10:10 p.m. Second suspect description is dispatched. Refers to a bald black man with a blue polo shirt. 4:10:19 p.m. First police personnel enter Building 2. K9 Units announce arrival. Plainclothes www.hillardheintze.com "] detectives report that they are on-scene. Air is restricted. Dispatch identifies that shots are being fired on 2nd floor. 4:11 p.m. The Virginia Beach Fire Department arrives on scene pursuant to dispatch. 4:11 p.m. Fire alarm sounds in Building 2. 4:12:40 p.m. Swipes card for entry into Building 2 Ops/PU 2nd Floor/West Side Business Unit. 4:13:49 p.m. Third suspect description is dispatched. Refers to a six-foot-tall black man with a blue shirt and a gun with a silencer. 4:15 p.m. The VBFD establishes Command Post. 4:15 p.m. The VBPD establishes on-scene commander. 4:15:07 p.m. Subject swipes card for entry into Building 2 2nd Floor/ East Side/ Engineering South. 4:18 p.m. All available Special Weapons and Tactics (SWAT) team members are responding to Building 2. 4:19 p.m. The name of the subject is dispatched. 4:20 p.m. Initial broadcast that an officer is shot. 4:21 p.m. Dispatch identifies that the subject is isolated and shooting actively on east side of 2nd floor. 4:22 p.m. HR Communications Coordinator sends email to all City employees marked, “Importance: High” with the subject, “URGENT: Shelter in Place @Mun. Ctr. Until further notice.” The message reads, “We have an active shooter at the Municipal Center, supposedly in or around Bldg. 2. Please shelter in place. Lock your doors. We’ll communicate when it’s safe to leave. Thank you.” 4:26 p.m. SWAT team reports it is inside Building 2. 4:43 p.m. First transmission that subject is in custody. 4:44 p.m. Second transmission that subject is in custody. 4:54 p.m. HR Communications Coordinator sends email to all City employees marked, “Importance: High” with the subject, “URGENT: Continue to Shelter in Place at Mun. Ctr.” The message reads, “For those at the Municipal Center, please continue to shelter in place. We’ll let you know when it’s safe to unlock doors. Even then, there are roads blocked which may keep everyone here for a while. But, we’ll keep you posted. Please be safe!” 5:30 p.m. Responders attempt to establish the Family Reunification Center (FRC) at United Methodist Church, but the Church is occupied, and the Center is established at Princess Ann Middle School. 5:32 p.m. Subject is pronounced deceased at Virginia Beach General Hospital. © 2019 HILLARD HEINTZE "_ THE CITY OF VIRGINIA BEACH: AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31, 2019 5:34 p.m. Building 2 is secured. No additional wounded are in the building. 7:18 p.m. Explosive sweeps of Building 2 are completed. 5:36 p.m. Subject’s backpack and additional firearms are found on 2nd floor. 7:19 p.m. Transmission that Building 2 is ready for forensics teams and detectives. 5:42 p.m. Explosive detection K9s begin sweeping parking lot. 9:00 p.m. Death notifications begin. 5:43 p.m. Subject’s vehicle is located in parking lot in front of South entrance. 5:55 p.m. HR Communication Coordinator sends email to all City employees marked, “Importance High” with the subject, “All Mun. Ctr. employees can leave except for Bldg. 2 employees.” The message reads, “Today’s situation is ongoing but the suspect is in custody. It is now safe for Municipal Center employees to leave the area. However, those who work in Bldg. 2 must remain here until further notice. Police/fire officials will inform Bldg. 2 employees when it’s safe to leave. Please drive safely when leaving. Thank you.” 12:00 p.m. Last local death notification is completed. 1:00 a.m. Final death notification completed out of state by assisting law enforcement agency. Days Following the Attack June 2, 2019 FRC closes. Family Assistance Center opens at Princess Ann Rec Center. June 9, 2019 Family Assistance Center closes at Princess Ann Rec Center. 6:09 p.m. Explosive sweep of Building 2 begins. 6:00 p.m. FRC is opened at Princess Ann Middle School. www.hillardheintze.com #f Summary of Recommendations 2 – RECOMMENDATIONS FOR THE POLICE DEPARTMENT’S ACTION ON SCENE 2.1 Policies and Procedures: Refine applicable policies and procedures that outline, in much greater detail, the specific roles and responsibilities of those responding to an active assailant incident, with a particular focus on clarifying the roles and responsibilities of supervisors and command offers on the scene. This would include leading, guiding and directing the actions of responding personnel; distinguishing the roles of SWAT personnel versus responding patrol units; establishing inner and outer perimeters; establishing family reunification centers; and notifying victims’ families. 2.2 Checklists for Communications Personnel: Refine and update protocols to include written checklist for communications personnel to use when handling an active assailant incident. Identify key things dispatchers could do to assist on-scene personnel in coordinating tasks and responsibilities and include protocols to more common incidents to help ensure that appropriate resources are sent immediately to the scene. 2.3 Unique Tactical and Operational Radio Channels: Provide additional training for ECCS personnel and first responders on the importance of establishing separate tactical and operational radio communications channels during critical incidents, along with the need to maintain radio discipline during critical incidents. • Establish priority protocols that automatically authorize the establishment of a second, third and fourth channel as needed. • Task supervisors on scene with the responsibility to ensure radio discipline. • Continually emphasize in roll call training and with after-action reports the value of radio discipline in large events. Too much radio traffic may prevent timely rescue and engagement. 2.4 Pre-Designation of Personnel Roles: Ensure communications personnel are trained and predesignated to assume specific roles in the event of a critical incident. Ensure the pool of personnel are identified in advance and pre-designated to report in shifts rather than mass response. • Consider key incident functions and develop a protocol for staff assignments to specific roles and functions. © 2019 HILLARD HEINTZE #e THE CITY OF VIRGINIA BEACH: AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31, 2019 2 – RECOMMENDATIONS FOR THE POLICE DEPARTMENT’S ACTION ON SCENE • Train to designated roles including the Emergency Operations Center (EOC) and Joint Information Center (JIC) support. • Allow for expansion and contraction, including secondary support for personnel who are absent. 2.5 ECCS’ Ability to Handle Incoming Texts: Enhance community outreach regarding ECCS ability to receive E-9-1-1 text messages at its communications center, since only two such text messages were sent to them during this active shooter incident. ECCS should increase its efforts to publicize this capability to the public. Sending silent text messages when under duress is one of the best ways for those involved in any active assailant situation to communicate. 2.6 Notification Procedures: Refine and update notification procedures for ensuring key personnel and citizens, in general, are notified of emergency events. This includes active assailant events. Use pre-programmed automated notifications whenever possible. Some police agencies have developed customized systems unique to their department while others use a third-party alert system. Have ECCS assume responsibility for notifications and review its current notification processes to clarify exactly who should be notified and how, taking into account that an effective emergency alert system may consist of any or all of the five following mechanisms for notifying emergency personnel: Emergency dispatch Text message Email Mobile app push notification Voice call 2.7 Broadcasting the Source of Information: Refine training and applicable written policies to ensure ECCS communications personnel provide as much information as possible about the source of an active assailant’s identification and description when advising first responders in an active assailant situation. Knowing the source of a suspect’s description is invaluable for the first responders making initial assessments and key decisions at the scene. www.hillardheintze.com #" 2 – RECOMMENDATIONS FOR THE POLICE DEPARTMENT’S ACTION ON SCENE 2.8 Facilitating First Responder Access: Ensure VBPD personnel have the ability to access secured areas of all City facilities immediately during a critical incident, and secure and have readily available adequate breeching tools to assist SWAT and other first responders in forcing entry into critical areas.1 3 – RECOMMENDATIONS FOR MULTI-AGENCY COORDINATION, COMMAND AND CONTROL 3.1 Roles and Responsibilities: Pre-designate roles and responsibilities for command members for the Incident Command Post (ICP), Emergency Operations Center (EOC) and other command functions that respond to critical incidents. Ensure that response personnel are tasked with pre-planned assignments and secondary duties for escalation contingencies. Train to these roles and anticipated contingencies for various scenarios – including the absence of an identified member, alterations in plan and potential gaps – such as preplanned locations not being available. 3.2 Victim Identification: Formalize specific written policies and procedures to guide VBPD personnel to identify victims in mass-casualty situations as soon as possible, with an emphasis on creating protocols for how VBPD personnel are to secure such information as quickly as possible when multiple law enforcement agencies are involved in the followup crime scene processing and investigation activities. 3.3 Chain of Command: Refine applicable written protocols and procedures to clarify the establishment of command for critical incidents. Chain of command, guidance and authority is critical to a successful police resolution. Issues that address radio communication and discipline, the effective allocation of resources, and operational issues such as crossfire, “blue on blue” and other concerns relevant to the risks faced within the jurisdiction should be addressed. 1 It is our understanding that such a program has been initiated since the incident. © 2019 HILLARD HEINTZE ## THE CITY OF VIRGINIA BEACH: AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31, 2019 3 – RECOMMENDATIONS FOR MULTI-AGENCY COORDINATION, COMMAND AND CONTROL 3.4 Unified Command: Refine written policies and provide additional training that emphasize the critical role of police commanders in establishing a unified command with other public safety entities during active assailant or other critical incidents, rather than having VBPD personnel continue to establish separate incident command posts during such incidents. 3.5 Next-of-Kin Notification and Supervisor Training: Improve written policies to ensure next-of-kin death notification processes are handled in the timeliest and most professional manner possible during mass-casualty incidents. Include signed MOUs relating to response requirements to mitigate barriers that could exacerbate the anxiety and grief that victims’ families are already experiencing. Provide specific and ongoing training for supervisors and command personnel regarding the revised policies for securing the identities of victims in mass-casualty incidents and for making death notifications in the most professional and compassionate way possible. 3.6 Case Management: Establish a case management system to track the EOC and Family Reunification Center process efficiently and effectively. Ensure that protocols identify the role for a scribe and that records are not only maintained but also reviewed and finalized with the closure of both the EOC and FRC. Consider making these parts of the CAD record system to ensure access through the incident. 3.7 Physical Security Improvements: When designing office space, ensure planners take into account best practices, as outlined throughout this report, with respect to issues such as access to exit doors, secured entry and places to hide in the event of an active assailant. 3.8 Active Assailant Training: Provide training specific to the continuum of possible events in an active assailant incident. Ensure that this training designates specific assignments and responsibilities for each responder. The training scenarios must expand to include roles, tasks and protocols beyond those associated with initial response training. Ensure rolefocused training for key components of an active assailant scenario – including communications, command, initial response and apprehension, evacuation and facility management, victim management, family reunification and post-incident investigations and management. Train to respond to specific scenarios, with after-action improvements and updating of plans to support these additional response protocols. www.hillardheintze.com #$ 3 – RECOMMENDATIONS FOR MULTI-AGENCY COORDINATION, COMMAND AND CONTROL 3.9 Family Reunification Center Procedures: Establish Family Reunification Center protocols that include muster and set-up support, sign-in logs and establishing discrete spaces for victims’ families. 3.10 Support Services for First Responders: Provide first responders and investigators with appropriate support services to address concerns over post-traumatic stress, fatigue and burnout. Ensure appropriate staffing and support to cover long-term work, including mutual aid as appropriate. In the early stages of an incident, specifically task a command member to plan for the long-term staffing needs, separate from the immediate response, and plan for staff coverage and relief to avoid burnout. 3.11 Post-Incident Investigations Support: Ensure MOUs between first responders incorporate more than initial response needs, such as post-incident support for evidence collection, victim property return, interviews and data review. Task victim outreach and communications support to staff not directly engaged in the investigation. 3.12 Emergency Operations Center Plan: Ensure that the EOC plan is tested and supported – with full staff tasked to be on site once an EOC is established. 4 – RECOMMENDATIONS FOR THE CITY’S WORKPLACE VIOLENCE PREVENTION CAPABILITIES 4.1 Physical and Technical Security: Assign a specific department with qualified staff the responsibility for physical and technical security for City facilities. Ensure this accountability includes strategy development, policy, procedures, standards, budget development, implementation and compliance. 4.2 Minimum Standards: Develop minimum security technology standards for all buildings and departments. This should include ACS controls on exterior doors and interior hallway doors separating public areas from employee work areas as well as intrusion detection © 2019 HILLARD HEINTZE #> THE CITY OF VIRGINIA BEACH: AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31, 2019 4 – RECOMMENDATIONS FOR THE CITY’S WORKPLACE VIOLENCE PREVENTION CAPABILITIES system (IDS) requirements. Standards should also address security camera coverage of public spaces, including: • • • • • Entry/exit points – interior and exterior Public hallways Elevator landings Stairwells Any location where transactions with the public regularly occur 4.3 24-hour Monitoring: Develop a 24-hour monitoring capability for the integrated security technology platform. For maximum impact during incidents like the May 31, 2019 shooting, locate the monitoring point in a central dispatch location or, at minimum, somewhere with direct communications capabilities to first responders. A trained operator may have been able to immediately deactivate doorways the attacker attempted to enter from the public hallway. 4.4 Numbered Entryways and Doorways: Mark all access control locations and doorways with information that is reflected in the monitoring platform so that first responders can request the release of a specific door while leaving other doors locked to restrict or contain a subject. For example, the 2nd floor of Building 2 had nine ACS door readers. By numbering these doors, such as 2-01 thru 2-09, an officer could have requested an operator release 2-02 or another number as they advanced through the building. 4.5 Security Technology Systems: Integrate security technology systems (ACS, IDS and VMS) to improve the overall level of security for City-operated facilities. Incorporate building asbuilt floor plans in the integration monitoring platform. Develop a graphical user interface (GUI) depicting all security devices on the floor plans. Program the GUI’s icons to correspond to specific device functions, e.g., allowing the operator to monitor and activate the security features from a single point of access. This will allow for easier and quicker use in the event of an emergency. This type of integration is possible with the Lenel and Genetic systems already in use in the City of Virginia Beach. 4.6 Go-Bags and Knox Boxes: Develop Knox Box go-bags for each City building. Ensure all first responders are aware of the go-bags and Knox Box locations and how to access them. At a minimum, these go-bags should include: • Digital and printed floor plans www.hillardheintze.com #H 4 – RECOMMENDATIONS FOR THE CITY’S WORKPLACE VIOLENCE PREVENTION CAPABILITIES • Multiple building all-access ACS cards • Master keys for all interior spaces • Codes for any manual push-button locks 4.7 Key Usage: Improve controls over the keys in distribution. Establish request protocols that task unit-level supervisors with responsibilities for requesting key access and conducting inventories annually. Develop a tracking system to allow for identification of who has keys and policies that mandate return upon transfer or termination of employment. Enhanced security controls to review include a master key system and marking keys with unique identifiers. Consider electronic controls in place of keys wherever possible. 4.8 Lock Upgrade: Replace magnetic locks with electric strikes or electric lock sets, wherever possible, that “fail secure,” meaning that during a power failure they are not required to automatically open upon fire alarm activation. 4.9 Panic or Emergency Alert Buttons: Incorporate panic or emergency alert buttons in the IDS and ACS. A monitored system provides the best option to evaluate the alarm and initiate the appropriate response in a timely fashion. The City’s Lenel Access Control system is capable of incorporating panic and emergency call buttons. The City can improve security by actively monitoring access control system activity at a central monitoring location and by both developing and conducting regular response training for building occupants. 4.10 Emergency Alert Platform Enrollment: Develop strategies to improve employee and citizen enrollment in emergency alert platforms. Consider mandatory entry of all Cityissued communication devices. Conduct a recurring review of employee contact information. To ensure current enrollment, update notification information during the annual performance evaluation. 4.11 Emergency Mass Notification Messaging: Apply an all-hazards approach to emergency mass notification messaging. Develop protocol and policy to ensure consistent messaging and outreach during emergencies, including appropriate pre-recorded messaging. Ensure contingencies are in place to send the initial message and updates as soon as possible. © 2019 HILLARD HEINTZE #M THE CITY OF VIRGINIA BEACH: AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31, 2019 4 – RECOMMENDATIONS FOR THE CITY’S WORKPLACE VIOLENCE PREVENTION CAPABILITIES 4.12 Security Support with Employee Meetings: Establish policies and protocols for when departments believe there is a concern regarding any actions or meetings with an employee. Minimally, such requests should occur for any meeting regarding significant discipline. Ensure that a risk tool is used to facilitate the evaluation of need for security support. Once the TAT is operational, consider addressing such concerns and requests through the TAT. 4.13 HR Department Organization: Restructure the City HR Department to achieve a centralized approach to HR functions. Consider expanding the staff of full-time HR professionals to support a holistic approach to employee issues. Tasking the professional HR staff with specific City departments and support will allow for ongoing engagement between the units and the City HR Department on key employee issues and ensure a balanced and professional approach to employee support services. HR representatives embedded in the departments should work closely with management but report directly to the Employee Relations Manager. Ensure HR professionals do not report to departmental managers but rather collaborate with them in order to curb internal gossip as well as facilitate information sharing from the departments to the City HR Department. 4.14 Hiring Standards: Establish consistent standards for hiring and train all hiring managers and persons with responsibility for hiring on these standards. 4.15 Championship of Workplace Violence Prevention: Ensure the City government leaders champion and support the violence prevention program. Having “buy-in” from the top creates the legitimacy and urgency critical to implementing a set of tasks that will be new to many, sometimes difficult to carry out and not always completely successful. At the same time, it will be crucial to saving lives. Strong support from leadership will also help establish the program as an integral and long-term priority for the organization as a whole, rather than simply a passing initiative. 4.16 Code of Conduct or Employee Handbook: Establish a Code of Conduct or Employee Handbook that identifies for all personnel the organization’s behavioral expectations in the workplace. This Code should incorporate the baseline standards for employee performance, as modified and updated through policies that address specific behaviors. Compiling all such policies into a single, digital handbook allows for consistent review and updating of standards and easy access for managers and employees. Annual training www.hillardheintze.com #] 4 – RECOMMENDATIONS FOR THE CITY’S WORKPLACE VIOLENCE PREVENTION CAPABILITIES should review not only the Code of Conduct but also identify newly adopted and revised standards. 4.17 Termination-Related Notices: When a decision has been made to terminate an individual’s employment contract with the City, communicate notice requirements to the employee via email or in person at a neutral location sufficiently distanced from the employee’s original workplace and colleagues. Discontinue the practice of bringing employees back on site after delivering pre-disciplinary notice in cases where termination is being considered. 4.18 Negative Performance Evaluations: Restructure how the City HR Department addresses negative performance by an employee. Shift to an improvement-centered approach that includes the provision of resources such as promoting the Employee Assistance Program to help employees in stressful situations. Doing so will help redirect employee performance to conform to established standards, mitigate potential issues or lesser grievances and possibly prevent workplace violence. 4.19 Supervisor Training on Discipline: Include HR in every case involving disciplining an employee. Train supervisors on the City’s discipline policy and their role in the process. Have HR own and direct employee performance improvement programs, but ensure that supervisors are trained on how to engage with employees exhibiting concerning behaviors, are provided strategies and support in approaching an employee who may be facing significant challenges inside and outside the workplace, and are made aware of the resources they can make available to employees who seem to be facing employment challenges. 4.20 Background Investigations: Enhance applicable policies and protocols to address validation of references, licenses, certifications and requirements for independent HR review. Consider expansion of security background checks prior to employment for select employees and recurring checks every three to five years for employees and contractors. This would help mitigate risk, reduce liability and promote workplace safety. City personnel should verify with vendors that contractors have undergone background screenings. While this may seem like a significant undertaking, background screening is becoming increasingly efficient as new technologies and databases are developed. © 2019 HILLARD HEINTZE #_ THE CITY OF VIRGINIA BEACH: AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31, 2019 4 – RECOMMENDATIONS FOR THE CITY’S WORKPLACE VIOLENCE PREVENTION CAPABILITIES 4.21 Employee Investigations Protocols: Develop an employee investigations manual with consistent standards for all city units. In support of this protocol: • Train City supervisors on their roles and responsibilities regarding employee investigations – including nondisclosure and confidentiality. • Remove the discipline decision from the party conducting the investigation, with, ideally, the discipline decision resting with the City HR Department in close coordination with the department manager. • Require independent investigators – with, from, or under the direction of the City HR Department – to conduct investigations into allegations of employee misconduct. • Identify early HR controls and guidance to lessen the potential conflicts of interest and bias. • Consider establishing a centralized investigations unit, or specifically trained personnel, under the control of the City HR Department for handling sensitive investigations to ensure strong controls over confidentiality and to ensure unbiased and independent misconduct investigations. 4.22 Centralized Personnel Record Database: Establish a centralized database with access controls determined by and under the authority of the City HR Department. The level of information available to users should be based on established criteria. This data should reside in the general employee personnel records management systems. 4.23 Threat Assessment Team: Establish an interdisciplinary Threat Assessment Team to handle behavioral threat assessment and management. The TAT can be convened and can operate similar to the current Charge and Conviction Panel, though with much more flexibility. TAT membership should include HR, Legal Counsel and an appropriate manager. Ensure a working relationship with the EAP managers. Emphasize a holistic approach to employee support while ensuring continued focus on workplace violence prevention and coordination through the TAT. 4.24 Employee Assistance Program: Develop a widespread campaign throughout the organization emphasizing that EAP referrals can be compassionate, are always confidential and will not jeopardize an employee’s career or job status. Add an EAP representative to the TAT on an ad-hoc basis to help provide insight and share relevant case information. However, ensure that only TAT members are present for case strategy discussions. EAP representatives might also be able to provide generalized summary information to the www.hillardheintze.com $f 4 – RECOMMENDATIONS FOR THE CITY’S WORKPLACE VIOLENCE PREVENTION CAPABILITIES team to give insight into a particular issue raised by employees or in a specific area of the business. 4.25 Privacy Rules: Have the City HR Department and management work with the Legal Department to clarify privacy expectations, as well as to identify how the various privacy rules apply to the City’s work environment. 4.26 HR Responsibility for Workplace Violence Prevention: Assign HR the responsibility for the workplace violence prevention program and designate the Employee Relations Manager as the TAT Leader. Establish, document and follow a formal process when investigating and assessing potential threats. Give HR the responsibility for investigating reported or suspected violations of the policy and concerns related to violence. 4.27 Employee Reporting Protocols: Modify the City’s HR policies to incorporate non-punitive language that projects a more caring tone to encourage reporting of concerns. Include information about the City’s multi-disciplinary TAT – once established – and what employees can expect once they report a concern. 4.28 Protection Orders: Revise applicable policies to require the reporting of protection orders that include the workplace to ensure appropriate security protocols are implemented. Privacy of the employee should be respected in these situations, such as reporting to the City HR Department rather than the department’s HR Liaison. Any such report should be accompanied by a subsequent safety plan development for the premise and the employee. 4.29 Centralization of Reports to Document Violence Risk Investigations: Establish a single “fusion” process to examine all potential sources of information pertaining to employee misconduct and inappropriate workplace behaviors. Develop protocols for recognizing and reporting potential concerns to a centralized point of contact for evaluation and tracking. Consider leveraging hotlines such as the City’s Waste Fraud and Abuse Hotline to permit anonymous reporting of concerns – supported by clear standards as to what the function, © 2019 HILLARD HEINTZE $e THE CITY OF VIRGINIA BEACH: AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31, 2019 4 – RECOMMENDATIONS FOR THE CITY’S WORKPLACE VIOLENCE PREVENTION CAPABILITIES role and responsibility for such reporting are and what outcome reporting requirements should attach to the report.2 4.30 Employee Awareness: Implement awareness campaigns on key issues affecting employees – for example, substance abuse, domestic violence and workplace harassment – that provides ongoing focus on the support measures offered by the City and how to seek help. Include information about the City’s multi-disciplinary TAT – once established – and what employees can expect once they report a concern. 4.31 Expansion of City HR Department’s Authority: Give HR the responsibility for investigating reported or suspected violations of the policy and concerns related to violence. 4.32 Single Chain of Command for HR: Ensure HR professionals collaborate with departmental managers to provide opportunity for privacy on sensitive issues, reduce internal gossip as well as facilitate information-sharing from the departments to the City HR Department. 4.33 Information Sharing Plan: Establish a team comprised of legal counsel, HR and law enforcement personnel to develop an information sharing plan with public safety exceptions that is easy to understand and implement – and one that will save lives. 4.34 EAP Threat Reporting Guidelines: Establish enhanced information sharing with EAP through applicable policies and procedures to facilitate formal reports to the City when any of the following circumstances are indicated: Threat of harm to or abuse of a child or elderly person, as part of mandated reporting. Threat of imminent risk to self or to another person. 2 Reporting Fraud, Waste, & Abuse. https://www.vbgov.com/government/departments/city-auditorsoffice/Pages/report-fraud-abuse.aspx. Accessed 10/24/19 www.hillardheintze.com $" 4 – RECOMMENDATIONS FOR THE CITY’S WORKPLACE VIOLENCE PREVENTION CAPABILITIES 4.35 Centralization of Records Related to Workplace Violence Prevention: Develop a centralized, standardized system for tracking incidents of potential workplace violence. Establish a system for keeping these records centralized regardless of employee location. 4.36 Notification to HR of Discipline Resulting in Time Off: Require that HR have notice and review of discipline of any employee that results in time off. The HR review should include sufficiency of the finding that resulted in discipline, notice leading to the discipline and proportional discipline given the penalty. We recommend elsewhere in this report that the City consider an Ombudsman; however, minimally, HR should have a citywide record of all discipline that results in time off. 4.37 Workplace Violence Prevention Training: Ensure through training that employees are made aware of the policy; have a basic understanding of violence prevention basics and warning signs; understand their responsibility to report; and have a general understanding of what will happen once they report. The multidisciplinary TAT should be trained in higher-level behavioral threat assessment concepts as well as team dynamics, management strategies, best practices and guidelines. 4.38 Training for Managers and Supervisors: Implement training for managers and supervisors on how to understand early warning behaviors and work with the City HR Department to manage difficult employees and situations. Supervisory training should include supportive measures for early indicators of performance decline, such as referrals to EAP, before such behaviors become larger problems. © 2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH: AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31, 2019 $# www.hillardheintze.com ..K ?I?x 1? I?ll2.5333983 In! v.