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HomeMy WebLinkAboutNOVEMBER 13, 2019 SPECIAL SESSION MINUTES r' 2 • rno°�eF ., Ire oUR two VIRGINIA BEACH CITY COUNCIL Virginia Beach, Virginia November 13, 2019 Mayor Dyer called to order the SPECIAL SESSION of the VIRGINIA BEACH CITY COUNCIL in the City Council Chamber, Wednesday,November 13, 2019, at 6:00 P.M Council Members Present: Jessica P. Abbott, Michael F. Berlucchi, Mayor Robert M. Dyer, Barbara M. Henley, Louis R.Jones,John D.Moss,Aaron R. Rouse, Guy K. Tower, Rosemary Wilson, Vice Mayor James L. Wood and Sabrina D. Wooten Council Members Absent: None 2 ITEM LA MAYOR'S CALL FOR SPECIAL SESSION ITEM#69773 Mayor Dyer read the Mayor's Call for the SPECIAL SESSION: November 7, 2019 "HONORABLE MEMBERS OF CITY COUNCIL In accordance with the Virginia Beach City Code Section 2-21, and by the authority vested in me as Mayor of the City of Virginia Beach, I hereby call for a SPECIAL SESSION of the VIRGINLA BEACH CITY COUNCIL to hold a public briefing on the INDEPENDENT INVESTIGATION FINAL REPORT: Wednesday,November 13,2019 6:00 P.M. City Council Chamber Building 1, City Hall,2"d Floor 2401 Courthouse Drive Sincerely, s/ Robert M. Dyer Mayor" Cc: City Manager City Attorney City Clerk Deputy City Managers FOIA Officer Communications Office November 13, 2019 3 CITY COUNCIL'S BRIEFINGS INDEPENDENT INVESTIGATION FINAL REPORT ITEM#69774 6:01 P.M. Mayor Dyer read the attached opening statement and welcomed Lyndon Remias, City Auditor and Arnette F. Heintze, CEO—Hillard Heintze. Mr. Remias expressed his appreciation to City Council for their continued support. Mr. Remias advised Hillard Heintze completed the independent review and submitted the final report, which will be available on the City Auditor's website following the presentation. Mr. Remias turned the presentation over to Mr. Heintze. Mr.Heintze expressed his appreciation to City Council for their continued support. Mr.Heintze distributed a copy of the presentation, Executive Summary and Final Report, all are attached hereto and made a part of the record. Mayor Dyer expressed his appreciation to Mr. Remias and Mr. Heintze for the presentation. November 13, 2019 Mayor Dyer Remarks November 13,2019 Special Meeting Thank you for joining us this evening. While not even six months have passed since the horrific May 31 st tragedy, we have arrived at another major milestone along our long road to recovery. To the families, friends, neighbors and coworkers of our victims who are here with us today or watching from a distance, I extend a very special welcome. We scheduled this meeting so we could receive the results of the independent review. We know we will never be the same. But we know we must move forward, and this is a critical part of our healing journey. Just two months following the shooting, this Council directed the city auditor to engage an independent consultant to conduct an independent review.The scope of the review is much broader than the criminal investigation. To be clear, we undertook this independent review as a complement to the criminal investigation so we could sort through the competing and often conflicting narratives, theories, speculations, allegations and insinuations to uncover the facts and learn the truth. This City Council and this City organization maintains a deep commitment to learning everything we can about the perpetrator and the circumstances surrounding his tenure here. We also sought an independent review of relevant City policies,procedures and practices, especially those related to facility security,prevention of workplace violence and employee alerting and response to active shooter notifications. Ultimately, we were seeking recommendations regarding best practices we can consider going forward. From this work, I am confident we will emerge stronger organization. It is also my personal hope that it will serve as a platform to help us work through our differences with civility and respect. I do want to remind everyone that the VB Strong Center is open. The sole mission of this facility, in partnership with Sentara Healthcare, is to provide care and support to anyone impacted by our greatest tragedy. Please visit TheVBStrongCenter.org for information about services and hours. I am going to ask City Auditor Lyndon Remias to introduce Hillard Heintze and talk about the logistics of tonight's briefing. AFTER PRESENTATION AND COUNCIL Q&A— Direct Acting City Manager to provide a management response to the report. Once we adjourn this meeting, we'll take a five minute break to set up for the media Q&A with Hillard Heintze. Some members of Council may choose to stay for that,but there is no transaction of City Council business and no votes will be taken. 4 ITEM VI ADJOURNMENT ITEM#69775 Mayor Robert M. Dyer DECLARED the City Council SPECIAL SESSION ADJOURNED at 7:22 P.M. Terri H. Chelius' Chief Deputy City Clerk manda ;ar,'es, MMC Robert M. Dyer City Cler Mayor *Following the adjournment,Mayor Dyer, as well as Council Members Henley and Wilson, attended the media Q&A with Hillard Heintze that began at 7:30 P.M. and concluded at 7:47 P.M. 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C u O Q Y ® CO A1 p � + Q E a +-+ a m L CI- E = •> Q Fes-- w • • • • E cL cc, O N O J �, W a •� z aJ U L.m co c a) = O o a J O4:5 J ® C c c N = CD 1:3 a) > > C 0> > U ® L. N 22 co c +, as � L a L O U o CD W U CU) •® fa OJ Q- CCD C a O E O al z > � > C o •> a •5 E o a ® N a = U l�A CO CAA Z 1- U U �: Tn. 0 W a C Q C O 0 a; •° = a 5 L L ° `� `- W OC • • • • ' Lii F.-- Z I . . . , . _ ..L_ tio ., ca ... iiiii., U O ., , o0E v) , c , ,.. „ 0 c ,_.,_ N O a ._ cu N D € ,f lew L L O co Q)C v O 14:1( 6 C CD v v n �j Uco v _ .L v > a Wm! CU .4:3 4' u a� LT u.. co __c x v N, > ._ al _ Q) 0 o _0 V) ry i .-C i O O aJ O O Q V cB 0 M N _ z z a _i 0 ,-, _,- 0 _ i, r- S.� xb THE CITY OF VIRGINIA BEACH An Independent Review of the W T Tragic Events of May 31, 2019 EXECUTIVE SUMMARY r- ate.®-.. =- �os _ _•� _ k _ November 13,2019 H I LLARD ip H E I NTZ E� A JENSEN HUGHES COMPANY .,,r„= 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. .. ,'"It'41/11 limait:';,-..,..,R v .r_ ^. ok §t, I J iso LaQuita C. Brown Ryan Keith Cox Tara Welch Gallagher 39 years old 50 years old 39 years old LaQuita "Quita"had a warm smile Ryan Keith Cox served 12%years Tara Welch Gallagher was a and a contagious laugh that as an Accounting Clerk for the devoted wife and mother.She brightened everyone's mood.She City of Virginia Beach. He was a was a beautiful person both was admired and respected by all. member of the New Hope Baptist inside and out.Tara's life The thoughtfulness and joy on her Church,Anointed Voices, Men of centered around her family.She was most proud of her role as a face will never be forgotten.At the Hope,the Male Chorus,and the mother to Patrick Ill.Tara age of 16,she symbolized her Men's Ministry. Ryan loved sports, touched many lives both dedication to Jehovah by reading,and studying the Bible. personally and professionally and undergoing water baptism.She He leaves to cherish his memory her absence will continue to be took her dedication to God his parents, Pastor E. Ray Cox,Sr. felt as an empty loss.Tara will seriously and chose the ministry as and Maxine Mills Cox;two always be missed and will never her vocation.She enjoyed many brothers,Tony F. Mills and Erin leave her family's thoughts. privileges of service and performed Ray Cox,Jr.,and a host of other all with zeal and humility. Her relatives and friends. 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. CO 2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 4111 * MRti' Mary Lou Gayle Alexander Mikhail Gusev Joshua O. Hardy 65 years old 35 years old 52 years old Mary Louise"Mary Lou" Crutsinger Alexander Mikhail Gusev was born Joshua Orion"Dennis" Hardy Gayle was a self-made woman in Mogilev, Belarus. He came to the is remembered by his family as from a strong and loving family. United States on May 31,2003, having the attributes of love She raised two children as a single looking for the American dream. residing in him,accompanied mother and after proudly seeing He graduated from ODU with a BS with the natural God-giving them through college, returned to in Science and Business instinct to protect and serve. school herself and earned both a Management,and eventually He is remembered as a God- Bachelor's and a Master's. Mary became a Right-of-Way agent for fearing man whose life spoke Lou was a dedicated public servant the Virginia Beach Public Works out to family,friends,the co- who proudly worked for the City of Department,allowing him the workers that he loved,and the Virginia Beach for 24 years, opportunity to bring his mother world in these few words: advancing to become a Senior from Belarus to join him in "This is my commandment, Right-of-Way Agent in the Public America.Alex was an easy-going That ye love one another,as I Works Department where her person with a great sense of have loved you. Greater love focus was on supporting projects humor, made many faithful friends hath no man than this,that a to improve and beautify the city and touched the lives of many man lay down his life for his that was her lifelong home. She others. He is survived by his friends"(John 15:12-13). was a dedicated and beloved parents, Mikhail and Alena, his twin mother,grandmother,sister,aunt, brother Aliaksei, his sister-in-law daughter and friend who enriched Olga,and his niece Arina. the lives of all with her generosity, infectious zest for life,quick wit, kindness,and unshakeable faith. www.hillardheintze.com ... ,, 11 , -, ,- , - Ni -__ ,, _,,,, Michelle"Missy" Langer Richard H. Nettleton Katherine A. Lusich-Nixon 60 years old 65 years old 42 years old Michelle Marie"Missy" Langer Richard Nettleton was a 10-year Katherine Lusich-Nixon is lived in Virginia Beach for the past veteran of the U.S.Army before remembered by her husband 20 years,loving the beach life and becoming a dedicated Virginia Beach as his best friend and one of serving her church,the Good Design and Construction Manager in the most loving, intelligent Shepherd Lutheran Church.She Public Utilities and loved being an woman he has ever met.A loved Paul McCartney and was an Engineer,with coworkers holding him loving wife and mother, avid fan of the Michigan in high regard as one who enjoyed Kate loved her daughters Wolverines, having been born in mentoring other engineers and who and her family more than Michigan,as well as the Pittsburgh put himself last on the list when others anything in the world.She Steelers. Left to cherish her had a need. Richard was proud of his loved volunteering in the memory are her sister, Deborah Chinese heritage on his mother's side, community and believed Borato and her husband, Ron; her and was a strong supporter of the that everyone should be brother, Herman"Fred" Langer and Minority Business Expo and believed in part of the solutions in life, his wife Kim;as well as several professionalism,diversity,and reaching not part of the problems in nieces, nephews,cousins,and out to all in the community. life.She touched many lives extended family.She touched the Remembered by his family as a strong, in both her personal and lives of many people in the City of steady presence during every family professional life.The world Virginia Beach and leaves many challenge, he leaves behind his wife, will not be the same without close friends behind. Sarah; his sons Richard Jr.and Robert; Kate Nixon in it. 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. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 t - .. _ rr-..„-- 0.- 3, 02, g. .....G:,,i4 1 At i,r, - 4fte .ikair 111 Christopher Kelly Rapp Herbert"Bert" Snelling Robert"Bobby"Williams 54 years old 57 years old 72 years old Christopher Kelly Rapp held an Herbert Ray"Bert"Snelling,Jr. Robert Thomas"Bobby" illustrious and varied career in loved to create custom gates and Williams was a veteran of the public service for public utilities, custom cabinetry with his master U.S. Navy before becoming an most recently as Stormwater carpentry skills. He was a humble employee of the City of Virginia Management Regulatory Engineer and self-sacrificing man with an Beach, most recently as a for the City of Virginia Beach. infectious laugh who found humor Special Projects Coordinator in Chris was gifted musically and in every opportunity and helped the Public Utilities Department. loved playing the bagpipes, others find joy in all things. He His family remembers him as learning to play the piano,and served the Lord and others his the most loving,extraordinary dancing, including line dancing, whole life, most recently as a husband,dad,and "Pop-Pop" ballroom dancing,and Filipino member of Crosswalk Church in who considered family his first Cultural dances. He is survived by Virginia Beach. He is survived by priority. He is survived by his his loving wife, Bessie M. Rapp; his wife, Sonja; his mother, wife,Sharon Williams; his son, his parents, Michael D.and Veronica "Roni"Sharrett; his Robert T.Williams,Jr.and his Patricia K. Rapp;and his brother, father, Herbert Ray Snelling,Sr.; wife Rachel; his daughter, Sarah Timothy A. Rapp. His brother, Eric his brother Micah Snelling; and his Hodges and her husband Rob; M. Rapp, preceded him in death. children, Melissa "Missy" Fay Hart his siblings Janice Sandlin, Kathy and Herbert Ray"BJ"Snelling Ill. 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 after- effects 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 Z i(L //.€ i-tff, 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 9 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 10 mismmimi 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 third- party 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. O 2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 11 111111111 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 12 Key Findings ACTION IN THE FACE OF DANCER 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 THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 13 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 mass- casualty 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 14 IAWORKPI.ACE 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 THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 15 i 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 16 tostismittaim 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. 0 2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 17 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 18 mommirm 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 all- hazards 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 THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 19 mmiummilami 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 follow- through 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 20 iiimemiemm 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 THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 21 NINEMMINMI 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 City- owned 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 23 Accepts offer of position as Engineer at The Timeline Lewis and White May 2003 Below is a timeline that details key Resigns from Lewis and White. events in the subject's life prior to the attack,and what happened and when Accepts offer of position as Project Engineer on May 31,2019. at MSA Engineering. February 2008 Hillard Heintze interviewed Gets laid-off from MSA Engineering.An stakeholders,reviewed law individual close to the subject said he enforcement and Building 2 records, complained about the lack of a promotion evaluated the subject's work and and perceived racism. personal devices and their contents, Marries. and leveraged other sources to construct this timeline to the best of Accepts offer of position as Project Engineer our ability. Ill at Draper Aden Associates. Note: Unless otherwise specified, July 2008 the subject is conducting the actions Resigns from Draper Aden Associates. described. November 2008 Accepts offer of position as Engineer II for the City of Newport News,Virginia. January 2010 Resigns from Newport News. Subjects History felevant to the Attack From 2011 to 2015 From 1996 to 2010 February 2010 Accepts offer of position as Engineer II at April 1996-April 2002 City of Virginia Beach. Serves in the Virginia Army National Guard. Assigned to Army National Guard units in 2011 -2017 Norfolk and Hampton,Virginia. Receives annual evaluation and is rated "Meets Standards." April 2002 Receives honorable discharge from the January 2012 National Guard. Purchases home in Virginia Beach. May 2002 September 2012 Graduates from Old Dominion University. Receives"Thumbs Up"Award. www.hillardheintze.com April 2014 Emails supervisor attesting that his Receives Excellence in Service Award. work was above average,but that his salary did not reflect that. May 2015 Receives Team Participation Award. 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. Management places subject on Performance April 2016 Improvement Plan for deficiencies in project Applies for and obtains Concealed Handgun management skills. Permit. Subject states he feels"singled out"for his July 2016 unsatisfactory work performance. Purchases H&K USP45C 45 ACP pistol. August 2017 Purchases JRC JRCV067138 45 Directs attorney to proceed with filing ACP carbine rifle. divorce. August 2016 Completes his Performance Improvement Plan successfully. Begins regularly visiting gun websites via his phone. Suppressor registration completed. September 2016 September 2017 Separates from wife. 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 2145 ACP pistol. December 2017 October 2016 Purchases Bond Arms Backup Derringer 45 Submits Suppressor Transference ACP pistol. Certification. The frequency of the subject's December 2016 communications with his mother begin to Issue occurs regarding missing contractor decrease. checks on subject's project. 2018 February 2018 January 2017 Subject's communications with ex-wife Management letter documents subject's increase. mishandling of these checks. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 25 April 2018 Stops communicating with ex-wife. Receives"Thumbs Up"Award. 2019 June 2018 January 2019 Purchases second Glock 2145 ACP pistol. Uses Smart TV Guide to visit a news report July 2018 about the Orland Square Mall shooting. Receives written reprimand for poor March 2019 performance as well as Letter of Performance Visits gun conversion kit websites. Expectations. Submits verbal grievance to supervisor about April 2019 written reprimand. 3 Drafts work email on his perceptions of his professional relationships and stressors. Supervisor verbally responds to grievance. Drafts but never sends emails that reflect August 2018 irrational and suspicious beliefs. Receives"Improvement Required - PIP 7 Browses Premier Body Armor website and Required"annual evaluation due to poor views body armor and ballistic plates. performance. Submits written grievance to supervisor. 8 Views Level 3A ballistic body armor panels via his mobile telephone. Submits written grievance to Department 10 Receives email confirming delivery of Head to remove reprimand. purchased body armor. Complains in response to annual evaluation 12 Purchases Ruger rifle. that he is discriminated against by being assigned critical projects above his paygrade. May 2019 Drafts work email expressing concerns about 20 Searches on computer for maps of Building 2 being"sandbagged." and the Municipal Center. September 2018 23 Sets message on computer that he will be out Emails Department Head after the meeting. of office from May 24 to 28. States that he is clearly discriminated through 24 Purchases three rifle gun magazines and rifle project assignments. Requests again that the reprimand be removed. case. Is informed that the reprimand will remain. 28 Emails Contracts Unit asking to expedite payment for$3,027.48 contractor invoice, Elects to end his grievance and not to appeal for which funds have not been properly it to the Personnel Board. obligated. November 2018 29 Contracts Specialist emails back requiring justification for and additional information Stops communicating with mother. about the purchase order and directs subject www.hillardheintze.com to email City Procurement Officer with this request. The Day of the Attack: May 31, 201 Emails Procurement Officer seeking assistance to resolve purchase order issue. Note: The timeline items in this section are based Procurement Officer leaves voicemail for on employee interviews,9-1-1 calls and subject about the purchase order issue, crime-scene details. Final determination of telling him that he has made an unauthorized the chronology of shootings and locations purchase and violated a City ordinance. cannot be made until the results of the Procurement Officer informs subject that she forensics examinations and scene will send him an email as well and asks him to reconstructions are available. call her back. 6:58 a.m. Procurement Officer emails subject that fiscal Leaves residence. policies have not been adhered to and procurement procedures have not been 7:16 a.m. properly followed on the matter,and that full Arrives at City's municipal complex. documentation will be required. Replays the voicemail for supervisors. 7:21:30 a.m. Swipes card for entry into Building 2 Ops/PU Emails supervisor on how he will respond to 2nd Floor Engineering North Hall. Procurement Officer's email. 7:23 a.m. Another employee receives pre-dismissal Starts up his work computer and checks his letter from supervisors.A Virginia Beach Outlook mail. Police Department(VBPD)officer is posted to Building 2 as a precaution. 10:00- 10:30 a.m. Conducts internet searches for Building 2 30 The other employee receives a termination maps,the ECCS and the Municipal Center letter and a supervisor escorts him out of Building Map. building. 10:31 a.m. Subject states he is too upset to meet with Emails supervisor his resignation and refers the Procurement Officer and will pay to personal reasons. $3,027.48 from his personal checking account to correct the error. 10:46 a.m. In the evening,places 54-second call from his Supervisor responds saying he hopes that the mobile phone to his desk phone. subject resolves his personal reasons and asks for confirmation that his last day will be In the evening,makes two personal calls - June 14. one to his ex-wife, in which he is apologetic in nature;the other to his mother, in which 10:49 a.m. he refers to his insomnia and problems with Supervisor forwards subject's resignation supervisors at work but is otherwise upbeat email to other managers and copies the in tone. subject. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 27 10:52 a.m. 4:00-4:05 p.m. Subject swipes card for entry into Building 2 Enters South Building 2 entrance.Witness PU 2nd Floor East Engineering South. hears gunshots,sees subject with a gun in his hand walk into the building.Sees a man 11:25 a.m. bleeding on the ground. Responds to supervisor's email with email, "Thank you.Yes,that is correct." 4:00 p.m. -4:16 p.m. Shoots Mary Louise Gayle,Alexander Mikhail 11:23 - 11:33 a.m. Gusev, Katherine Nixon, Michelle Langer, Sends routine work-related emails. Ryan Cox, Robert Williams,Christopher Rapp,Tara Gallagher, Laquita Brown, Richard 11:58 a.m. Nettleton, Herbert Snelling,Joshua Hardy. Swipes card for entry into Building 2 Ops/PU 4:05:56 p.m. 2nd Floor Engineering North Hall. Swipes card for entry into Building 2/PU 2nd 12:08 p.m. Floor East Engineering South. Swipes card for entry into Building 2 Ops/PU 4:06:32 p.m. 2nd Floor Engineering South. First 9-1-1 call is received (call duration is 1:00 p.m. 4:59).Caller reports seeing body on ground Swipes card for entry into Building 2 Ops/PU with blood, hears shots, sees black man in 2nd Floor Engineering South. blue shirt running into building, hears more shots near his office and ends call. 1:04 p.m. 4:08 p.m. Subject and two co-workers leave Building 2 Call is dispatched regarding man in front of to travel in car for routine inspection of three Building 2 who is possibly shot. project sites. 1:06 - 3:06 p.m. First suspect description is dispatched. Refers to Hispanic man on 2nd floor. Dispatcher Subject is at project sites with co-workers hears gunshots on the call in the background. and in transit. 4:08:13 p.m. 3:11:49 p.m. Swipes card for entry into Building 2 Ops/PU Swipes card for entry into Building 2 Ops/PU 2nd Floor/West Side Business Unit. 2nd Floor Engineering South. 4:10:10 p.m. 3:55 p.m. Second suspect description is dispatched. Sends routine work-related email. Refers to a bald black man with a blue polo shirt. 3:57 p.m. Subject is observed brushing teeth in 2nd 4:10:19 p.m. Floor bathroom. First police personnel enter Building 2. K9 Units announce arrival. Plainclothes detectives report that they are on-scene.Air www.hillardheintze.com is restricted. Dispatch identifies that shots 4:22 p.m. are being fired on 2nd floor. HR Communications Coordinator sends email to all City employees marked,"Importance: 4:11 p.m. High"with the subject,"URGENT: Shelter in The Virginia Beach Fire Department arrives Place @Mun.Ctr. Until further notice." on scene pursuant to dispatch. The message reads, "We have an active 4:11 p.m. shooter at the Municipal Center,supposedly Fire alarm sounds in Building 2. in or around Bldg. 2. Please shelter in place. Lock your doors.We'll communicate when 4:12:40 p.m. it's safe to leave.Thank you." Swipes card for entry into Building 2 Ops/PU 4:26 p.m. 2nd Floor/West Side Business Unit. SWAT team reports it is inside Building 2. 4:13:49 p.m. Third suspect description is dispatched. 4:43 p.m. Refers to a six-foot-tall black man with a blue First transmission that subject is in custody. shirt and a gun with a silencer. 4:44 p.m. 4:15 p.m. Second transmission that subject is in The VBFD establishes Command Post. custody. 4:15 p.m. 4:54 p.m. The VBPD establishes on-scene commander. HR Communications Coordinator sends email to all City employees marked,"Importance: 4:15:07 p.m. High"with the subject,"URGENT:Continue Subject swipes card for entry into Building 2 to Shelter in Place at Mun.Ctr." 2nd Floor/East Side/ Engineering South. The message reads,"For those at the 4:18 p.m. Municipal Center, please continue to shelter in place.We'll let you know when its safe to All available Special Weapons and Tactics unlock doors. Even then,there are roads (SWAT)team members are responding to blocked which may keep everyone here for a Building 2. while. But,we'll keep you posted. Please be safe!" 4:19 p.m. The name of the subject is dispatched. 5:30 p.m. Responders attempt to establish the Family 4:20 p.m. Reunification Center(FRC)at United Initial broadcast that an officer is shot. Methodist Church,but the Church is occupied,and the Center is established at 4:21 p.m. Princess Ann Middle School. Dispatch identifies that the subject is isolated and shooting actively on east side of 2nd 5:32 p.m. floor. 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 29 5:34 p.m. 7:18 p.m. Building 2 is secured. No additional Explosive sweeps of Building 2 are wounded are in the building. completed. 5:36 p.m. 7:19 p.m. Subject's backpack and additional Transmission that Building 2 is ready for firearms are found on 2nd floor. forensics teams and detectives. 5:42 p.m. 9:00 p.m. Explosive detection K9s begin sweeping Death notifications begin. parking lot. 12:00 p.m. 5:43 p.m. Last local death notification is completed. Subject's vehicle is located in parking lot in front of South entrance. 1:00 a.m. Final death notification completed out of 5:55 p.m. state by assisting law enforcement agency. HR Communication Coordinator sends email to all City employees marked,"Importance - High"with the subject,"All Mun.Ctr. Days Following the Attack: employees can leave except for Bldg. 2 employees." June 2,2019 The message reads,"Today's situation is FRC closes. ongoing but the suspect is in custody. It is now safe for Municipal Center employees to Family Assistance Center opens at Princess leave the area. However,those who work in Ann Rec Center. Bldg.2 must remain here until further notice. Police/fire officials will inform Bldg.2 June 9,2019 employees when it's safe to leave. Please Family Assistance Center closes at Princess drive safely when leaving.Thank you." 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 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 pre- designated 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. CO 2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 31 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: 1 Emergency dispatch 2 Text message 3 Email 4 Mobile app push notification 5 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 32 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 pre- planned 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 follow- up 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 33 imumemem • ' . ..•44..a..vt,DATIQ c:.:.C' .'._® _.`.;: • COMMANDAD 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 role- focused 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 34 isimmommo 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. 4.1 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 0 2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 35 miumomm 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 as- built 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 36 immommi '.. c rrscsersg-osa.mn+q„�s v a-a :f.�.resm:'. 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 City- issued 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 THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 37 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 38 mummeni 4 RECOMMENDATIONS FOR TEE 'S WO', ? Y . .• w._ •� h. . • ., < • 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 39 usio 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 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 THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 41 mumwmomil 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-auditors- office/Pages/report-fraud-abuse.aspx.Accessed 10/24/19 www.hillardheintze.com 42 menimeim 4—RECO A� .� . r . �a L.• C_ _..,_ ,T ON cAP $ILITIES 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 43 msmNINI www.hillardheintze.com F ems. • H I L L A R D HE I N TZ E hillardheintze.com A JENSEN HUGHES COMPANY _ THE CITY OF VIRGINIA BEACH A n In dep endent Review of the Tragic Events of May 31, 2019 ------ - - -- - am... __ , .... { . . _ _._ ,______ _ . ___ _ ___ __ _. _.„....... - __,,,__ _ ,_„.., ,,_,,__ ,..... _ _ __-__ ----_ _ „..... ,;...„,_ _ __ __,.., __ __ , _. _ TM 4 .� _ '- ''A wH+.. .,_+�^` ;:.✓^ ter-".. -- *-` srs -c '.vim ,.—Y'^ ."'e.:.:.. yt ,�.�,•-'•�,— �. - A ". ,-... . .s,�-..*ram a^-- _ ... «— *+.,►,_ --.. .._ ...•-. - s +mow.-. November 13, 2019 1 I LLAR D ip H E l NTZ E A JENSEN HUGHES COMPANY _ �.. , : -_, _ 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 u and successes. Let's continue to honor them, share their stories and remember their lives. I p 41 etr ',4 4t4: '''''' -16-1°' -' '444.4%..t.-'. : it , e '�F -' lit 4 . t - _yr 1 ' 44 --,,,,-.. , t4 i 4114 414 Ili f X 4 4'711t- ' 'IS tt* 4cilliiir--/ , ' LaQuita C. Brown Ryan Keith Cox Tara Welch Gallagher 39 years old 50 years old 39 years old LaQuita"Quita"had a warm smile Ryan Keith Cox served 12%years Tara Welch Gallagher was a and a contagious laugh that as an Accounting Clerk for the devoted wife and mother.She brightened everyone's mood.She City of Virginia Beach. He was a was a beautiful person both was admired and respected by all. member of the New Hope Baptist inside and out.Tara's life The thoughtfulness and joy on her Church,Anointed Voices, Men of centered around her family.She was most proud of her role as a face will never be forgotten.At the Hope,the Male Chorus,and the mother to Patrick Ill.Tara age of 16,she symbolized her Men's Ministry. Ryan loved sports, touched many lives both dedication to Jehovah by reading,and studying the Bible. personally and professionally and undergoing water baptism.She He leaves to cherish his memory her absence will continue to be took her dedication to God his parents, Pastor E. Ray Cox,Sr. felt as an empty loss.Tara will seriously and chose the ministry as and Maxine Mills Cox;two always be missed and will never her vocation.She enjoyed many brothers,Tony F. Mills and Erin leave her family's thoughts. privileges of service and performed Ray Cox,Jr.,and a host of other all with zeal and humility. Her relatives and friends. 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. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 es* orvi\ ar ' 4.41‘ is Mary Lou Gayle Alexander Mikhail Gusev Joshua O. Hardy 65 years old 35 years old 52 years old Mary Louise"Mary Lou"Crutsinger Alexander Mikhail Gusev was born Joshua Orion"Dennis" Hardy Gayle was a self-made woman in Mogilev, Belarus. He came to the is remembered by his family as from a strong and loving family. United States on May 31,2003, having the attributes of love She raised two children as a single looking for the American dream. residing in him,accompanied mother and after proudly seeing He graduated from ODU with a BS with the natural God-giving them through college,returned to in Science and Business instinct to protect and serve. school herself and earned both a Management,and eventually He is remembered as a God- Bachelor's and a Master's. Mary became a Right-of-Way agent for fearing man whose life spoke Lou was a dedicated public servant the Virginia Beach Public Works out to family,friends,the co- who proudly worked for the City of Department,allowing him the workers that he loved,and the Virginia Beach for 24 years, opportunity to bring his mother world in these few words: advancing to become a Senior from Belarus to join him in "This is my commandment, Right-of-Way Agent in the Public America.Alex was an easy-going That ye love one another,as I Works Department where her person with a great sense of have loved you. Greater love focus was on supporting projects humor, made many faithful friends hath no man than this,that a to improve and beautify the city and touched the lives of many man lay down his life for his that was her lifelong home. She others. He is survived by his friends"(John 15:12-13). was a dedicated and beloved parents, Mikhail and Alena, his twin mother,grandmother,sister,aunt, brother Aliaksei, his sister-in-law daughter and friend who enriched Olga,and his niece Arina. the lives of all with her generosity, infectious zest for life,quick wit, kindness,and unshakeable faith. www.hillard hei ntze.com ,.a- : . II % M1 t ',„ 4 lot `` q Michelle "Missy" Langer Richard H. Nettleton Katherine A. Lusich-Nixon 60 years old 65 years old 42 years old Michelle Marie"Missy" Langer Richard Nettleton was a 10-year Katherine Lusich-Nixon is lived in Virginia Beach for the past veteran of the U.S.Army before remembered by her husband 20 years,loving the beach life and becoming a dedicated Virginia Beach as his best friend and one of serving her church,the Good Design and Construction Manager in the most loving,intelligent Shepherd Lutheran Church.She Public Utilities and loved being an woman he has ever met.A loved Paul McCartney and was an Engineer,with coworkers holding him loving wife and mother, avid fan of the Michigan in high regard as one who enjoyed Kate loved her daughters Wolverines,having been born in mentoring other engineers and who and her family more than Michigan,as well as the Pittsburgh put himself last on the list when others anything in the world.She Steelers. Left to cherish her had a need. Richard was proud of his loved volunteering in the memory are her sister, Deborah Chinese heritage on his mother's side, community and believed Borato and her husband, Ron; her and was a strong supporter of the that everyone should be brother, Herman"Fred"Langer and Minority Business Expo and believed in part of the solutions in life, his wife Kim;as well as several professionalism,diversity,and reaching not part of the problems in nieces, nephews,cousins,and out to all in the community. life.She touched many lives extended family.She touched the Remembered by his family as a strong, in both her personal and lives of many people in the City of steady presence during every family professional life.The world Virginia Beach and leaves many challenge, he leaves behind his wife, will not be the same without close friends behind. Sarah; his sons Richard Jr.and Robert; Kate Nixon in it. 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. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 r _ „.. ,_ -., 7,f':\ rP ri- dam,..,,,,,. y e go. , 4v. .. ,. ,, .,, Christopher Kelly Rapp Herbert "Bert" Snelling Robert "Bobby" Williams 54 years old 57 years old 72 years old Christopher Kelly Rapp held an Herbert Ray"Bert"Snelling,Jr. Robert Thomas"Bobby" illustrious and varied career in loved to create custom gates and Williams was a veteran of the public service for public utilities, custom cabinetry with his master U.S. Navy before becoming an most recently as Stormwater carpentry skills. He was a humble employee of the City of Virginia Management Regulatory Engineer and self-sacrificing man with an Beach, most recently as a for the City of Virginia Beach. infectious laugh who found humor Special Projects Coordinator in Chris was gifted musically and in every opportunity and helped the Public Utilities Department. loved playing the bagpipes, others find joy in all things. He His family remembers him as learning to play the piano,and served the Lord and others his the most loving,extraordinary dancing, including line dancing, whole life,most recently as a husband,dad,and "Pop-Pop" ballroom dancing,and Filipino member of Crosswalk Church in who considered family his first Cultural dances. He is survived by Virginia Beach. He is survived by priority. He is survived by his his loving wife, Bessie M. Rapp; his wife,Sonja; his mother, wife,Sharon Williams; his son, his parents, Michael D.and Veronica "Roni"Sharrett; his Robert T.Williams,Jr.and his Patricia K. Rapp; and his brother, father, Herbert Ray Snelling,Sr.; wife Rachel; his daughter,Sarah Timothy A. Rapp. His brother, Eric his brother Micah Snelling;and his Hodges and her husband Rob; M. Rapp, preceded him in death. children, Melissa "Missy" Fay Hart his siblings Janice Sandlin, Kathy and Herbert Ray"BJ"Snelling III. 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 after- effects 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 ifiti(c ii(i0;tic 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 9 mmommoui Table of Contents OVERVIEW 14 KEY FINDINGS 17 THE TIMELINE 28 SECTION 1 THE ATTACKER AND HIS BACKGROUND 35 1.1 Personal Background 37 1.2 Court Records 37 Criminal Records 38 Civil Filings 39 1.3 Employment History and Workplace Interactions 40 Work History 40 Performance Evaluations 41 Recognitions and Awards 41 1.4 Press and Social Media 42 1.5 Risk Factors Identified in the WAVR-21 Framework 42 Job Performance Issues in 2017 43 Job Performance Issues in the Days Before the Attack 46 Weapons Skill and/or Access 49 Violent Preoccupations 50 Pre-Attack Planning and Preparation 51 Entitlement 51 Anger Problems 52 Irrationally Suspicious Beliefs 52 Workplace Behaviors 53 Resignation 53 Work Emails 54 Increasing Isolation 57 www.hillardheintze.com History of Criminality 57 1.6 Retrospective Analysis 58 Behavior and Experiences at Work 58 Motivations 60 The Subject's Relationships to the Victims 61 Could This Attack Have Been Prevented? 63 SECTION 2 THE POLICE i?E PART MENT'S ACTIONS ON SCENE ! c 2.1 Initial Response to the Active Shooter 67 2.2 Initial Communications 68 The First Calls and Execution of ECCS Protocols 68 Calls from Witnesses 68 ECCS Guidance for Personnel Trapped in Building 2 69 ECCS Text Messages 69 Notification Systems 70 Public Safety Serious Incident Notifications, Policy 545 70 VBPD General Order 11.02, First Responder Notifications 71 Early Incident and Subject Information 71 Four Descriptions of the Shooter 72 2.3 The VBPD Response to the Scene 72 Emergency Radio Communications 72 Arrival and Entry into Building 2 73 Movement within Building 2 73 Indirect Notification to Key Personnel 74 SWAT Members Arrive On Scene 75 Recommendations 75 SECTION MULTI-AGENCY COORDINATION,COMMAND AND CONTROL,. ,..:_ _..._ ..... 3.1 Incident Command System and Key Agency Roles 80 Active Assailant Training 80 ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 11 Critical Incidents and Incident Command 80 Overview of the Incident Command System(ICS) 81 Incident Command System Hierarchy and Policy 82 The Emergency Operations Center(EOC) 83 Incident Communications 84 Building 2 Incident Notification and Evacuation 87 Evacuation Policies and Practices 89 Unified Command 90 Fire Command and Rescue Operations 91 EMS Response and the Medical Branch 93 Police Incident Command 94 Public Communications 95 3.2 Post-Attack Incident Command 97 Victim and Witness Management 97 Investigation and Interviews with Witnesses and Victims 98 Victim Identification 98 Family Reunification Center(FRC) 99 Entry to the Family Reunification Center 101 Medical Coordination with the Family Reunification Center 101 Notification Management at the Family Reunification Center 101 Post-Event Incident Management 102 3.3 Managing People and City Services 103 Immediate Aftermath and Business Continuity 103 Response of the Facilities Management Office 104 Future Planning 105 Post-Event Employee and Victim Engagement and Support 106 Recommendations 107 www.hillardheintze.com 12 immoommo SECTION 4 THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES 11'! 4.1 Physical and Technical Security Measures in Building 2 113 Facility Security 113 Physical and Technical Security 114 Emergency Alert and Notification System 118 4.2 The City HR Department's Structure and Operational Model 119 A Decentralized Organizational Structure 120 The Role of HR Liaisons 120 Reliance on Direct Managers Rather than HR and Legal Experts 121 Poor HR Visibility into Employee Performance 121 Structural Challenges for the City HR Department 122 Inconsistency across the Organization in How the City Addresses HR Issues 122 4.3 The City's Policies Related to Workplace Violence Prevention 123 Recruitment, Hiring and Background Investigations 123 Code of Conduct 125 Grievances 126 Discipline 127 Termination of Employment 129 Substance Abuse, Drug Screening and Testing 132 Workplace Harassment 133 Employee Assistance 134 Privacy and Information Sharing 136 Criminal and Administrative Charges and Convictions 139 Resignation of Employment 141 Workplace Violence Prevention 142 Zero Tolerance 144 Weapons 145 Visitor Management 146 ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 13 Meeting with Difficult Employees 148 Termination/Separation Checklist 150 4.4 The Need to Establish a Workplace Violence Prevention Program 151 Leadership:The Importance of Championing Workplace Violence Prevention 151 Behavioral Threat Assessment:The Capability to Identify,Assess and Manage Risk 152 Threat Assessment Teams:A Critical Component of Behavioral Threat Analysis 153 Complaint Categorization:The Need for a Central,Standardized System 157 Training and Education:Workplace Violence Prevention Awareness 159 4.5 Survey Conducted of City of Virginia Beach Stakeholders 161 Survey of Building 2 Employees 161 Workplace Violence Issues 161 Employee Satisfaction and Safety 162 Survey of City of Virginia Beach Residents by People Element 164 The Value of Establishing a Public Advocate or Ombud 167 4.6 Community Forums and Employee Meetings:Out-of-Scope Issues Raised 169 Recommendations 171 SECTION 5 RECOVERY, RESILIENCY AND PREVENTION ON THE PATH AHEAD 178 5.1 Recovery and its Impact on Employees and Victims: Managing Future Challenges 180 5.2 Recovery and its Impact on City Services to the Community: Returning to Business 181 yECTION 6 APPENDICES • 182 Appendix 6.1 -Acknowledgements 184 Appendix 6.2-About the Review Team's Experts 185 Appendix 6.3 -Summary of Recommendations 192 Appendix 6.4 - List of Acronyms and Abbreviations 205 Appendix 6.5 -Questions Submitted by the Interdenominational Ministers Conference 207 Appendix 6.6 -Survey of Virginia Beach Residents by Third-Party Survey Firm 210 www.hillardheintze.com 14 meansmomm 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. p r A NOTE ON HOW WE REFER TO T 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. 0 2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 15 siumw 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 third- party 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. www.hillardheintze.com 16 Nimimilimmom 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. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 17 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. www h i l la rd h e i ntze.com 18 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 mass- casualty 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. 2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 19 osimoim 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 www.hillardheintze.com 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. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 21 inumow 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. www.hillardheintze.com 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. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 23 imismoms 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 all- hazards 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 www.hillardheintze.com 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 follow- through 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 ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 25 iimiNimom 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. www.hillardheintze.com 26 sis 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 City- owned 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. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 27 iimmimomm 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. www.hillardheinte.com 28 ismammownsim Accepts offer of position as Engineer at The Timeline Lewis and White May 2003 Below is a timeline that details key Resigns from Lewis and White. events in the subject's life prior to the attack,and what happened and when Accepts offer of position as Project Engineer on May 31,2019. at MSA Engineering. February 2008 Hillard Heintze interviewed Gets laid-off from MSA Engineering.An stakeholders,reviewed law individual close to the subject said he enforcement and Building 2 records, complained about the lack of a promotion evaluated the subject's work and and perceived racism. personal devices and their contents, Marries. and leveraged other sources to construct this timeline to the best of Accepts offer of position as Project Engineer our ability. Ill at Draper Aden Associates. Note: Unless otherwise specified, July 2008 the subject is conducting the actions Resigns from Draper Aden Associates. described. 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 2011 to 2015 From 1996 to 2010 February 2010 Accepts offer of position as Engineer II at April 1996-April 2002 City of Virginia Beach. Serves in the Virginia Army National Guard. Assigned to Army National Guard units in 2011-2017 Norfolk and Hampton,Virginia. Receives annual evaluation and is rated "Meets Standards." April 2002 Receives honorable discharge from the January 2012 National Guard. Purchases home in Virginia Beach. May 2002 September 2012 Graduates from Old Dominion University. Receives"Thumbs Up"Award. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 29 April 2014 Emails supervisor attesting that his Receives Excellence in Service Award. work was above average, but that his salary did not reflect that. May 2015 Receives Team Participation Award. 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. 201r. Management places subject on Performance April 2016 Improvement Plan for deficiencies in project Applies for and obtains Concealed Handgun management skills. Permit. Subject states he feels"singled out"for his July 2016 unsatisfactory work performance. Purchases H&K USP45C 45 ACP pistol. August 2017 Purchases JRC JRCV067138 45 Directs attorney to proceed with filing divorce. ACP carbine rifle. August 2016 Completes his Performance Improvement Plan successfully. Begins regularly visiting gun websites via his phone. Suppressor registration completed. September 2016 September 2017 Separates from wife. Divorce is finalized. First images of weapons appear on his phone. Texts somebody close to him that he"finally Purchases Glock 2145 ACP pistol. got my suppressor today." October 2016 December 2017 Purchases Bond Arms Backup Derringer 45 Submits Suppressor Transference ACP pistol. Certification. The frequency of the subject's December 2016 communications with his mother begin to Issue occurs regarding missing contractor decrease. checks on subject's project. 201-. February 2018 January 2017 Subject's communications with ex-wife Management letter documents subject's increase. mishandling of these checks. www.hillardheintze.com April 2018 Stops communicating with ex-wife. Receives"Thumbs Up"Award. June 2018 Purchases second Glock 2145 ACP pistol. January 2019 Uses Smart TV Guide to visit a news report July 2018 about the Orland Square Mall shooting. Receives written reprimand for poor March 2019 performance as well as Letter of Performance Expectations. Visits gun conversion kit websites. Submits verbal grievance to supervisor about April 2019 written reprimand. 3 Drafts work email on his perceptions of his professional relationships and stressors. Supervisor verbally responds to grievance. Drafts but never sends emails that reflect August 2018 irrational and suspicious beliefs. Receives"Improvement Required - PIP Required"annual evaluation due to poor 7 Browses Premier Body Armor website and performance. views body armor and ballistic plates. Submits written grievance to supervisor. 8 Views Level 3A ballistic body armor panels via his mobile telephone. Submits written grievance to Department 10 Receives email confirming delivery of Head to remove reprimand. purchased body armor. Complains in response to annual evaluation that he is discriminated against by being 12 Purchases Ruger rifle. assigned critical projects above his paygrade. May 2019 Drafts work email expressing concerns about 20 Searches on computer for maps of Building 2 being"sandbagged." and the Municipal Center. September 2018 23 Sets message on computer that he will be out Emails Department Head after the meeting. of office from May 24 to 28. States that he is clearly discriminated through 24 Purchases three rifle gun magazines and rifle project assignments. Requests again that the reprimand be removed. case. Is informed that the reprimand will remain. 28 Emails Contracts Unit asking to expedite payment for$3,027.48 contractor invoice, Elects to end his grievance and not to appeal for which funds have not been properly it to the Personnel Board. obligated. November 2018 29 Contracts Specialist emails back requiring justification for and additional information Stops communicating with mother. about the purchase order and directs subject ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 31 ammimmo to email City Procurement Officer with this request. Tb-„Da, • .the Attack: May 3 Emails Procurement Officer seeking assistance to resolve purchase order issue. Note: The timeline items in this section are based Procurement Officer leaves voicemail for on employee interviews,9-1-1 calls and subject about the purchase order issue, crime-scene details. Final determination of telling him that he has made an unauthorized the chronology of shootings and locations purchase and violated a City ordinance. cannot be made until the results of the Procurement Officer informs subject that she forensics examinations and scene will send him an email as well and asks him to reconstructions are available. call her back. 6:58 a.m. Procurement Officer emails subject that fiscal Leaves residence. policies have not been adhered to and procurement procedures have not been 7:16 a.m. properly followed on the matter,and that full Arrives at City's municipal complex. documentation will be required. 7:21:30 a.m. Replays the voicemail for supervisors. Swipes card for entry into Building 2 Ops/PU Emails supervisor on how he will respond to 2nd Floor Engineering North Hall. Procurement Officer's email. 7:23 a.m. Another employee receives pre-dismissal Starts up his work computer and checks his letter from supervisors.A Virginia Beach Outlook mail. Police Department(VBPD)officer is posted to Building 2 as a precaution. 10:00- 10:30 a.m. Conducts internet searches for Building 2 30 The other employee receives a termination maps,the ECCS and the Municipal Center letter and a supervisor escorts him out of Building Map. building. 10:31 a.m. Subject states he is too upset to meet with Emails supervisor his resignation and refers the Procurement Officer and will pay $3,027.48 from his personal checking to personal reasons. account to correct the error. 10:46 a.m. In the evening, places 54-second call from his Supervisor responds saying he hopes that the mobile phone to his desk phone. subject resolves his personal reasons and asks for confirmation that his last day will be In the evening, makes two personal calls - June 14. one to his ex-wife, in which he is apologetic in nature;the other to his mother,in which 10:49 a.m. he refers to his insomnia and problems with Supervisor forwards subject's resignation supervisors at work but is otherwise upbeat email to other managers and copies the in tone. subject. www.hillardheintze.com 10:52 a.m. 4:00-4:05 p.m. Subject swipes card for entry into Building 2 Enters South Building 2 entrance.Witness PU 2nd Floor East Engineering South. hears gunshots,sees subject with a gun in his hand walk into the building.Sees a man 11:25 a.m. bleeding on the ground. Responds to supervisor's email with email, "Thank you.Yes,that is correct." 4:00 p.m. -4:16 p.m. Shoots Mary Louise Gayle,Alexander Mikhail 11:23- 11:33 a.m. Gusev, Katherine Nixon, Michelle Langer, Sends routine work-related emails. Ryan Cox, Robert Williams,Christopher Rapp,Tara Gallagher, Laquita Brown, Richard 11:58 a.m. Nettleton,Herbert Snelling,Joshua Hardy. Swipes card for entry into Building 2 Ops/PU 4:05:56 p.m. 2nd Floor Engineering North Hall. Swipes card for entry into Building 2/PU 2nd 12:08 p.m. Floor East Engineering South. Swipes card for entry into Building 2 Ops/PU 4:06:32 p.m. 2nd Floor Engineering South. First 9-1-1 call is received(call duration is 1:00 p.m. 4:59).Caller reports seeing body on ground Swipes card for entry into Building 2 Ops/PU with blood,hears shots,sees black man in 2nd Floor Engineering South. blue shirt running into building, hears more shots near his office and ends call. 1:04 p.m. 4:08 p.m. Subject and two co-workers leave Building 2 Call is dispatched regarding man in front of to travel in car for routine inspection of three Building 2 who is possibly shot. project sites. 1:06-3:06 p.m. First suspect description is dispatched. Refers to Hispanic man on 2nd floor. Dispatcher Subject is at project sites with co-workers hears gunshots on the call in the background. and in transit. 4:08:13 p.m. 3:11:49 p.m. Swipes card for entry into Building 2 Ops/PU Swipes card for entry into Building 2 Ops/PU 2nd Floor/West Side Business Unit. 2nd Floor Engineering South. 4:10:10 p.m. 3:55 p.m. Second suspect description is dispatched. Sends routine work-related email. Refers to a bald black man with a blue polo shirt. 3:57 p.m. Subject is observed brushing teeth in 2nd 4:10:19 p.m. Floor bathroom. First police personnel enter Building 2. K9 Units announce arrival. Plainclothes detectives report that they are on-scene.Air J 2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 33 is restricted. Dispatch identifies that shots 4:22 p.m. are being fired on 2nd floor. HR Communications Coordinator sends email to all City employees marked,"Importance: 4:11 p.m. High"with the subject, "URGENT:Shelter in The Virginia Beach Fire Department arrives Place @Mun. Ctr. Until further notice." on scene pursuant to dispatch. The message reads,"We have an active 4:11 p.m. shooter at the Municipal Center,supposedly Fire alarm sounds in Building 2. in or around Bldg.2. Please shelter in place. Lock your doors.We'll communicate when 4:12:40 p.m. it's safe to leave.Thank you." Swipes card for entry into Building 2 Ops/PU 4:26 p.m. 2nd Floor/West Side Business Unit. SWAT team reports it is inside Building 2. 4:13:49 p.m. Third suspect description is dispatched. 4:43 p.m. Refers to a six-foot-tall black man with a blue First transmission that subject is in custody. shirt and a gun with a silencer. 4:44 p.m. 4:15 p.m. Second transmission that subject is in The VBFD establishes Command Post. custody. 4:15 p.m. 4:54 p.m. The VBPD establishes on-scene commander. HR Communications Coordinator sends email to all City employees marked, "Importance: 4:15:07 p.m. High"with the subject,"URGENT:Continue Subject swipes card for entry into Building 2 to Shelter in Place at Mun. Ctr." 2nd Floor/ East Side/ Engineering South. The message reads,"For those at the 4:18 p.m. Municipal Center,please continue to shelter in place.We'll let you know when it's safe to All available Special Weapons and Tactics unlock doors. Even then,there are roads (SWAT)team members are responding to blocked which may keep everyone here for a Building 2. while. But,we'll keep you posted. Please be safe!" 4:19 p.m. The name of the subject is dispatched. 5:30 p.m. Responders attempt to establish the Family 4:20 p.m. Reunification Center(FRC)at United Initial broadcast that an officer is shot. Methodist Church, but the Church is occupied,and the Center is established at 4:21 p.m. Princess Ann Middle School. Dispatch identifies that the subject is isolated and shooting actively on east side of 2nd 5:32 p.m. floor. Subject is pronounced deceased at Virginia Beach General Hospital. www.hillardheintze.com 5:34 p.m. 9:00 p.m. Building 2 is secured. No additional Death notifications begin. wounded are in the building. 12:00 p.m. 5:36 p.m. Last local death notification is completed. Subject's backpack and additional firearms are found on 2nd floor. 1:00 a.m. Final death notification completed out of 5:42 p.m. state by assisting law enforcement agency. Explosive detection K9s begin sweeping parking lot. I! v 'wing be ' c,., 5:43 p.m. Subject's vehicle is located in parking lot in June 2,2019 front of South entrance. FRC closes. 5:55 p.m. HR Communication Coordinator sends email Family Assistance Center opens at Princess to all City employees marked,"Importance Ann Rec Center. High"with the subject,"All Mun.Ctr. June 9,2019 employees can leave except for Bldg.2 employees." Family Assistance Center closes at Princess Ann Rec Center. The message reads,"Today's situation is ongoing but the suspect is in custody. It is now safe for Municipal Center employees tb 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." 6:09 p.m. Explosive sweep of Building 2 begins. 6:00 p.m. FRC is opened at Princess Ann Middle School. 7:18 p.m. Explosive sweeps of Building 2 are completed. 7:19 p.m. Transmission that Building 2 is ready for forensics teams and detectives. 6 2019 HILLARD HEINTZE T - . -.f` i ,ea'x's te` _ - _ as-r I Ai ...ow.OW ,,,,,,,,,,,,, ,,,. • v a-WI P7 tt' '''''' -4 Z .1 - Section 1 An Examination of the Attacker and His Background The City of Virginia Beach: An Independent Review of the Tragic Events of May 31, 2019 HILLARDIIPHEINTZE A JENSEN HUGHES COMPANY 36 SECTION 1 AN EXAMINATION OF THE ATTACKER AND HIS BACKGROUND SECTION 1 - AN EXAMINATION OF THE ATTACKER AND HIS BACKGROUND To understand what happened on May 31, 2019, we focused intensively on the individual who took so many lives - his past, any criminal or civil litigation history and known personal and workplace behaviors leading up to the mass shooting. Our analysis was instructed by our experience conducting both direct violence risk psychological evaluations and indirect threat assessments of individuals who have displayed concerning behaviors to this effort. An Important Note on Information Requests Our data requests to the City of Virginia Beach were We were given access to the personal digital supported and we received potentially critical information information that was in the possession of the relevant to this effort. Specifically.we requested City late into our review. Other data obtained information from the Virginia Beach Police Department and held by the Federal Bureau of Investigation shortly after our initial engagement regarding the seizure was not shared and may have relevance to our and analysis of the subject's work telephone,work email. analysis. However, based upon our interviews, home security camera files, his personal mobile phone, access to work and personal emails, certain personal computer and other personal digital information digital files and other sources of information,we and effects. were able to arrive at our analysis below. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 37 1.1 Personal Background The subject was born on October 15, 1978 as We found little information regarding the DeWayne Antonio Hamilton and died on May subject's childhood. He lived in Virginia 31,2019 in an exchange of gunfire with law Beach and the surrounding area for most enforcement personnel responding to the of his life,apart from when he joined the attack in the City of Virginia Beach's Building 2. Virginia Army National Guard in 1996 and served as an army reservist.This training His mother was 19 years of age,and his father took place at Fort Sill,Oklahoma over the 22,at the time of his birth.The subject's course of a few months. parents ended their marriage in the mid-1990s. His mother subsequently remarried. In 1998, He was married from February 2008 until the subject changed his last name from September 2017,when the couple Hamilton to Craddock, his step-father's divorced in Chesapeake,Virginia. surname. 1.2 Court Records Federal and State Criminal Court Records We conducted a combination of on-site and online research for criminal records associated with the subject in relevant federal,state and county jurisdictions.1 We also sent public records requests to local law enforcement agencies in the following key jurisdictions with which the subject was associated. Chesapeake,Virginia Hampton,Virginia Newport News,Virginia Norfolk,Virginia Virginia Beach and York County,Virginia Comanche County,Oklahoma Durham County, North Carolina 1 There are limitations on this search.Not all states allow for a statewide search and must be searched in separate county- level jurisdictions.Certain states provide information on arrests,while other states provide information on felony and misdemeanor convictions,and some only on felony convictions.The date coverage also varies by state. www.hillardheintze.com 38 SECTION 1 AN EXAMINATION OF THE ATTACKER AND HIS BACKGROUND These queries included requests for any public information related to arrests,calls for service or other records in which the subject was listed as the complainant or in which the subject was mentioned in an incident report.We queried the records repositories listed in the table below. Criminal Records Table 1:Criminal Records National Federal Criminal We did not identify any criminal cases naming the subject as a Records defendant during a search of federal courts nationwide. State Criminal Court We did not identify any records. Records National Sex Offender A search of sex offender public registries indicates that the Public Registry subject was not registered as a national or state sex offender. International Infractions We did not identify records for the subject in a search of national and international watch lists. Traffic Records Table 2:Traffic Records September 8,1997 Virginia Beach,VA Reckless driving-99 mph in a 55-mph zone February 20,2000 Hampton,VA Speeding-74 mph in a 55-mph zone May 21,2000 Nottoway,VA Speeding-71 mph in a 55-mph zone February 19,2003 Hampton,VA HOV violation November 8,2005 Northampton,VA Speeding-63 mph in a 45-mph zone May 20,2013 Virginia Beach,VA Violation related to tinting films,signs,decals and stickers on windshields or windows O 2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 39 Civil Filings Federal,State and County Civil Court Records We conducted a combination of on-site and online research for civil records associated with the subject in relevant federal,state and county jurisdictions.The records repositories we queried are included below. National Federal Civil Records We did not identify any cases naming the subject as a party in federal courts nationwide. State Civil Court Records Other than his divorce detailed below,we did not identify any litigation naming the subject as a party. As with our search for criminal records,our search for litigation records covered key jurisdictions with which the subject was associated. Table 3: State Civil Court Records August DeWayne Chesapeake, The subject petitioned for a divorce from his 21,2017 Antonio Virginia wife,stating that the two had been separated Craddock v. Circuit Court since September 2016,with the subject living in Virginia Beach and his wife in Durham,North Carolina.The couple had been married in Virginia Beach in February 2008.A final decree Case No. of divorce was entered on September 29, CL17-2728 2017.The couple's divorce settlement stated that the subject would give his ex-spouse $25,000,and the remaining assets and liabilities were split between them. www.hillardheintze.com 40 SECTION 1 AN EXAMINATION OF THE ATTACKER AND HIS BACKGROUND 1.3 Employment History and Workplace Interactions The subject began his professional engineering career in May 2002. He held four jobs before being hired by the City of Virginia Beach in February 2010,with the longest of these lasting five years. In 2008,after being married that February,he resigned from one employer and was unemployed for a period of four months. Early in his tenure with the City of Virginia Beach,he was recognized for his work through various incentive awards,and his annual performance evaluations through 2017 stated he"Meets Expectations."According to many who knew him,he did not develop any close friendships at work and was seen as quiet and reserved. Work History Table 4:Work History`' April 1996-April 2002 Served in the Virginia Army National Guard.During his time serving in the military,he was assigned to Army National Guard units in Norfolk and Hampton,Virginia.Honorably discharged. May 2002- May 2003 Project Engineer at Lewis and White Associates.Resigned. May 2003- February 2008 Project Engineer at MSA Engineering.An individual close to the subject said he complained about the lack of a promotion and perceived racism.Laid off. February 2008-July 2008 Project Engineer III at Draper Aden Associates.Resigned. November 2008-January 2010 Engineer II for the City of Newport News,Virginia.In November 2009,a Supervisor with Newport News gave the subject an excellent evaluation.Subject recommended for salary increase.Resigned. February 2010 Hired by the City of Virginia Beach. 2 Primary source for this content was the Virginia Beach Police Department;prior employers had no comment relative to the subject's work performance. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 41 Performance Evaluations At the start of the subject's employment,and His 2017 and 2018 Annual Performance over the seven-year period between 2010 and Evaluations indicated some challenges for him 2017, his performance evaluations were in the workplace and are discussed in more categorized as"Meets Performance detail below. Standards." Beginning in 2018,the City changed the term to"Meets Performance Expectations." Recognitions and Awards The subject received the following Department of Public Utilities recognitions and awards.After 2015, the pace of recognition slowed. He only received one award in the period between January 1,2016 and May 31,2019. Department of Public Utilities Recognition and Awards Table 5:Department of Public Utilities Recognition and Awards September 26,2012 "Thumbs Up" Subject was project manager;went above and beyond on a project. April 11,2014 "Excellence in Subject was project manager;went above and Service" beyond on a project. May 18,2015 "Excellence in Subject was project manager;went above and Service" beyond on a project. December 28,2015 "Class Act" Subject was project manager;was able to manage a project despite significant barriers presented by a challenging citizen. April 18, 2018 "Thumbs Up" Provided HR staff a tour of Public Utilities Operations. www.hillardheintze.com 42 SECTION 1 AN EXAMINATION OF THE ATTACKER AND HIS BACKGROUND 1.4 Press and Social Media The subject maintained a relatively low press profile.We did not identify any adverse press coverage for him before May 31,2019.We also did not identify any social media profiles maintained by the subject. 1.5 Risk Factors Identified in the WAVR-21 Framework We applied the Workplace Assessment of Violence Risk(WAVR-21,3rd Edition)to this analysis.The WAVR-21 is a scientifically-based structured instrument for organizing risk and protective factors to assess targeted workplace violence risk.' Risk factors are circumstances,characteristics or behaviors associated with an increased likelihood that an individual may choose to act aggressively or violently. Protective factors are elements that decrease this likelihood and serve as buffers against risk. For example,protective factors include having positive interpersonal relationships with family and friends, being motivated to avoid negative legal consequences and seeking out mental health care and treatment if needed.While the subject exhibited several risk factors, he did not exhibit any protective factors. About Workplace Assessment of Vo ence Risk (WAVR-21, 3rd Edition) The WAVR-21 - Workplace Assessment of Violence Risk - is a 21-item coded instrument for the structured assessment of workplace and campus targeted violence risk. First published in 2007 by its co-developers, Drs. Stephen White and Reid Meloy,the WAVR-21 reflects the authors' extensive case and forensic experience as well as a thorough review of the research and clinical literature.The WAVR-21 is now in its third edition, published in 2016. The revised V3 Worksheet and Grid coding forms are appropriate for use by both clinical and non-clinical professionals.typically involved in threat assessment and management endeavors. Source:www.wavr2l.com/the-wavr-explained/ 3 Risk factors identify items that may increase risk,whereas protective factors may mitigate risk. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 43 Job Performance Issues in 2017 As 2016 came to a close,the subject began to encounter challenges at work regarding maintaining appropriate financial and contracting records and engaging with citizens and contractors. In January 2017,the subject received a letter from his supervisor about an incident that involved his not depositing a$50 check from a contractor in a timely manner.Additional investigation determined that the subject allowed a total of 13 checks to surpass their"stale date"of 180 days from the date of issue.The supervisor directed him to contact the firms and request new checks,which the subject did. The supervisor told the subject that it was not a letter of reprimand, but rather a letter to record the incident,also known as a record of incident.The supervisor explained that this was a lesser corrective standard and not considered discipline; however, it was considered serious and required that the subject take appropriate corrective action. In June 2017,the subject was placed on a Performance Improvement Plan(PIP)that began on June 20,2017 and ended successfully on August 15, 2017. Specifically, he was placed on the PIP for deficits in the following categories:Working Relationships, Project Management and Responsiveness to Customers. Despite earning a "Meets Expectations"on several domains for his 2017 Annual Performance Evaluation,the subject was rated as"Improvement Required"in the following categories. Professional and Management Skills Demonstrated:This involved mishandling contractor checks. Working Relationships,Communication and Coordination with Other Departments:The subject made inappropriate remarks to coworkers, both verbally and in writing.Additionally,his supervisor cited him for occasionally demonstrating insubordination with regard to specific instructions from management. Commitment to Exception Customer Service:The subject avoided or delayed responses to citizens regarding his projects. Although the subject had successfully completed the earlier Performance Improvement Plan,his supervisor noted that he was unable to maintain an acceptable level of performance with respect to his project management duties and did not exhibit good judgment.On July 12,2018,the subject's supervisor issued him a Written Reprimand for Poor Performance. In sum, his supervisor cited him for failing to perform assigned duties as an Engineer III.The supervisor reminded the subject that they had had several prior discussions with him to address his deficits. www.hi lla rdhe intze.com 44 SECTION 1 AN EXAMINATION OF THE ATTACKER AND HIS BACKGROUND The subject's supervisor also prepared a Letter of Performance Expectations to ensure a shared understanding regarding the subject's performance.This letter was sent on July 12,2018. Items addressed included using effective oral/written communication skills,exercising good judgment, meeting project deadlines and dealing effectively with the public.These were the same factors for his earlier PIP.The letter stated that this was not considered a disciplinary action. In his 2018 Annual Performance Evaluation,on August 22,2018,the subject received an "Improvement Required - PIP Required"rating.Specifically,the following domains were rated as "Improvement Required"in the following categories. Working Relationships with Coworkers,Supervisors,the Public and Outside Contacts: It was noted that appropriate work methods,such as timely engagement with customers,were not always implemented. Knowledge of Field:The supervisor stated that the subject's performance did not reflect completeness,accuracy and timeliness as previously addressed in the Letter of Performance Expectations. Compliance with City and Departmental Policies and Procedures:The subject's supervisor cited him for not keeping the public accurately informed as to the schedule and intent for some projects,as previously addressed in his Letter of Performance Expectations. Conflict Resolution:The supervisor cited him for not clearly informing a citizen of a project's parameters,as previously addressed in his Letter of Performance Expectations. Commitment to Exceptional Customer Service:The subject's supervisor noted that he had not been consistent in conveying to the public that he was the principle authority for his projects,and that some projects needlessly escalated above his level as a result.This was previously addressed in his Letter of Performance Expectations. Oral and Written Communication: His supervisor indicated that the subject struggled to respond clearly to a citizen email complaint about a project. He had enlisted the help of a supervisor and a bureau manager to craft a response.This was previously addressed in his Letter of Performance Expectations,highlighting that he was failing to engage with customers and contractors in a timely manner. Management did not issue him a second Performance Improvement Plan, but rather referred to the previously issued Letter of Performance Expectations to ensure a shared understanding of his deficits in performance. This intervention was intended to be used as a tool to improve his performance. After being presented with this 2018 Annual Performance Evaluation,the subject typed a response under the employee comments section. He initially wrote,in part: 0 2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 45 "I hold my position with the City of Virginia Beach in Public Utilities Design&Construction in high regard and I appreciate those opportunities where I get to express my creativity through design. I am also happy to work for an organization that believes in diversity, inclusion,and the ethical treatment of its employees and is willing to hold individuals accountable who fail to meet these requirements." He then hand-wrote an additional comment,which stated: "I am in disagreement with the assigned scores and accusations. I feel that I am being placed at a different level of scrutiny than my peers. I [sic] clearly being asked in some cases to meet a level of expectation that did not exist with the performance of my job.What this means is that anything can be unfairly called into question." The next day, he sent an email to his superiors and included his personal Gmail account in the CC line. In part, he wrote: "I would like to revise my remarks on the Performance Evaluation Form for Employee Comments. I felt a little under the gun and I have developed a more appropriate response. I know I have an additional(30)days to finalize the document. My revised comment is listed below. Response: I do love being a City employee,but I am clearly being blindsided and railroaded in this review which is directly related to the recent reprimand that was issued simultaneously. Please refer to my grievance in response to that reprimand. Up until a month ago I was completely unaware that any issue exists with my performance.These allegations are trumped up and exaggerated. Below are my quick responses to the claims." He then outlined a detailed seven-point response spanning 1% pages.As part of the HR process,he initiated the formal grievance procedure on a departmental level. He completed thee steps in the grievance process,but after initiating Step 3 - Department Director, he ultimately chose to end his grievance process in September 2018 and did not elect to appeal his grievance to the Personnel Board. www.hillardheintze.com 46 SECTION 1 AN EXAMINATION OF THE ATTACKER AND HIS BACKGROUND During these discussions regarding his 2018 Annual Performance Evaluation,the subject communicated with his supervisor and managers that he felt he was not being treated fairly and was being held to higher standards than others at his paygrade. Job Performance Issues in the Days Before the Attack The subject was working toward complying with the expectations identified in his 2018 Annual Performance Evaluation,which would have been addressed upon his next review. On May 29,2019,the Finance Officer in the Business Division received an invoice that the subject submitted for work performed for a contractor or vendor totaling$3,027.48.A few minutes later,the Finance Officer received a purchase acquisition for the contractor or vendor for$3,027.48 on work the subject authorized in December 2018.The Finance Officer perceived this as a serious violation of fiscal guidelines because the work was clearly unauthorized and performed before funding was approved for the work. The Finance Officer reported that the subject had a pattern of not following fiscal policies and procedures. He noted that the subject was the engineer with the most fiscal violations and that he often submitted his documentation late.The Finance Officer denied the subject's purchase acquisition funding request.The Finance Officer told his staff to inform the subject that he had violated multiple sections of the Virginia Public Securities Act,which is a terminable offense,and that the subject would have to seek special permission from the City Procurement Officer to get the funding request approved. A supervisor tasked a coworker assigned to Public Utilities Contracts to inform the subject that his actions in this matter were in violation of the law and his employment was subject to termination.This coworker stated that he did not tell the subject this,but rather sent an email to the subject explaining that he needed to provide full documentation regarding the invoice and would be required to seek approval from the City's Procurement Officer. Following this email,on May 29,2019,the subject sent an email to the City's Procurement Officer requesting assistance with expediting the payment of the purchase order in an effort to avoid incurring associated late fees.The Procurement Officer responded a few hours later via email and left him a voicemail informing him that(1)he signed a contract with a vendor but was not an authorized representative of the City,(2)contracts need to be reviewed by the legal department and(3)his conduct violated a City ordinance. O 2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 47 On May 29,2019,an employee in the Procurement Office contacted an attorney in the City Attorney's Office about a work authorization totaling$12,115.31 for a contractor or vendor that was signed by the subject.The Procurement Office was deciding how to process the document after routinely receiving it from the Public Utilities Business Unit.The Procurement Office employee sought guidance on the best way to proceed.The attorney advised the Procurement Office employee that the work authorization signed by the subject could be processed, but that the preference is for work authorizations to be What Are Prohibited Behaviors? signed by a City Procurement Agent. Neither the Procurement Office employee Examples of prohibited behaviors include nor the attorney had any contact with the the following: subject regarding the$12,115.31 work Direct threats or physical intimidation authorization. No email messages were Implications or suggestions of violence located showing the subject had any Bullying contact with the Procurement Office or Stalking City Attorney's Office regarding this work Assault of any form authorization. Physical restraint or confinement Dangerous or threatening horseplay A supervisor reported that the subject had Blatant or intentional disregard for the a negative reaction to the Procurement safety or well-being of others Office's voicemail regarding the$3,027.48 Commission of a violent felony or purchase order and became very upset; misdemeanor on agency property however,the supervisor stated that the Any act that a reasonable person would unit management team minimized the issue perceive as constituting a threat of and told the subject they would handle it violence on his behalf. Loud,disruptive, or angry behavior or language that is clearly not part of the The subject reportedly sought further typical work environment advice from a coworker after-hours on Possession of weapons of any kind on May 30. He told this coworker that he agency property,including parking lots had been very busy the prior year shortly and other exterior agency premises,or before the Christmas holiday and had while engaged in agency activities in forgotten to get the$3,027.48 purchase other locations or at agency-sponsored order. He said that,once he realized his events, unless such possession or use is error,he had tried to request the purchase a requirement of the job order but a coworker informed him he was too late and that the purchasing Source: Interagency Security Committee. Violence in the Federal Workplace.2019 department was"giving him a hard time." www.hillardheintze.com 48 SECTION 1 AN EXAMINATION OF THE ATTACKER AND HIS BACKGROUND During their conversation, he told the coworker about his mistake and that he had 30 days in which to get it addressed. He told his coworker he had sent an email to another employee in Public Utilities Contracts requesting assistance with the matter. He said he subsequently learned three weeks later that this employee claimed to have never received his email request for help on this matter.This left him approximately one week in which to rectify getting the purchasing order.A search of the subject's emails failed to locate the email he claimed he sent.Our review of the subject's emails did not identify contact with either that Public Utilities Contracts member or any other member of that team until May 28,2019. The same coworker said the subject was very upset by this news and encouraged him to address this directly and in-person with What Are Concerning Behaviors? the Purchasing Department.The coworker While we can't predict targeted violence, said the subject said he was too upset to every employee needs to be aware of have an in-person meeting and discussed behaviors in coworkers that could paying for this error from his personal potentially escalate into a workplace checking account as a means to correct his violence incident if not reported. Examples oversight. of these include the following: This purchase order was not resolved before Excessive use of alcohol or drugs the May 31 incident. Unexplained absenteeism,change in behavior or decline in job performance A supervisor reported that this incident Depression,withdrawal or suicidal involving the purchase order would not comments have led to the subject's termination. In fact, Resistance to changes at work or the supervisor reported that his persistent complaining about unfair performance for the year was on a positive treatment trajectory and he was going to receive a Violation of company policies "Meets Expectations"on his Annual Emotional responses to criticism, mood Performance Evaluation scheduled for swings August 2019.The employee review did not Paranoia occur,there was no draft of the review and Source:National Safety Council. the subject was not aware of the upcoming https://www.nsc.org/work-safety/safety- performance evaluation. topics/workplace-violence On the evening of May 30,2019,the subject placed a call from his mobile phone to his office phone that was less than a minute in duration. 0 2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 49 Although the subject did not engage in routine contact with his mother and had failed to respond to any of her communications for several months, he did call her on May 30,2019,the night before the attack. He disclosed that he was suffering from insomnia,was only getting three to four hours of sleep per night and that he had started taking a prescriptive sleep aid.4 He also complained about his supervisors at work,but she described him as otherwise upbeat and future-oriented in the discussion. On the evening of May 30,2019,he also called his ex-wife,with whom he had not spoken for some time. During this conversation,which lasted about 40 minutes,the subject was amicable and stated that he wanted to remain friends. Weapons Skill and/or Access The subject served in the Army National Guard and received basic and advanced individual training. He was detailed to the Battery A 1st Battalion 111th Field Artillery Regiment in Hampton,Virginia and received an honorable discharge as a Specialist - Cannon Crew Member. Starting in 2016,the subject began to purchase firearms,acquiring at least six. He regularly went to local shooting ranges to practice. It was reported he mostly went alone or with a family member. He also went with a coworker who described him as being both comfortable and proficient with his firearms. Chronological Weapons History Table 6:Chronological Weapons History April 20,2016 Obtained a concealed handgun permit July 2,2016 Purchased a Heckler&Koch USPC 45 ACP pistol July 21,2016 Purchased a Just Right Carbine's carbine rifle August 21,2016 Began regularly accessing gun websites via his cellular telephone September 13,2016 Purchased a Glock 2145 ACP pistol 4 We do not know whether prescription medication was recovered by the VBPD or the FBI. www.hillardheintze.com 50 SECTION 1 AN EXAMINATION OF THE ATTACKER AND HIS BACKGROUND October 18,2016 Submitted Suppressor Transference Certification August 29,2017 Suppressor registration completed September 6,2017 Told someone close to him that he"finally got my suppressor today" December 19,2017 Purchased a Bond Arms Backup Derringer 45 ACP pistol June 8,2018 Purchased a second Glock 2145 ACP pistol April 7,2019 Browsed Premier Body Armor's website and viewed body armor and ballistic plates April 8,2019 Viewed level 3A ballistic body armor panels via his cellular telephone April 10,2019 Received email confirming delivery of purchased body armor April 12,2019 Purchased Ruger rifle May 24,2019 Purchased three rifle gun magazines and a rifle case The VBPD reported that the subject had ordered a bullet-resistant vest from an online purveyor and also owned a collection of knives. Violent Preoccupations A review of the subject's personal cell phone revealed that he conducted at least five queries to websites that contained news about mass shootings between May 2018 and May 2019.On January 21,2019, he specifically clicked on a news story about a mall shooting in Orland Park, Illinois. He also had other cell phone searches that coincided in time with multiple casualty acts of violence,based upon the dates he accessed news sites. On May 21,2018,the subject clicked on a CNN news website that included coverage of a Texas school shooting;on September 22,2018, he accessed a Washington Post website that discussed two separate shootings in the Washington DC area; on January 21,2019,he clicked on an ABC7 Chicago news story about the Orland Square Mall Shooting;on March 8,2019,he viewed content on the CNN website and one of the stories on that website was on a triple shooting in Willowbrook,California; and,finally,on May 4,2019, he viewed CNN's site that included a story about a shooting at the University of North Carolina at Charlotte. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 51 Pre-Attack Planning and Preparation We identified the following records on the subject's work-issued computer and personal cell phone and found them to be relevant.As noted earlier,our access to his personal devices was limited due to the ongoing forensic analysis by criminal investigators. Our analysis is based on facts known to date. On May 20,2019,the subject searched for maps of Building 2 and the Municipal Center campus. On May 23,2019,he set up an automatic out-of-office email reply and indicated he would be out of the office on May 24 and return to work on May 28,2019. His movement during this time was not available to the team,so it is unclear what,if any,of his time off was related to pre-planning activities. On May 31,2019,between 10:00 and 10:30 a.m., he searched for maps of Building 2, Emergency Communication&Citizen Services(ECCS)and the Municipal Center building map.At 10:31 a.m., he sent a resignation letter to his supervisor via email."I want to officially put in my(2)weeks' notice to vacant[sic] my position of Engineer III with the City of Virginia Beach. It has been a pleasure to serve the City, but due to personal reasons I must relieve [sic] my position." His supervisor responded by email at 10:46 a.m.that he hoped the subject would resolve his personal issues and asked to clarify if the subject's last day would be June 14,2019.The subject replied, "Thank you.Yes,that is correct." The subject maintained a series of emails that provide insight into his perception of being treated unfairly by his employer. For example, in one draft email, he described how one project interfered with his vacation time and asked if this would make him eligible for on-call pay. He also sent an email requesting a salary evaluation,believing he deserved an increase due to the fact that recent projects he was assigned were crucial,and therefore should be assigned to an Engineer IV. The subject felt that he was not being properly recognized for his work. In another undated draft email,he wrote: www.hillardheintze.com 52 SECTION 1 AN EXAMINATION OF THE ATTACKER AND HIS BACKGROUND "It's been stated that I have all of Public Utilities most crucial projects. How can we make the department more fair and equable [sic]...Their[sic]seems to be dual standards when it comes to recognition and rewards.At one point I had [employee's name has been redacted] close my door and tell me that I was one of the best members of the staff and then I have almost no recognition.On the other hand,I see others receiving awards for volunteering for a few hours....I feel like I'm taking on a lot of liability with no reward or even acknowledgement, I mean that in comparison with other engineers at my level.Why don't get to select the consultants that I work with?" Anger Problems We did not find evidence that the subject was physically aggressive with coworkers or others prior to the May 31,2019 incident. Early rumors indicated that the subject had been involved in a physical altercation at the worksite.Several employees we interviewed referred to this as a factual, known occurrence. Our review determined that this was an unfounded rumor and the subject did not engage in this behavior.' However,the subject's draft emails on his work email account confirm he had real or perceived grievances toward his employer,and specifically involving managers and employees with whom he worked on a regular basis. Irrationally Suspicious Beliefs Some individuals we spoke with identified certain behaviors or actions of the subject as either "paranoid"or associated with"obsessive-compulsive"behavior.We found no record of the subject seeking mental health treatment or having been subject to clinical evaluation. An individual close to the subject described him as shy,introverted and uncomfortable around people. This individual described him as having the type of personality that believed everybody was against him and characterized him as"paranoid."According to the individual,in one instance,while at a ' There was another employee who was well known within the workplace for concerning behaviors.The early statements that the attacker was engaged in a physical altercation were determined to be the actions of this other employee whose job was terminated on May 30,2019. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 53 restaurant,the subject believed other patrons,who were strangers to him,were talking about him and wanted to hurt him.This person stated that the subject"struggled mentally." He installed at least three closed-circuit television(CCTV)cameras at his residence. He placed them on the interior of his residence facing outwards. It is not clear if he did this as a preventive security measure or for another purpose. He reported his vehicle sustained damage while in the shared parking lot of his residential building. Individuals who exhibit paranoid traits can and do use CCTV to monitor their environment;therefore,it is possible the cameras served to relieve his reported feelings of paranoia. Workplace Behaviors Some of his coworkers described him as a very private person.Others described him as disciplined, organized and,at times,inflexible.Still others characterized his behaviors as consistent with those suffering from obsessive-compulsive disorder- referencing,for example,that he brushed his teeth in the workplace restroom every day at the same time.Some coworkers noted that he could be distant and reserved while some found him to be engaging.All emphasized that most of their interactions with him were about work duties rather than personal matters.We located several email threads relating to his personal life in which he discusses with two coworkers that he was getting divorced.As outlined above,the subject separated from his wife on or about September 6,2016. In 2017, his wife moved to North Carolina and the divorce was finalized in September of that year. Another individual close to him reported that he was frustrated about management passing him over for a promotion and choosing those he felt had less time on the job. He believed race played a role; however, no evidence suggested that he had formally applied for a promotion or for another vacant position within the City of Virginia Beach.We did not find any formal grievances,other than the departmental grievance that was voluntarily ended in September 2018,or workplace complaints filed by the subject. Resignation The subject learned that a manager had discussed his resignation with others when a coworker asked him about his departure from the City of Virginia Beach.One source reported that the subject became "very upset"about this disclosure of his resignation to others. Another coworker who spoke with the subject on May 31,2019 said he did not seem to have a negative reaction regarding coworkers knowing he had resigned.This coworker inquired about the www.h illardheintze,com 54 SECTION 1 AN EXAMINATION OF THE ATTACKER AND HIS BACKGROUND subject's future plans and said the subject told him he wanted to take some personal time off before looking for new employment. This coworker said the subject shook his hand and thanked him because he listened to and supported him while he was getting divorced. He reported that the subject became somewhat emotional during this meeting and teared up before leaving his office. Work Emails The scope of our people don't fight their hardest because they wort or have a comfortable analysis included the lead. They tight their hardest when they are desperate for change,when subject's emails. they are at a tremendous loss,feed up,pissed off,near defeat. That is why Most were routine in they send employees to fight for them their hardest on their way out. nature; however,as fighting hard usually cannot be sustain. The harder they fight the more noted earlier,there rcmifortable you should feel. It means they are near personal defeat. were emails on his work computer that 6 months on and 6 months off(3/15 9/15) April - Oct on Oct -April off he drafted but never sent.These emails Now the pattern is to first ingratiate new or remote employees(2 or so shed light on how he contacts)and then have them reject you. Same as usual,but they are may have perceived running out of employees to reject you. Generally rejection is the stressor his professional after making you fatigue through sleep deprivation. relationships and how he may have Shock>When information is delivered(or used against you)by an unexpected chosen to cope with source these stressors.The -the surprise is that they are revealing they that are an enemy and the surprise emails reflect of this reality sparks anger which is then assumed to be a loss. irrational and -In others the quicker we can piss you off the higher the emotional feedback suspicious beliefs. which in turn we can then reinterpret(but it is still a lie) -We want to interpret your emotions for you .>lie to you in order claim The following are recognition for emotionally impacting you. screenshots of an email the subject toss>Betrayal of a relationship(recent or established) usually at its end Or wrote dated April 3, during a transition(no witness approach) 2019. -like shock,it's the surprise factor that is intended to cause a sharp emotional response which then they will lie about. -Awareness of a threat is only the first step > not defeat ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 55 Stress Test Shame, Threaten, Reject to Excite Stress > excite paranoia and panic = stress -means that they really are powerless to take real action (you don't threaten when you actually plan to take action, you just do it usually by surprise) They have been defeated repeatedly— baseline attack to show they haven't given up even though they want to or would chose to (losers) In fact losers that can't stop playing the game which makes them hateful losers (you win). They want to upset you, but they themselves are upset (you win) Harrassment Protocol < .1 Party Line, Preparatory Command, Key Word assault update on current events by listening to a choreographed assault (previous harassers to bridge), attention getter, announcement of key words www.hillardheintze.com 56 SECTION 1 AN EXAMINATION OF THE ATTACKER AND HIS BACKGROUND Solution: get mad early...enough to give rise the physical attributes of stress (which will normalize them during and after the 15 min harassment) New objective: Frustration. Harass until there is a physical acknowledgement of a threat (aka stressed) This is generally paired with lack of sleep the proceeding night which creates a vulnerability for heart failure If physical reaction is the goal then (look for stressers near physical examinations) documentation of increased blood pressure. Why? Heart attack? Normal is 120/80 New strategy: Say to each other what your too afraid to say to him deniability Key times: 8-8:15am, 11:25-11:40am,4:25-4:40pm Harass you so that you will chose not to participate in work/social events (exclusion) Acknowledgement Words F:cho Writes Hai rassrnent Woo.. Method 1)Pre-Argument, 2)Thought Suggestions ('), 3)Attack on Acknowledge (also turn-up or down the thermostat) 8:00-8:30, 11:00-11:30, 1:30-2:00,4:00- 4:30 Approach 1)Setup>ptss you off, 2)To make you think your weak/Insecure, 3)At this point you're ready to retaliate (record or present) Proper Response 1)fill them all (`) feels repetitive>:>»like its being pushed in waves of 3 - . _ ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 57 Harrassment Categories: Shaming, Ac ws:itions, Kitchen Sink(everything), attack your concentration,attack your fatigue/tired feeling Weak Attack: Key words(to excite paranoia) Defense: Rationalization—Using perspective because here the goal is to convince you that your weak/vulnerable (realty if you have to be convince its because it not true) Pause—Because here the goal is to break your concentration (eliminates the goal) Agreement—Here the goal is disagreement or to create an argument (eliminates the goal) Dive—Again confrontation is the goal (eliminates the goal) Reverse Psychology—Keep them talking by questioning their statements (remember their statements are pre-approved)usually they can't respond or they must stick to the script One up—agree and add exaggerate until any claim becomes completely silly Increasing Isolation It was reported that the subject was social in his youth and that this changed as he became older. He did not have close friends within the last decade and became increasingly isolated before and after his divorce.The subject did not engage in routine work events or socialize after hours with other employees. His contract with mother was fairly consistent until late 2017 when it dropped considerably and became more infrequent. History of Criminality The subject had no recorded criminal history other than traffic citations. www.hillardheintze.com 58 SECTION 1 AN EXAMINATION OF THE ATTACKER AND HIS BACKGROUND 1.6 Retrospective Analysis Behavior and Experiences at Work The case materials and information reviewed to date°inform our analysis. Many of the interviewees described the subject as shy,socially introverted,odd and disciplined in his daily regimen. Many coworkers described him as socially awkward,reserved and unfriendly while others saw him in a different, more positive light.The assessment team learned about many examples of the interactions informing these opinions. However,even where there was a positive relationship,it developed after establishing rapport,which, in some cases,took years. Even in those circumstances,he was reported to have remained guarded and provided limited personal information. The attacker preferred to maintain his privacy,even with those closest to him. His personal life at times involved conflict,including his 2016 separation from his wife. He began to demonstrate a decline in his professional performance,as evidenced in his Annual Performance Evaluations, Letter of Performance Expectations,and Performance Improvement Plans that followed the divorce in 2017. While he maintained a consistent outward appearance, he was struggling with a range of issues that included his perception that he was the victim of favoritism and racism on the part of his supervisors. He demonstrated traits associated with paranoia. A supervisor stated to assessors that,at one time,the subject made a derogatory comment to a female manager during a meeting.We found no written documentation about this incident. It is possible that the subject's primary grievance was grounded in how he felt his coworkers and supervisor were treating him.This is evidenced in his most recent performance evaluation,in which he initially typed a rather canned and superficial response. He then added a hand-written note that had a more assertive tone and expressed his disagreement with his overall evaluation.After having an evening to reflect on his comments,the subject offered a detailed,typed rebuttal. He addressed each deficit in his evaluation, provided his version for each to clarify and defended himself to and from his superiors while challenging their interpretation of his performance. He was focused,able to identify his specific grievances and,seemingly, kept a running record of his beliefs in his draft emails.Some of his draft emails suggested he was becoming increasingly more fixated on and preoccupied with his perceived grievances within the workplace. ° This incident remains an active criminal investigation,with both local and federal law enforcement engagement.Our review of materials is limited to those made available to our team by the City,as the FBI declined to share any evidence. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 59 Most individuals placed on a Performance Improvement Plan are aware they need to make significant and consistent improvements in their professional duties.The subject's supervisor noted that he was making good progress and anticipated a "Meets Expectations" review. However,before any meeting to discuss his annual performance could be convened,an error from many months ago surfaced and again presented him with workplace challenges. Information provided by interviewees confirmed that the subject perceived that this could have put his employment in jeopardy. This incident involved the scrutiny over the$3,027.48 purchase order that was under the management of the subject as part of one of the subject's projects. He then learned that this oversight was identified as a serious violation of City policies. He had been engaged in emails to correct the matter and had received internal phone calls regarding the issue,which was aligned with the issues raised in his earlier PIP- managing accounts and financials.This incident likely created new stress for him. He reached out to at least two coworkers in an attempt to understand how he could rectify the matter- an action that is not normal for a typically"private"and reserved individual. He engaged his supervisor and managers when he received a voicemail stating that he violated the policies of the City of Virginia Beach and potentially the law in this matter. He even reportedly considered reconciling this monetary error by paying the fee out of his personal funds. His draft emails offered him a platform in which to put his feelings into words and supply limited but insightful evidence regarding how he perceived his professional environment.Composing these emails may have been his way to address and cope with his stressors.When viewed collectively,these messages may have provided him the rationale to take aggressive action toward those he felt wronged him. We interviewed multiple survivors from Building 2 and heard a range of accounts describing how the shooter walked by people or their offices and let others run away and escape. In one case, he fired shots at or around one individual but did not strike her,which is notable given the close proximity and his proficiency with firearms.While he shot some people he did not know,or knew only slightly, he did target those against whom he had a real or perceived grievance. He also decided not to shoot some people,even when presented with the opportunity to do so,as evidenced by the reports of several survivors who stated that he had the opportunity to target them but spared them for unknown reasons. www.hillardheintze.com 60 SECTION 1 AN EXAMINATION OF THE ATTACKER AND HIS BACKGROUND Motivations On May 31,2019,the attacker shot 16 people,killing 12 of them.A police officer was also shot while wearing a protective vest during an exchange of gunfire with the shooter. Based on the information reviewed to date,we cannot definitively state what motivated the subject to initiate this mass shooting.While we have insight into the subject, it is very limited.The draft emails provide one window into his thoughts, but they are limited in breadth and clarity and remain open to interpretation. In some mass-casualty events, perpetrators have provided a clear path and explanation as to why they resorted to violence to solve a real or perceived grievance. In some instances, perpetrators have communicated their intent on carrying out an attack to third parties - behavior that sometimes referred to as"leakage warning behaviors."7 In this case,we did not find any evidence of leakage behaviors,nor did the attacker write a descriptive manifesto or create a pre-recorded video to explain why he chose to take such violent action. He had low engagement with personal relationships. His most significant relationship,which was with his ex-wife,formally ended in 2017 -and informally came to an end in 2016 when she moved out. However, he and his wife maintained contact through 2018.We found no evidence of his ongoing friendships or relationships that were seemingly central to him.Since his divorce and leading up to the shooting,he remained distant from his family,with only intermittent contact. From 2002 through 2010,the attacker had four employers. His employment with the City of Virginia Beach was the longest term of employment he held. Early in his career with the City,he received intermittent performance awards.As of 2016,he no longer earned comparable recognition at work. Beginning in 2016,his performance began to decline but he performed at a level where he continued to be engaged in assignments. In June 2017,he was placed on a PIP.We now know that this was shortly after his wife had moved out.Some of his colleagues at work, including his supervisor, had knowledge of the divorce. In July 2018, he received a written reprimand and was given a Letter of Performance Expectations. He had completed the first PIP in August 2017 but was still struggling to meet his professional expectations,which was to be reviewed later that year. 7 J.R.Meloy,et al(2012)The Role of Warning Behaviors in Threat Assessment:An exploration and Suggested Typology, Behavioral Sciences and the Law 30:256-279. 0 2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 61 While he submitted his resignation the day of the shooting, he also engaged in typical work behaviors such as answering emails and going about routine activities associated with his job. He was out in the field with two other coworkers for approximately two hours - neither of whom had any indication that he was about to kill so many of their coworkers.One of these coworkers had left minutes before the shooting;the other was barricaded in the office during the shooting. Hillard Heintze identified several pre-incident(mass shooting) risk factors associated with this attacker, but taken either collectively or by themselves,these are not high-risk warnings - and frankly, the lives and behaviors of many American citizens align with these criteria (e.g.,own weapons,are skilled in their use,have challenges on the job and are divorced). In reviewing what the City of Virginia Beach knew and when (before the mass shooting),we note the following risk factors were present. Known Risk Factors Before the Attack Table 7:Known Risk Factors Before the Attack Weapons Skills and/or Access The City was aware he served in the Virginia Army National Guard and it can be reasonably assumed that they knew he received weapons training. Recent Job Problems The City was aware of his recent deficits with respect to his performance as evidenced by his past Annual Performance Evaluations,PIP and Letter of Performance Expectations. Personal Stressors Coworkers and at least his supervisor were aware that he had gone through a divorce. The Subject's Relationships to the Victims By the subject's actions,we can state that he moved with purpose through Building 2 during the shooting, but that he did not leave any indication of why he shot the people he did.The common relationship between him and each victim was that each was connected to Building 2, in one manner or another. For example,the non-employee who was shot was likely"in the wrong place,at the wrong time"as he was headed into Building 2 to address contracting business when the subject was entering with his guns. www.hillardheintze.com 62 SECTION 1 AN EXAMINATION OF THE ATTACKER AND HIS BACKGROUND • Of the 16 civilians shot,three were managers within the Engineering Division or with Public Utilities.Our team identified interactions and/or emails between the subject and the three managers who were shot. • Two of the managers were in his direct line of report,and were aware of the subject's belief that he was being treated unfairly at work. He had only one reportable or significant contact with the other manager who was shot. • These individuals were targeted, based upon our observations and interviews. The subject's relationships with the other employees and his reason for shooting them is less clear. He seemingly targeted some individuals,and we know from our interviews that he chose not to shoot others,even where he had the opportunity to do so. One witness described the subject approaching three people with his gun clearly pointed not at the person in the front,but at another person located further away. He shot employees with whom he had little-to-no contact and for no apparent purpose. For example,we did not identify any significant relationship between the attacker and the employee who was shot in the parking lot or a few of the others,such as a newer employee who had only recently met the shooter. We know that some employees put themselves at risk to warn others and get them to safe locations. We know that conversation was limited between the subject and his victims,but that some employees tried to engage him to stop. For the 16 civilians shot,it was not due to their actions.Only one person can fully explain why some victims were spared while others were killed -and he is no longer living. Our team heard many rumors— which is not unanticipated,given that so many City employees are trying to make sense of the tragedy—and some were presented as fact to the team. However,none of the rumors heard by the team have been determined to be valid or have informed our understanding of what happened.One significant rumor was that the employees who were shot were engaged in a promotion board. No nexus was identified between this role and the subject,as he had not formally sought promotion.Another was that he had or was seeking a relationship with one person; however,there was no evidence that would indicate a romantic interest between the subject and this person in either his work or personal email. We also know that he deliberately allowed some people to survive.The reason for the subject's decision to not shoot some employees is unknown.One employee surmises that he was allowed to live based on his work relationship with the subject.Another employee,after having a gun pointed at 0 2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 63 her by the subject who then walked away,surmised that she was allowed to live because she smiled and said good morning to the subject while passing in the hallway almost every day over the past several years. Our understanding of the subject's relationship to the victims is derived from interviews and a review of the subject's emails,as well as the evidence of the incident itself. Could This Attack Have Been Prevented? As noted above,the subject was a very private individual. He did not display concerning behavior typical of many other cases we have assessed in which we identified significant early warning signs that could be observed and acted upon.The three risk factors associated with this attacker—weapons skills and/or access, recent job problems and personal stressors—in their reported context of his professional work environment would not normally rise to a perceived level of concern for violence toward others. It appears this was the case,as no one reported any significant pre-incident concerns with respect to his behavior. In other sections,we discuss holistic human relations practices and introduce the concept of threat assessment teams(TATs)as a means to help address workplace violence.A best practice approach to mitigating and preventing workplace violence includes having comprehensive policies and procedures that describe the range of concerning behaviors and provide a specific reporting and response protocol. It is vital that both the general workforce and leadership receive regular training to increase their awareness and create an organizational culture that is receptive to these efforts. Some organizations have the capability of establishing an interdisciplinary TAT,which is often tasked with investigating,screening,assessing,intervening and providing ongoing case management support. These elements are discussed more in depth in Section 4. Threat awareness is often based on an employee's engagement in prohibited behaviors.Concerning employees typically demonstrate serious,disruptive, bizarre or aggressive behaviors that are escalated to a threat concern.We do not have that in this attack. Even with the knowledge provided by a retrospective look of the subject's risk factors,some which were not accessible to the City,we find no clear defined link to the violence he perpetrated on May 31,2019. Given that the three clear risk factors we identified were relatively low on a WAVR-21 risk evaluation, they alone would likely not have triggered a report to or a response from management. www.hillardheintze.com 64 SECTION 1 AN EXAMINATION OF THE ATTACKER AND HIS BACKGROUND Given the limited information regarding the risk factors that the City may have known about before the mass shooting,we believe that,on a scale measuring risk potential for targeted workplace violence to others from Low to Moderate to High to Imminent,the subject would have presented as a Low risk potential. ©2019 HILLARD HEINTZE Section 2 An Assessment of the Police Department's Actions On Scene The City of Virginia Beach:An Independent Review of the Tragic Events of May 31, 2019 HILLARD vpHEINTZE A JENSEN HUGHES COMPANY 66 SECTION 2 AN ASSESSMENT OF THE POLICE DEPARTMENT"S ACTIONS ON SCENE SECTION 2 - AN ASSESSMENT OF THE POLICE DEPARTMENT'S ACTIONS ON SCENE Minutes after the first 9-1-1 call was received by the City of Virginia Beach's Emergency Communications and Citizens Services Center at 4:06:32 p.m. on May 31, 2019, the first Virginia Beach Police Department officers were on scene. Plain- clothed detectives and K-9 units arrived. As the first officers entered the City of Virginia Beach's Building 2, they heard shots fired on the second floor. The attack continued over a 36-minute period, ending at 4:43 p.m. when the attacker was shot and taken into custody. During this time, the VBPD (1) responded to the scene, (2) secured the location,(3) located the shooter and (4) took him into custody. He was pronounced deceased at the Virginia Beach General Hospital at 5:32 p.m. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 67 seimim 2.1 Initial Response to the Active Shooter Upon notification of an active shooter in Building 2,the City immediately mobilized first responder units. In addition to the VBPD,these included the Virginia Beach Fire Department and Virginia Beach Emergency Medical Services(EMS). Dispatch from Emergency Communications and Citizens Services(ECCS)Center ensured that the necessary first responders were sent to the scene. Figure 1:City of Virginia Beach-Map of Municipal Campus ,i \ /,/ pq ! / m . me . u — .n�pq,yy . j m.., m \ f :�� X �, 41 C /III/,/%I/���I�jM x a-.a 9 q r till ® it _Fe€- i- ,t Q' 0 '�r+c.:ir, 0 V --:----`:.,-"a:. `✓ ,--• ce Ij '' - E Cr =:_ t 6! / � � �i ° s sue= �_ z ,;it/ t_r;.. sg :, arm b s 4. .p _S i — :P I 7, NM ,.\,it: 1 t k. r; t v`ti• Sri 71 r _ . y 1,,.: f, O �r t /' ::..... ._r �- Buikfing\ ' "`w. , Operations:Planning, Public Utilities;Public Works \e: —is 2406 Courthouse Drive Police Department ,� Municipal Cents 8" "g 11 2509 vnr,a s Anne Road Fire and Rescue Station rlf5 swung 13:248,1 Minces*Anne Road www.hillardheintze.com 68 SECTION 2 AN ASSESSMENT OF THE POLICE DEPARTMENT"S ACTIONS ON SCENE 2.2 Initial Communications The First Calls and Execution of ECCS Protocols • ECCS communications personnel on duty received the first 9-1-1 call moments after the subject shot the second victim from a caller who could see the shooter and provided the first description for responders. As the volume of calls from individuals in and around Building 2 and the public surged, ECCS staff escalated the matter promptly to nearby supervisors. • ECCS staff acted professionally and were efficient and compassionate. Incoming 9-1-1 call volume surged as family members and individuals with a connection to Building 2 employees called in information they received via text messaging from people within the facility. • ECCS protocols ensured an immediate integration of all ECCS operations and capacity expansion to accept and triage these 9-1-1 notifications. • ECCS staffing during the attack consisted of 13 personnel dedicated to processing incoming emergency 9-1-1 calls and six to answering non-emergency or City service-oriented 3-1-1 calls.This core team was supplemented by supervisors as the call volume increased. Last year on the same date between 4:00 and 4:29 p.m.,20 emergency calls were received.On this date, 110 emergency calls for service were received.As a result,some callers were not able to get through to the ECCS Center on their first attempt.Others reported that they were placed on hold for a period of time before they could speak to a communications staff member. Calls from Witnesses • The first callers,who heard gunshots and witnessed a victim on the ground at the South Entrance of Building 2,shared the incident's location and a physical description of a possible shooter to communications personnel.The communications specialists included this information in the initial radio broadcast to personnel at the scene or on their way to support the response. ECCS staff were effective in obtaining relevant and useful tactical information from callers who were struggling to communicate under intense personal duress,fear and trauma.They were able to glean information regarding the shooter's location - including on which floor and in which rooms—and where victims were located. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 69 • In several of these calls,communications personnel elicited critical information while struggling to hear callers who whispered in low voices or at times went totally silent.These callers, despite fear for their own safety while hiding under desks and whispering or speaking quietly to avoid attracting the shooter's attention,were trying to guide responders and get help for coworkers and themselves. These calls were emotionally charged for ECCS staff and the victims in Building 2. During several of the calls,gunshots are audible in the background while callers share information with the operators. • During one particularly difficult call,after an ECCS staff member received information from a caller,eight loud gunshots were heard in rapid succession before the line went silent. ECCS Guidance for Personnel Trapped in Building 2 • In addition to obtaining and dispatching critical information needed by first responders, ECCS staff also counseled and guided callers who remained in Building 2 or were in fear for family and friends in Building 2. ECCS staff advised those sheltered in rooms to lock doors, hide and remain barricaded and quiet until police instructed them to come out. Communications personnel further instructed some callers that when police directed them to exit rooms,they should be sure to have their hands up in the air and visible,and to follow all police commands closely. In circumstances like these, law enforcement responders are trained to maintain high levels of awareness in case attackers attempt to exit the facility or gain tactical advantage by blending into the stream of people under evacuation from the scene. ECCS Text Messages According to many people we interviewed,employees in Building 2 were sending text message updates to family members,who in turn called 9-1-1 to convey the information. During emergencies, it is increasingly common for victims to rely on text messaging to notify emergency responders or seek help.The ECCS, however, received only two text messages during this event- in spite of the fact that its staff are trained to handle E-9-1-1 texts and have received policy guidance,as documented in ECCS Policy 540-Text to 911. www.hillardheintze.com 70 SECTION 2 AN ASSESSMENT OF THE POLICE DEPARTMENT"S ACTIONS ON SCENE Notification Systems The City uses a range of automated notification systems that deliver both text and email notifications.Most of the communication for this event occurred through the"staff alert" system,which is described more fully in the section on the City's internal communications,and does not go out to all staff.The first staff alert went out at 4:38 p.m. The VBPD does not use an internal,structured notification or pre-programmed response and tasking protocol for critical events. Key operational personnel who responded to the attack indicated that they learned of the event through various informal communication channels, including social media and telephone calls.SWAT and command members responded based upon this information,rather than from a formal notification system,which let them know what was happening and where and when to respond.These personnel,including some who were off-duty,were subsequently tasked with supporting the overall operational response, including being assigned the command of key functions. In fact,on May 31,2019, many key personnel"self-deployed,"in effect, responding without command direction and knowledge of their assignment and the location to which they should respond. Public Safety Serious Incident Notifications,Policy 545 During the early stages of the event,while the shooter was still active,little coordinated information was shared with key personnel beyond the initial broadcast by the ECCS. The City uses the Public Safety Serious Incident Notifications, Policy 5458 to drive notifications from the ECCS to the Public Safety Department's command staff.This policy predates the establishment of an independent communications center and relies upon internal communications through the public safety branches. Based upon the event type,a command member within the impacted public safety department is supposed to be notified.The policy directs that,once a specific command member is notified within a specific public safety department(Police, Fire, EMS or 9-1-1),then that department and command member is responsible for ensuring the subsequent internal command notifications. 8 Policy 545 Public Safety Serious Incident Notifications Adopted 5/18/07;Current Revision 5/10/16 ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 71 simiNoma VBPD General Order 11.02,First Responder Notifications • While not directly on point,VBPD General Order 11.02, First Responder Notifications,states that first responders shall make notification to supervisory members of any incident in which there may be a concern regarding the Department's liability or significant community interest, and that such reports shall be made through the chain of command. - This policy should leverage the professional communications staff more effectively. Often those notified are responding and mustering resources,as occurred on May 31, 2019. For example,when there is no VBPD Command Duty Officer present,the commanding officer on scene at the incident is responsible for notifications. In this matter,the 1st Precinct Captain was actively engaged in the scene.To expect public safety command members to detail and coordinate internal command notifications, particularly for a critical incident, instead of a centralized communication center, is not an effective use of resources. Early Incident and Subject Information • Some of the survivors, relatives or friends who called in to the ECCS Center and were later interviewed by Hillard Heintze assessors raised concerns about not being believed by the intake operators.This type of caller experience is common during mass-casualty attacks or high-volume call conditions.Operators authorized to take 9-1-1 calls undergo extensive training designed to ensure that they are exceptionally diligent in ensuring the accuracy of information provided by callers who,themselves, may be extremely emotional, inarticulate or difficult to hear,struggling to cope under traumatic conditions and perhaps sharing information provided by others under comparable or greater duress. During these early calls,communications personnel also received conflicting information on the shooter's description and identity. Four differing descriptions of the shooter were broadcast. The first officers on scene, however,quickly obtained accurate first-hand witness descriptions of the shooter and immediately broadcast this information over the radio to other responding officers.The risk in providing incorrect offender information in the early stages of an event, particularly when employees are self-evacuating,can present acute - and potentially fatal - challenges for both officers and victims. www.hillardheintze.com 72 SECTION 2 AN ASSESSMENT OF THE POLICE DEPARTMENT"S ACTIONS ON SCENE Four Descriptions of the Shooter Some of the information coming into the ECCS Center was inaccurate.One caller fleeing Building 2 stated that another person told him that the shooter was a Hispanic male.The ECCS broadcast this information to first responders as the first description of the shooter. • Another of the early callers said he witnessed a possible suspect running into Building 2 away from a victim who lay in front of the South Entrance and described him as a bald black man wearing a blue polo shirt.This was the second description of the shooter broadcast by ECCS. • Several other callers stated that they did not see the shooter but believed he was an employee who had been terminated the day before.One caller provided a physical description of the suspect as a tall white man around 40 years of age,with dark hair and glasses.This was the third description of the shooter broadcast by ECCS. Three subsequent callers who witnessed the shooter described him as a tall black man wearing a blue polo shirt.One of those callers knew the shooter and was able to provide both a description of the shooter and his name.This became the fourth description of the shooter broadcast to first responders. • The accuracy of information is always compromised in the early stages of an event. However, when the telecommunicators broadcast these descriptions,they did not identify whether these were first-person observations or speculation on the part of a witness or third-party source. 2.3 The VBPD Response to the Scene Emergency Radio Communications ECCS documents receipt of the initial 9-1-1 call at 4:06 p.m.9 This call was then dispatched in a radio alert broadcast that informed police,fire and emergency medical services(EMS) personnel of the incident. 9 Although initial reports indicated the incident was at the courthouse or on Courthouse Drive,officers were able to quickly establish that Building 2 was the proper location. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 73 • An emergency call Priority One Incident,in adherence to Dispatch Policy 702,was broadcast over the police radio.This included the alert tone prior to call details,followed by a dispatch assignment to a police unit. • Most of the early response communications occurred on one radio channel. • Although ECCS established a second radio channel,officers continued to use the primary channel, resulting in missed communications.Command staff alerted officers to this second channel, but a timely switchover did not occur. Arrival and Entry into Building 2 • Assessors confirmed dispatch records indicating that police personnel of various ranks and assignments were assigned and responded to reports of shots fired in Building 2. Many personnel, including the first detectives who went into the building, responded from the Police Administrative Headquarters and 1st Precinct building,which is approximately 800 feet from Building 2. ECCS call records identify that at 4:10 p.m.,two detectives and two K9 officers,among the first on the scene,entered Building 2 in pursuit of the attacker. Once inside the building,the K9 officers and detectives formed a team to locate the shooter based on the active gunfire they heard and encountered the shooter behind a secured interior door with a window located off of the main hallway on the 2nd floor.An exchange of gunfire ensued and the subject retreated down an interior hallway behind the secured door. Communications with officers in Building 2 and between officers in Building 2 were challenging given extensive radio traffic. Officers could not directly communicate with one another inside the building and were actively engaged with an armed subject who was shooting. Movement within Building 2 Officers entered the building from various entry points as employees continued to evacuate the facility.Some officers, however,could not access Building 2 employee entrances or secured employee entrances to the floors until they acquired access cards from employees fleeing the building. Not all cards allowed access to all areas. Most permissioned the officer into the authorized card owner's work area only. The ECCS received many radio requests for assistance with access control to interior doors. Radio logs indicate at one point an officer was en route to the shooter's location with an www.hillardheintze.com 74 SECTION 2 AN ASSESSMENT OF THE POLICE DEPARTMENT"S ACTIONS ON SCENE employee's key card.The closest initial entry points from the VBPD headquarters building were the lower-level"sally port"doors,through which the initial responding officers who located the active shooter entered the building.The Special Operations Team members who eventually joined these officers on the 2nd floor entered Building 2 mainly from the public entry doorway on the south side of the building. • VBPD officers were not familiar with the building layout or the floor plans.Communications with and between officers in Building 2 were challenging,given the extensive radio traffic between personnel coordinating activities outside of Building 2.As a result,officers actively engaging the shooter inside Building 2 had difficulties communicating directly with each other -which at times placed them in harm's way due to concerns regarding crossfire- and did not allow for effective coordination of resources. • Officers eventually obtained employee cards that helped them pursue the shooter and search for victims in the secured employees'area on the east side of Building 2,although they also breached doors as necessary to gain entry.The ECCS did not have remote access to control the doors in Building 2,as discussed elsewhere in this review. Indirect Notification to Key Personnel • Members of the SWAT unit,along with those from other City Departments,were at the City's main beachfront,preparing for the City's Memorial Day Patriotic Festival,when word of the shooting surfaced. Hillard Heintze found no record that emergency communications directly notified either SWAT team members or command staff in the early stages of the mass-casualty event.VBPD General Order 13.03 tasks the initial VBPD supervisor for an event with the decision to request a SWAT response. Some of the Special Operations personnel at the festival were made aware of the incident from other VBPD personnel. Based on this knowledge,the SWAT team members began to self- deploy to the City's municipal complex. One SWAT member said he learned of the incident through a coworker;another said he learned of the incident when he received a text message from a department friend;and a third informed the team he learned of the incident through a phone call from an officer who was at the City Hall complex as the incident was developing. It is widely recognized as a best practice that key police personnel are typically notified when a major event requiring their response is occurring,and traditionally members of a department's command staff and SWAT team members receive direct official notification of a critical event that will require their mobilization as part of such a protocol. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 75 immommi SWAT Members Arrive On Scene <. At 4:18 p.m., ECCS records indicate that all available SWAT personnel were responding to Building 2.SWAT members mustered quickly and entered Building 2 at 4:26 p.m. Officers inside the building had engaged the shooter once and one officer had been shot. The SWAT unit entered the building and,along with the initial officers, isolated the shooter on the 2nd floor and apprehended him. ECCS was notified twice that the shooter was in custody at 4:43 and 4:44 p.m. 2 RECOMMENDATIONS 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. www.hi Ilardheintze.com 76 SECTION 2 AN ASSESSMENT OF THE POLICE DEPARTMENT"S ACTIONS ON SCENE 2 RECOMMENDATIONS • 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 pre- designated 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. fi Consider key incident functions and develop a protocol for staff assignments to specific roles and functions. • 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: 1 Emergency dispatch 2 Text message G©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 77 sommomo 2 RECOMMENDATIONS 3 Email 4 Mobile app push notification 5 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. 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." i0 It is our understanding that such a program has been initiated since the incident. www.hillardheintze.com Section 3 An Evaluation of Multi- Agency Coordinatia► . Command and Co • The City of Virginia Beach:An Independent Review of the Tragic Events of May 31,20 it 'fill I 111' 11 I ft 11 I 1) 1 11)1\2, I .1! ).1 11 \ { . rt HILLARDHEINTZE A JENSEN HUGHES COMPANY -a THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 79 SECTION 3 - AN EVALUATION OF MULTI-AGENCY COORDINATION, COMMAND AND CONTROL As Virginia Beach Police Department personnel responded to the scene, searched for the attacker, secured the location and later stopped the attack, many other first responders from various City and other public safety agencies were convening at the location. They immediately began organizing their commands and resources in line with established Incident Command System response protocols, training and tactics designed to resolve incidents quickly while minimizing risk of harm or loss to others. While Section 2 focused on the immediate issues involved in the first responders' initial focus on locating and stopping the shooter, Section 3 concentrates on the broader multi-agency response. www.hillardheintze.com 80 SECTION 3 AN EVALUATION OF MULTI-AGENCY COORDINATION,COMMAND AND CONTROL 3.1 Incident Command System and Key Agency Roles Active Assailant Training The investment in ongoing active shooter training by the City of Virginia Beach and the Virginia Beach Police Department made in prior years proved valuable in the response on May 31,2019, when VBPD officers organized into teams,entered the building where an active shooter was located,ensured the safety of victims and engaged the shooter. The actions of the officers who entered Building 2 on May 31,2019 and apprehended the shooter were consistent with current best practices in law enforcement response to an active assailant. Their actions saved lives.The attacker was armed and capable of killing and wounding many more had he not been stopped. The City should modify applicable policies and training for a range of critical incident response scenarios as part of its overall critical incident response and training. For example,a good practice followed by many current law enforcement agencies differentiates response protocols for an active assailant incident from those for a barricaded suspect or hostage incident.At the time of the incident,the City and VBPD did not have a stand-alone active assailant protocol. Critical Incidents and Incident Command In the years following tragedies such as the Columbine High School shooting,the attacks on 9/11 and the Virginia Tech shooting,first responders have examined and studied actions taken during these events and how to ensure that first responders are best equipped to address complex critical incidents.There are multiple stages to a critical incident,particularly one involving mass casualties. Primary is the first response:law enforcement agencies have trained their officers to enter quickly, locate the suspect and stop the threat.These officers are often supplemented by other specialty units that have unique and specific training,and these other units are engaged in a systemic way as the incident unfolds.Then there is overall incident management:the people, systems and processes that help address the evolving issues typical during critical incidents,such as demand for more resources, management of victims and families, need for medical resources and ongoing coordination and communication in a complex,critical and fast-changing environment. Many municipalities train for these events, but most will never encounter such an incident.This is the challenge of effective incident command. U 2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 81 NNW 4 Overview of the Incident Command System(ICS) For well over a decade, public safety agencies and first responders across the country have trained on variations of a concept called "direct to threat"for response to active assailant incidents.Since 9/11,the City of Virginia Beach has invested heavily in its emergency response capabilities, including conducting training designed to improve overall responses and to address issues identified during this training. These preparation-and prevention-oriented activities have been predicated upon a nation-wide response framework referred to as the Incident Command System(ICS). At its core, ICS is an organizational framework for the efficient and effective command,control and coordination of an emergency response to a critical incident.The foundation of ICS is a centralized command for deployment of resources and decisions. In complex or very large incidents involving multiple agencies with varying jurisdictional requirements, it is vital that a unified command be established to ensure key resources are collectively working to identify and address objectives through collaborative strategies predicated upon the effective use of resources. Figure 2:A Typical Incident Command System Organizational Chart Incident Commander Public Information Officer Liaison Officer Safety Officer Operations Section Planning Section Finance/Admin Section Staging Resources Demob l Time Compensation Area Unit Unit Unit Claims Unit AIIOps Situation Doc Procurement Cost Branches Branch Unit Unit - Unit Unit Divisions Groups "MEM Task Force Single Resource www.hillardheintze.com 82 SECTION 3 AN EVALUATION OF MULTI-AGENCY COORDINATION,COMMAND AND CONTROL Incident Command System Hierarchy and Policy Coordinated command is not easy, nor is it the routine approach of most first responders. Each of the key public safety responders in the City of Virginia Beach have unique,specific responsibilities. The response to an active assailant incident is directed by the Emergency Operations Plan(EOP)11 and Unified Response Guidelines: Patient Care at Criminal Mass Casualty Incidents(CMCI)as well as various protocols and policies of the first responders.12 Policy direction for the police command control and coordination of response to an active assailant is provided by VBPD General Order 13.01 - Unusual Occurrence and Special Events. The City and VBPD could benefit by having a written policy specifically addressing an active assailant response.The CMCI specifically identifies the recognition and need for unified command of police,fire and EMS as the proper vehicle for the command and control of a critical incident. This document defines the role and responsibilities of first responders with respect to a variety of functions. The Role of the Emergency Operations Center A high-performing ICS requires support from the Emergency Operations Center(EOC). Under a well- structured ICS,the EOC is the central location for support and assistance,serves as the backbone of the ICS and drives resources to help the operational command deliver on its goals of engagement and reduction in harm, loss and criminal activity.The EOC coordinates decisions,resources and logistics across an event,allowing for a single source of information and resourcing decisions as well as an informed view of the entirety of the event. 11 Enacted September 20,2016 12 Initially published October 26,2015 and updated August 23,2017 and signed by the Deputy City Manager Public Safety,Chief of EMS,Chief of the VBPD,Chief of the VBFP,Director of OEC and Director ECCS ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 83 soinimm The Role of the Office of Emergency Management The Office of Emergency Management is responsible for promoting a comprehensive emergency management program to mitigate the impact to the community from disasters and potential catastrophic incidents. It also serves the key resource coordination function during a critical incident. The Emergency Operations Center(EOC) EOC Activation and Arrival of EOC Members The most effective emergency management occurs when a dedicated representative from every relevant public safety department is in the EOC.They serve as their department's liaison, providing real-time communication with the Incident Commander and participating in strategic decisions. When ECCS broadcast the dispatch regarding the active shooter in Building 2 on May 31, 2019,the Emergency Management Agency(EMA) Director responded from the beach, where she was preparing for the Patriotic Festival with other public safety personnel.The Director reported to the EOC and declared the EOC operational. Administrative staff from the ECCS supported the OEM until the other staff reported to the EOC. However,the majority of the public safety agency representatives did not respond in a timely manner to the EOC,as trained and required under the Emergency Operations Plan(EOP). Key personnel who staff the EOC remained present at the scene.The Virginia Beach Fire Department was the first to respond to and support EOC operations at or about 6:00 p.m. VBPD and EMS representatives arrived at or about 7:00 p.m.and the Deputy City Manager(DCM)arrived thereafter.The DCM holds a key EOC role,as he is responsible for all public safety agencies in the City.The coordination and communication issues that emerged during a critical incident are most effectively addressed through a unified command approach,facilitated by the EOC. www.hi llard heintze.corn 84 SECTION 3 AN EVALUATION OF MULTI-AGENCY COORDINATION,COMMAND AND CONTROL i The OEM Director convened the Virginia Beach Incident Management Team(VBIMT)by sending a message through the City's electronic message system.The VBIMT is comprised of select public safety personnel representing police,fire and EMS who serve as the planning and logistics team for a critical incident.The Director could call approximately 25 trained members to report during emergencies and begin building the Incident Action Plan to support the emergency response.VBIMT specifically supports operations by planning for needs that arise independent of the specific operational response,as well as issues associated with ongoing,long-term and post-event management.VBIMT members responded and assumed their roles,including the OEM Emergency Planner,whose immediate priority was establishing the Family Reunification Center(FRC). During and into the immediate aftermath of the shooting,the EOC was open and fully operational until approximately 2:00 a.m.on Saturday,June 1,2019.The last family notification was made at approximately 1:00 a.m.At this time,the EOC turned over incident command to the ECCS. Stakeholders in the EOC reported for the next operational period on Saturday,June 1, 2019 at 8:00 a.m.for a situational briefing.The EOC remained open for the next 12 days to support the ongoing investigation and other related coordination and follow-up work. The EOC continued to provide support to the actions related to the incident under the direction of the OEM Director from 8:00 a.m.to 8:00 p.m.daily. The EOC functioned effectively and according to its designated role to deliver emergency management support and resource assistance across the incident and responders. Fully staffing the EOC with the key public safety stakeholders provides early coordination of a mass-casualty attack and facilitates clear communications across teams,as well as helps ensure shared,informed operational decisions. Incident Communications An effective command and control starts with communications.Allowing first responders to have the communications capabilities to keep them safe while engaging an active assailant is primary. Further,the need to get resources to the scene and to direct those resources requires sufficient communications capacity.An effective ICS is supported by a strong communications system. Information is key to the coordination and delivery of resources.The City of Virginia Beach had engaged in training on communication practices,and this was demonstrated in the communications activities that occurred on May 31, 2019. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 95 Ann Emergency Response and Radio Communications The City of Virginia Beach faced a unique circumstance - not only were they dispatching public safety services on May 31,2019,but also their own fellow employees were calling for help.There was a mass convergence on the site of Building 2 in rapid time after the initial call of an active attacker. However, most of the response was self-deployment, either in an active role that was assumed or as an onlooker.This was not a scenario addressed in protocols or in previous trainings. The City of Virginia Beach Emergency Communications and Citizen Services(ECCS)personnel received 9-1-1 calls from persons inside Building 2. Early calls to dispatch were instrumental in directing resources and identifying the attacker. ECCS Policy 702, ECCS Dispatch of Police Incidents,directs the dispatching protocols.Specifically,in Priority One Incidents,which includes an active shooter,two police officers are to be assigned and provided the nature of the call, location of the incident,suspect/s and descriptions,weapons,vehicles and direction of travel. Dispatchers followed the overall guidance of this policy. In a critical incident,it is more effective to use separate communication channels.This practice allows officers actively engaged in an event to keep the primary channel open for critical tactical operations purposes and allows other personnel responding to handle perimeter operations or other administrative matters to use another channel. Communication records indicate dispatchers tried but were unsuccessful in clearing the main channel for officers to manage the threat in the building by redirecting other operational communications to another radio channel. A separate operations channel was established at 4:28 p.m., more than 20 minutes into the attack.This new channel was disregarded by many on the scene. Personnel inside Building 2, who directly engaged the attacker,had problems hearing one another and coordinating their actions. Commanders also instructed officers to use radio channel 11, but in the chaos of the response some officers continued to use the primary radio channel as they evacuated victims and coordinated transportation for wounded individuals. The VBPD Department General Order 13.03,Special Weapons and Tactics Team, identifies the need for those managing the threat or incident to operate on a separate radio channel from those engaged in other tasks. Establishing clear communication channels for operational personnel and maintaining radio discipline during critical events is a function of command and control. City's Internal Communications A programmed emergency alert system would have ensured timely,direct notification to all key personnel,thereby allowing the start of a structured response to the attack.The City of Virginia www.hillardheintze.com • 86 SECTION 3 AN EVALUATION OF MULTI-AGENCY COORDINATION,COMMAND AND CONTROL Beach has multiple mass communications systems to provide information to the general public and employees.The ECCS provides both 9-1-1 and 3-1-1 services.The non-emergency number 3-1-1 is staffed on a 24-hour basis like 9-1-1.The city uses VBAlert as the"Reverse 9-1-1"mass communication mechanism for its general public messaging system. VBAlert is commonly used to provide significant weather alerts, however it can also be used to provide awareness of emergencies, public utilities messaging and related notifications. It is managed by the ECCS and based on the master street address guide.The system is flexible, allowing targeted alerts based on geographic area. For example,the residents of a specific area can be specifically targeted to receive information such as a water boil alert. During the May 31, 2019 shooting,VBAlert was not used to inform those registered of the active attacker event,and mass communication was limited to employee notifications at the municipal complex.This was a conscious decision based on management's awareness of low employee enrollment and the risk of an audible phone alert. In lieu of VBAlert,an"ALL USERS"group email was sent to City employees at 4:22 p.m.to inform them to shelter-in-place.This initial email was followed by two additional messages:the first at 4:54 p.m. informing all employees to continue sheltering-in-place and finally at 5:55 p.m. indicating that the subject was in custody and first responders were engaged in recovery operations. Several persons interviewed commented that they found the absence of the VBAlert to be surprising because they received a previous weather alert but did not receive alerts about this critical incident.The alert referenced was a severe thunderstorm warning issued at 12:23 a.m.on May 31,2019.This type of alert is automatically generated by the National Weather Service and sent to individuals who have self-registered their contact information with the ECCS.VBAlert was used to provide information to residents and identify the establishment and location of the Family Reunification Center. The City is transitioning to a new digital notification system for use in mass communicating to first responders and employees.We learned that in this attack,given the low enrollment in the existing system,the City elected not to use it. City of Virginia Beach employees are not required to provide their cellular telephone numbers for entry into the notification system.Current contact information for employees is not routinely updated and,as a result,notifications would not have reached the majority of the employee population. Further,unlike the geographic coding,the system does not isolate employees by work locations,which would allow direct notifications to employees in specific locations.Such notification would have required manual programming that the resource at ECCS could not support.The new system will allow for pre-programming flexibility based on a variety of group messaging determinations. The City also uses preprogrammed notifications that are established and linked through their CAD system. Designations of"E-Staff,""P-Staff"and "F-Staff"are used as a group text messaging ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 87 platform for EMS, police and fire personnel.The ECCS can provide group messaging to provide a method of sending the CAD incident to a pre-determined select group via text or email for review. Members receive the group text or email and click on the embedded link to access the CAD incident for ready access to the details.As described above,these personnel are then required to provide internal notifications under the ECCS Policy 545, ECCS Public Safety Serious Incident Notification. Early into the attack,the ECCS Director contacted the Deputy City Manager with a recommendation that they lock down the municipal complex.The ECCS mass notification system was known not to have all employee information included and would not be effective to notify staff of this decision. The ECCS Director contacted the HR Communications Coordinator to send the notification to employees via the City's email system.The challenge with messaging during a critical incident is that not all employees have access to digital communications and that information is not routinely updated. However,absent intercom systems or other means, it is the best possible option to inform people of fast-moving events. Interviewees referenced and confirmed receiving the"ALL USERS"group email at 4:22 p.m.which was marked Importance: High, notifying recipients of an active attacker "supposedly in or around Bldg. 2. Please shelter in place. Lock your doors.We'll communicate when it's safe to leave." Recipients were able to share this information with others in the building as well. Building 2 Incident Notification and Evacuation Many employees were still at work on that Friday afternoon. In the early stages,employees were mostly unaware of what was happening but quickly learned through word of mouth from other employees or first-hand observation. Employees started yelling,grabbing coworkers and escaping or sheltering in place. Calls to 9-1-1 from within the building were the first warnings received. Employees were texting and calling loved ones to tell them what was happening and to ask them to summon help. Supervisors, managers and employees were united in trying to remain safe as the attack unfolded. In a chaotic atmosphere,employees had to make life-and-death decisions about what was in the best interest of their safety- without much guidance or knowledge about what was happening. Employees either self-evacuated or hid in the building during the shooting. Many tried to aid those who were victims,and supervisors and managers stepped up to protect their staff. Building 2 does not have an intercom system and,as discussed elsewhere,communication from the City about what to do and what was happening was limited. www.hillardheintze.com 88 SECTION 3 AN EVALUATION OF MULTI-AGENCY COORDINATION,COMMAND AND CONTROL At one point,an employee in Building 2 pulled the fire alarm in an attempt to warn all personnel of the attack because the employee felt it was the only means available.We raise it here as a reminder,since this has occurred in other similar critical incidents. Best practice in an active assailant attack is not to pull a fire alarm because it can quickly put people in harm's way,if they believe the crisis is a fire and emerge from barricaded rooms or hiding and expose themselves to an assailant. It also disables elevators that may be needed for evacuation purposes or for responding to the incident. The benefit of the City's progressive active assailant training, including its Rescue Task Force(RTF) discussed below and its tactical medic response programs,was evident as first responders engaged in early rescue and evacuation efforts with victims.As officers streamed into the building, employees streamed out.As the tactical operation progressed,so did the self-evacuation of employees,including those who were wounded.Once the threat was contained,commanders coordinated the subsequent building sweeps, rescue and evacuation operations. The importance of effective command and control became apparent during the evacuation and in the immediate aftermath of the event. In the early stages of police response,the evacuation efforts were not as well organized but clearly focused on the safety of the employees.Once outside,officers instructed the employees to crouch behind cars as shooting continued inside. Officers moved them incrementally from one line of cars to the next back through the parking lot. Multiple interviewees stated that first responders were"everywhere,"but they were not consistently told where to go.Once directions on where to evacuate were provided,there was some confusion,as evacuees were moved to two locations. Police officers escorted employees to the post office for a brief time period before they instructed them to walk across the complex to the courthouse.Check-in at the muster location was not operational early during employee evacuation and people other than victims and employees entered,including the media.A fully staffed and engaged EOC could have had the plans ready to activate for those employees to muster and have staff prepared to assist them. Many employees did not have access to their vehicles in the Building 2 parking lot,as it was now designated a crime scene.Additionally,many left their cell phones in the building.Without a phone or the ability to leave,employees experienced tremendous stress.Supervisors, managers and responders did not have employee lists to validate who was accounted for and who was not. One manager spoke of having to coordinate child care, reach out to a spouse to assure them that they were okay and to determine who from the manager's unit was accounted for-all without any means of doing so. The employees as a whole faced a tense and emotionally draining process after which they could not easily contact family. Many were left to their own devices to find a way home. Families ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 89 mismasams seeking loved ones at the scene added to the situation and inadvertently became part of the criminal investigation. Evacuation Policies and Practices The City of Virginia Beach is required to have evacuation plans for its facilities,and the City HR Department's Occupational Safety and Health Services(OSHS)is responsible for this plan.13 OSHS requires that each building and individual department develop a building evacuation plan, including a floor evacuation team that includes floor managers,searchers and stairwell monitors. Each department is responsible for ensuring employees are adequately trained and familiar with the plan. The City did not have a consistent City-wide active assailant plan as part of its overall evacuation planning and focus. Building 2's evacuation plan addressed the basics, including primary exit routes,such as stairwells,and the response to a workplace violence incident. Building 2 employees responsible for carrying out evacuation plans expressed that neither the plan nor security measures in the building are sufficient.The City's OSHS director has identified this as an area requiring review and is currently working with federal and City partners on policies related to such incidents.The Building 2 Building Evacuation Plan Workplace Violence section includes a link to the Department of Homeland Security(DHS) Run, Hide, Fight video as well as response instructions. An active attacker incident is dynamic,and it is not reasonable to provide rigid and universal instructions, nor is it always advisable to expect employees to follow the building evacuation plan strictly.That is why plans need to be tested. For example, Building 2's plan directs employees to stairwells,which the attacker intermittently occupied.Additionally,while most floor evacuation teams assembled in accordance with the plan,in at least one department,the attacker shot the floor manager and assistant floor manager, rendering them incapable of any evacuation tasks. The benefit of training is that it tests the potential outcomes and risks in a safe learning environment that helps employees make the best possible decisions in the worst of circumstances. While the Building 2 evacuation plan was tested within the last three years, it did not result in updated plans or after-action improvements.At least one employee in Building 2 identified challenges with evacuation plans not being updated or cohesively trained. 13 Administrative Directive AD 3.04 and Occupational Safety and Health Standards 29CFR1910.38(Emergency Action Plan). www.hillardheintze.com 90 SECTION 3 AN EVALUATION OF MULTI-AGENCY COORDINATION,COMMAND AND CONTROL Police officers did not actively train in nor were familiar with the layout of each building on the Municipal Campus.The VBFD had greater familiarity as a result of their inspection activities. However, Building 2 redesigns and other current construction within the building were not incorporated into the floor or evacuation plans. For example, Building 2 was described by some as three floors and by others as four floors(as documented in the Building 2 evacuation plan),which could have contributed to some confusion that day by first responders. It does not appear that this miscommunication affected the incident outcome, but building awareness is important to first responders pursuing an active assailant and incorrect floor plans can complicate efforts.The OSHS Manager has identified that these issues are under review within his office and has engaged a task force,including federal partners,to help address future safety and evacuation planning. Unified Command The VBFD Battalion Chief,along with EMS,relocated back to VBFD Station 5 to initiate the next level of command. He notified dispatch that he had established "Courthouse Command"as the Incident Command Post(ICP)with EMS in accordance with unified command protocols. The Battalion Chief himself used a whiteboard removed from his vehicle to list the resources known to be on scene.While seemingly simple in concept,this was the initial step toward forming a unified command with EMS.The ICP,pursuant to City of Virginia Beach policy and training,assumed responsibility for coordinating the victim rescue operations through participation and liaison with EMS. EMS heard the dispatch of the active shooter as well.The EMS Chief and other command quickly joined the VBFD commanders.The Battalion Chief instructed the Station 5 Captain to establish the forward command, Rescue Task Force Staging,following the Incident Command System(ICS)structure to begin to support and manage the emergency response efforts.At this time,the attacker was still active. Pursuant to the structure that supports Unified Command, EMS was designated as the medical branch,assuming patient care and transport responsibilities.The medical branch contacted the area hospitals and trauma designations for victim transport were established.The medical branch had 35 EMS ambulances available as well as a fleet of reserves available through established Memoranda of Understanding(MOU)with neighboring jurisdictions.A total of 12 ambulances were staged near the ICP awaiting patient transport. EMS established casualty collection points at Station 5 and on the south side of Building 2 at George Mason Drive.These actions were in accordance with Unified Response ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 91 Guideline: Patient Care at Criminal Mass Casualty Incidents(CMCI)14 to guide the public safety response. • As Incident Commander,the Battalion Chief requested a tactical radio channel (TAC)be established. He also requested additional resources in the form of an additional fire engine and ladder truck. Additional VBFD command and supervision continued to arrive,and a VBFD supervisor was designated by the Incident Commander as the Police Liaison.The VBPD had not joined the ICP.The Incident Commander designated a VBFD supervisor as the Communications Unit to monitor all radio traffic. He assigned a third Battalion Chief to retrieve floor plans for Building 2 and to liaise with the VBPD to provide building structure guidance as needed. Fire Command and Rescue Operations When the dispatch regarding Building 2 first came out,a VBFD Battalion Chief was at VBFD Station 5 and within eyesight of Building 2,approximately 700 feet away.The Station 5 Captain and crew responded in the fire engine,along with the Battalion Chief,to the intersection of Courthouse Drive and Mattaponi Road.At this time,a police officer on scene told them they were too close to Building 2 and to move back.The VBFD then staged at the parking lot on the northeast corner of the intersection, still in view of Building 2. Both VBFD command officers stated they were on scene within minutes of being dispatched. At this time,in accordance with the ICS planning and role designations for response personnel,a VBFD Safety Officer was tasked by the Battalion Chief,who assumed the role of Incident Commander. Under the ICS,the Safety Officer is responsible for assessing,identifying and mitigating any hazardous situations discovered in the operational function. As additional fire commanders arrived,the Incident Commander assigned them responsibilities in accordance with the ICS structure. 14 The document was most recently revised on August 23,2017 and bears the signatures of the deputy city manager for public safety and lead representative for all five public safety agencies. www.hillardheintze.com 92 SECTION 3 AN EVALUATION OF MULTI-AGENCY COORDINATION,COMMAND AND CONTROL 111111111111,1111111111111.11 Rescue Task Force Operations The Rescue Task Force is a coordinated team including the VBFD, EMS and VBPD personnel responsible for early entry into a scene to search for and evacuate victims.This is a good practice as it ensures the timeliest engagement with victims who need emergency medical care,often located in a"hot zone"or"warm zone"of a scene and while the assailant may still be active. The VBFD Captain and Engine 5 were the forward command and were tasked with coordinating the RTF operation. The Incident Commander designated Engine 5 crew as RTF Team 1 and the team had"go- bags" ready to initiate rescue operations. After arriving on scene,another VBFD Battalion Chief was sent to forward command to assume the RTF Staging Command.This Battalion Chief requested additional fire resources and formed RTF Teams 2,3,4, 5 and 6.These trained personnel arrived at the forward command and were staged and ready to access victims quickly and provide emergency medical services to this active shooting. In addition to RTF Teams, EMS tactical medics, both career and volunteer,train with SWAT weekly to address events, including mass casualties.These tactically trained medics are unarmed but train and respond in tactical gear for safety and operational effectiveness.The goal of the tactical medic is to provide medical support that can work seamlessly with SWAT during high-risk incidents to locate,treat and evacuate victims in warm zone and hot zone operations. These progressive approaches to victim management is commendable as many other jurisdictions' medical services personnel stage in a "cold zone,"waiting for the situation to stabilize and until the building is cleared before providing treatment to victims. The VBFD established command and control quickly,pooled resources and engaged in Unified Command for effective emergency management response. Its Forward and Incident Command was well organized and quickly established.Overall,VBFD personnel's strong awareness of ICS requirements and resource coordination were clearly demonstrated. As with the other first responders,the VBFD did not join the EOC at the time it was activated. The EOC support position is key to ensuring that all resources are timely and appropriately directed in support of field operations. For example,Building 2 employees needed transportation once they were evacuated because their personal belongings and vehicles parked at Building 2 were now part of an ongoing incident and crime scene.Staff at the EOC arranged for buses and drivers to provide transportation for victims,but the VBFD had already begun transporting employees with a VBFD bus and driver.This effort was not communicated to the EOC.This resource allocation should have occurred at the EOC level but instead efforts were duplicated. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 93 EMS Response and the Medical Branch Shortly after the active shooter call was dispatched,the EMS Chief,deputy chiefs and field supervisors responded to the scene.The EMS Chief is well versed in ICS. The EMS command responded to the scene at Courthouse Drive and Mattaponi Road and quickly linked up with the VBFD to establish initial first responder communications.The EMS has dedicated tactical medics,and many self-deployed to the scene.An EMS commander was assigned to the RTF Staging Area,where they also assigned the medics to the RTF Teams for rescue operations. Perimeter control was not established and civilians continued to arrive on scene.Although willing to help,the presence of civilians presented challenges for command and control over the scene and patient care and transport.As employees evacuated Building 2,they were not consistently directed where to go.One example of control interference occurred when a civilian loaded a wounded employee onto the trunk of his car and another placed a wounded employee in the bed of a pick-up truck for delivery to the ICP. • A communications delay resulted in the ICP learning of the incoming patient as they were passing Casualty Collection Point 1.This evacuation was approved to continue on to the ICP, as stopping would not have provided any benefit to the wounded individual. The EMS demonstrated strong adherence to the ICS principles, its training and the CMCI by responding in a quick and organized fashion. Had the EOC been engaged or the VBPD active in the ICP,direct communication with the officer who was speaking with the civilians driving the victims would have allowed him to direct them to the nearest collection point.As a result of this civilian transport,an EMS supervisor was assigned from the ICP to stay with the police commander at the VBPD command post to establish a communications and awareness link. EMS,as with the other first responders,did not join or staff the EOC until hours into the incident. Given the complexity of the EMS system,which includes volunteers and formal MOUs with other jurisdictions for mutual aid,the EOC's removed overview and coordination capabilities could have assisted with resource management. For example,while the City staged 12 of its available ambulances at the ICP and engaged others via its MOUs, in the end, more ambulances were present than were needed.As the event transpired,the ability to return service to these jurisdictions and other locations would have been smoother with EMS support at the EOC. Had EMS been involved at the EOC,the on-scene commanders could have remained engaged in patient care and the EOC staff could have addressed the administrative call-up and management of the support resources. www.hillardheintze.com 94 SECTION 3 AN EVALUATION OF MULTI-AGENCY COORDINATION,COMMAND AND CONTROL Police Incident Command When the initial call of an active attacker came in,VBPD personnel responded,several within the first two minutes.Without hesitation and consistent with national law enforcement practices,officers entered Building 2 to locate the attacker.The officers overcame challenges presented by the complex building layout with nearly 400 employees and a multi-floor crime scene. Officers assisted victims,identified wounded and deceased individuals and facilitated the safe and orderly evacuation of victims. While the VBPD's response to the active shooter was appropriate and timely,the ICS practices were not as strong. ICS roles and functions are important to provide overall visibility on resources and emerging issues and to help drive response.The ICP is key to effective incident and resource management. Early identification of resources and information allows for increased victim and officer safety,an appropriate response to address the threat and provide support for personnel actively engaged in the incident.The operations of the overall incident should be driven through the ICP to manage limited resources most effectively and to establish a common operating picture. The police command viewed its first responsibility as locating the attacker to stop the threat.The VBPD did not engage in the efforts to establish unified command.VBPD command did not use the ECCS to assist in directing resources and were not focused on coordinated resourcing with other responders.Although VBPD operations were in close proximity to the other operating command posts,they did not share an operating environment that drove resourcing decisions. The VBPD established a Forward Command,with the Captain announcing he was the Incident Commander.This conflicted with the Unified Command containing VBFD and EMS,where a VBFD Battalion Chief identified as the Incident Commander. When the SWAT team arrived on scene,VBPD General Order- 13.01 Unusual Occurrence and Special Events directs the Special Operations Commander to assume the role of Incident Commander.The Special Operations Commander did not assume this role.These command issues should have been resolved immediately to establish an efficient chain of command and control over the scene. The VBPD did not establish the ICS structures for planning,logistics or administrative support. Internal protocols did not identify or pre-task these assignments.The VBPD Incident Commander assigned an officer to be his scribe,a common role and practice in managing large events, but the officer broke off,limiting the ability to track decisions and information. For example,the VBPD Incident Commander did not know which officers were in the building and had difficulty establishing coordination and accountability for all units on scene.A scribe and other support ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 95 branches would have had responsibility for managing these issues under Incident Command.We did not identify any communications records for VBPD commanders nor any internal unified command of operations. Surrounding law enforcement jurisdictions began to deploy to the scene.The Virginia Beach Sheriffs Office(VBSO),the Chesapeake Police Department(CPD)and the Virginia State Police (VSP)offered support for the VBPD. However,VBPD was not at the EOC or integrated at the ICP to help task and direct the additional personnel. Initially,while some were directed by VBPD to report to the ICP,others responded to the scene and self-deployed in an attempt to help the victims evacuating from Building 2. As the attack progressed,and the VBPD command was able to refocus its efforts,Sheriff's deputies were tasked with providing security at the Family Reunification Center,and the VSP was tasked with perimeter security for the municipal complex and Building 2.VSP personnel managed scene security at Building 2 for employees returning to the site to retrieve their vehicles that had been previously unavailable due to crime scene processing. While establishing command and control is challenging in the early stages of an event,the value of Unified Command to the overall success in the management of a critical incident cannot be overstated. For example,when the police located the subject in Building 2,they were locked out of the employee access areas and it delayed their response. Had the VBPD and VBFD been working under a Unified Command approach,the VBFD could have provided the VBPD the key for the Knox Box located on the basement level of Building 2,which contains universal key cards for building access.The ability to have the VBPD representative in the EOC coordinate with the outside jurisdictions - and to task them - would have taken that burden away from the operational command. Public Communications The Joint Information Center(JIC)operates to ensure consistent and accurate messaging across all entities engaged in a critical incident and is an important component of the ICS. In the past few years,the City of Virginia Beach has been increasing its emphasis on ensuring that regional and localized training incorporates the JIC and its role in public messaging in conjunction with an emergency response to a critical incident. When the City opened the EOC,the JIC was established quickly to share disclosable information about the attack,the victims and the response with the public and media outlets as quickly as possible. www.hillardheintze.com 96 SECTION 3 AN EVALUATION OF MULTI-AGENCY COORDINATION,COMMAND AND CONTROL 11 • The City's Communications Director,who leads the JIC,was contacted when the attack unfolded and reported to the ECCS building at approximately 5:00 p.m.to ensure connectivity and begin active engagement. However, many of her staff members were in lockdown in Building 1 in the early stages of the shooting. Fortunately,there were numerous individuals who self-reported to the JIC based on their awareness of the need and from previous experience.These individuals have trained and worked with the City's communications staff and public safety departments through previous emergencies and exercises and were able to provide immediate communications support. For example, it was quickly determined that the size and complexity of the attack was going to overwhelm the routine staff assignments and required additional personnel.A tasking and staffing schedule was implemented to organize the staff assignments to ensure the JIC was appropriately staffed during all operational periods. Key governmental stakeholders were instrumental in assisting in the coordination of the messaging activities and managing the multiple challenges for media coordination,such as ensuring Building 2 and the grounds were not a gathering point for media as well as making public representatives available for comments at appropriate locations.The JIC was closely aligned to the EOC,as required by ICS,and the information flow was facilitated through the EOC.VBPD's Public Information Officers were assigned to the JIC to ensure a seamless communications network was established. The first public message was released from the City Manager's Office at 6:00 p.m.,informing the public of the attack and that the press briefing would be held at the ECCS at 7:00 p.m. The next briefing and all that followed were conducted at one location,the courthouse, providing a unified voice and consistency in messaging.This site was already staffed with security,which provided for a well-organized and orderly meeting location for the press briefings.The press briefings were augmented by the City's website,VBgov.com. In addition to routine scheduled press briefings,City representatives,accompanied by the Communications Director,visited the media camp to make themselves available to reporters for interviews and to answer questions. During our interviews regarding the media,many interviewees complimented the City for its approach,especially under exceptionally difficult circumstances. Assessors also learned that while most reporters openly demonstrated empathy,some gained access to victim's families under false pretenses,such as delivering food,flowers or claiming to be an acquaintance in efforts to interview them. The JIC,like the staff at the Family Reunification Center,was challenged with the delay in identifying victims.This information was a key focus for the media and public alike.Some of the delay in disclosure was attributed to the fact that it was a key concern for the JIC staff that reporting about victims be accurate and respectful. O 2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 97 mimmimiim The size,complexity and duration of the attack exceeded prior preparation and planning.As the hours wore on,the stress of managing the need for information against the limited flow and prolonged identification of victims proved challenging.Although land lines were available and the City published the telephone number to the JIC,the Communications Director received the majority of the calls on her cell phone.This became a choke point for information,given the volume of calls,and it impacted the ability to provide available information in a timely manner. Release of Information Briefings of the incident, including social media updates,were provided through the JIC.The briefings were announced in advance and were based in part on information detectives provided to the JIC. Establishing such a partnership to ensure consistent messaging in mass-casualty incidents is a best practice. In the absence of official notification early on,consistent with any such critical incident,a lot of early information was not validated and proved incorrect. During employee interviews,we learned that some early information that incorrectly identified the deceased and wounded circulated at the courthouse where employees were evacuated.Some families referenced unofficial statements made by City personnel regarding their loved ones that were incorrect.The ability to manage the informal exchange of information like this under crisis,and in sometimes chaotic conditions, is often a challenge for entities and their representatives. 3.2 Post-Attack Incident Command Victim and Witness Management What distinguished the May 31,2019 mass shooting from many others is that those tasked with responding to and helping support victims in this tragedy were doing so when the victims were their own colleagues and fellow city employees. Normally,when the first responders are called to a scene,they are not responding to their own "home"and as a result are able to respond, return and continue to operate without any long-term impact to City operations. However,the events in Building 2 did not occur at a private corporation or other unrelated entity- it occurred on City premises and involved City employees.While the basement continues to be the work space for the IT Department, Building 2 is still unoccupied on the upper floors and remains behind fencing - serving as a daily reminder of the tragic loss of life.As such,this attack continues to have reverberating issues for the City and its first responders. www.hillardheintze.com 98 SECTION 3 AN EVALUATION OF MULTI-AGENCY COORDINATION,COMMAND AND CONTROL Under ICS,a key component of resource coordination is centered on victim and witness management,particularly when dealing with mass casualties and injury.These type of events require significant engagement post-attack and include interviewing witnesses and victims, reviewing and evaluating evidence in support of the investigation,returning personal belongings left at the crime scene,assisting victims with contacting family and loved ones and providing trauma assistance for those not hospitalized. Investigation and Interviews with Witnesses and Victims Department records indicate Homicide Unit investigators began interviewing witnesses within an hour of Building 2 being cleared and declared safe. Personnel from the Detective Bureau worked pursuant to a plan of action developed and coordinated by VBPD while the critical incident was still active.According to VBPD, investigators established two goals:obtain evidence without compromising any future criminal investigations and identify the victims.The Bureau assigned its entire team to investigate the incident. Consistent with contemporary practices, Detective Bureau personnel led the investigation and requested assistance from the Federal Bureau of Investigation(FBI);the Bureau of Alcohol, Tobacco, Firearms and Explosives(ATF);the Chesapeake Police Department(CPD);and the Virginia Beach Sheriffs Office(VBSO). CPD detectives assisted in interviewing witnesses at the courthouse complex, FBI agents helped to manage the crime scene and the ATF assisted in tracking the attacker's firearm and any other firearms he owned. VBSO detectives interviewed victims and witnesses in Building 2 and sought to identify the attacker's possible motive.This collaboration exemplified the teamwork typically involved in mass-casualty incidents. Victim Identification Virginia Beach General Order 11.15, Emergency Notification provides that the investigating officer or a designee familiar with the circumstances of the incident notifies next-of-kin. However, it does not advise who is responsible for this task in mass-casualty incidents or in joint operations with other agencies.The ICS stakeholders included the FBI,the VBPD and the Medical Examiner. Victim identification and notification of the next-of-kin was not supported by formal written protocols and was not something that surfaced in earlier training. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 99 The FBI was managing the crime scene and had it secured.The Medical Examiner traditionally provides formal identification of victims.Virginia State Iaw15 stipulates that any person or institution having initial custody of the deceased shall make a good faith effort to identify and to notify the next-of-kin of the decedent. In most circumstances,the police address identification and notification in the course of the criminal response and investigation and as such the VBPD is usually the party to notify next-of-kin. However,given the significance of the overall scene,VBPD was unwilling to make notification without confirming the identity of the victims.VBPD command felt it was critical to ensure accurate identification of the victims given how many there were as well as the level of investigation and multi-jurisdictional review required by the scope of the attack. As a result, identification of the victims took longer than anticipated.The VBPD sought assistance from the Office of the Medical Examiner. However,when the City was informed by the Office of the Chief Medical Examiner that it would respond on Saturday,June 1 to conduct its investigation, the City sought assistance through stakeholder intervention to ensure a more timely response. Command members for both the FBI and VBPD were engaged in order to expedite the Medical Examiner's response and VBPD's access to the scene, under control by the FBI,to ensure timely identification of the victims.Assessors were informed that the FBI's on-scene,crime scene personnel were given direction to sufficiently secure and process the scene to allow timely victim identification.These actions were significant,as families and loved ones were waiting at the Family Reunification Center for information. The timeliness of the notifications was subject to criticism from some of the next-of-kin of the victims. Notwithstanding the efforts to expedite the process by VBPD,it still took time to verify the victims.A department member experienced in providing fatality notifications was tasked with informing the next-of-kin of the circumstances involving their family member.The last notification for a local family occurred at midnight. The last notification for an out-of-state family, made with the assistance of another law enforcement agency,occurred at 1:00 a.m. Family Reunification Center(FRC) The City of Virginia Beach Human Services Department is responsible for the Family Reunification Center(FRC)and Family Assistance Centers(FAC), in cooperation with the Office of Emergency Management. 15 §32.1-309.1.Identification of decedent,next of kin;disposition of claimed dead body. www.hillardheintze.com 100 SECTION 3 AN EVALUATION OF MULTI-AGENCY COORDINATION,COMMAND AND CONTROL The OEM has a comprehensive draft plan in progress regarding FRC and FAC establishment. In January 2019,the City HR Department and OEM had scheduled a meeting to develop the final FRC/FAC plan. Unfortunately,staff changes impacted the FRC planning progress.OEM took ownership and drafted the current plan without input from the City HR Department but outlined HR personnel's roles. The City has engaged in training and education regarding the FRC and FAC with police,fire, EMS, the Office of Emergency Management, healthcare professionals and community partners. In March 2019,the OEM facilitated a full-scale active assailant training exercise at a local school that included a focus on the FRC.OEM has worked closely with public safety entities,community partners and charitable organizations to ensure readiness in the event an FRC is needed to support an emergency. On May 31,2019,personnel from the OEM and Human Services responded to the United Methodist Church near the municipal complex,which was consistent with the OEM's draft plan. Upon arrival,they learned that a large funeral inside the church made it a poor location for the FRC. - The team began assessing alternate locations, namely schools,when the public school representative arrived at the EOC and leadership quickly decided to transition the FRC to nearby Princess Anne Middle School.We commend the EOC for this fast-moving field decision. Human Services personnel,although largely absent in the planning phase,filled their roles. OEM looked to adjacent community OEM personnel to help support the FRC. The police commander who was assigned to the FRC by the on-scene police Incident Commander was not familiar with the concept or process and was not a trained, pre- designated commander. However,this commander met the responsibility,took ownership of the process and guided the family assistance with careful consideration of the emotional stress and impact on family members. The FRC's purpose is to provide a meeting location for families waiting to hear about their loved ones. Families were in a very tense and apprehensive environment.The longer they waited,the more they expected bad news. Interviewees shared that providing services to the grief-stricken families deeply affected FRC personnel. Families sat and waited - for information and contact from officers,friends or other families.The FRC serves a necessary function, but as time goes on, the process involved with a FRC also contributes to anxiety for the families waiting for news. In this case,the longer a family sat in the FRC,the more likely they were awaiting the news of the death of a loved one,and the families realized this. ®2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 101 Entry to the Family Reunification Center One of the early challenges was media personnel attempting to access the FRC.The FRC staff did not anticipate this unexpected and unwelcomed advance by media.Subsequently,VBPD officers were assigned to the FRC to ensure the safety and privacy of family members.VBFD personnel were called upon to assist in this endeavor by parking fire trucks to surround the entrances and vulnerable observation areas. Government representatives appeared at the FRC while families were still waiting to hear about loved ones.These visits were challenging,as FRC personnel were not prepared, nor had they prepared the families for such an interaction.Another challenge surfaced regarding interviewing witnesses who arrived at the center. Detectives needed to do interviews,and rather than moving witnesses back to a police station,the VBPD located available detectives from other functions,such a Vice Operations,to conduct the interviews at the FRC.This contributed to families'time spent at the FRC. Established protocols for this type of leveraged response did not exist. Medical Coordination with the Family Reunification Center Sentara Health,the local hospital,participated in the active assailant exercise in March,trained with City personnel and agreed to support victim management for future critical incidents.The care provided by the medical community was well regarded. However,the agreed upon information protocols faced challenges on May 31,2019. Media inquiries and the overwhelming push for information created a privacy concern for local hospitals. As a result,they were not providing any patient information, including to those coordinating the public safety response.This challenge was amplified for the OEM as the personnel identified as points of contact for hospital resources were not available to assist in facilitating the process. Notification Management at the Family Reunification Center The team at the FRC devised a systematic plan for notification whereby the immediate family members of a victim were escorted to a classroom well away from the remaining families. Counselors attended to family members in the adjacent hallway. www.hillardheintze.com 102 SECTION 3 AN EVALUATION OF MULTI-AGENCY COORDINATION,COMMAND AND CONTROL A counselor,clergy and a VBPD officer notified families of a death.The same police representative notified every family at the FRC in a consistent manner,and a police commander was present for each notification. The families were afforded time to grieve,and when they were prepared to leave,police officers escorted them out of the opposite end of the school,away from other families awaiting news.The families had mixed opinions about this process, namely the time duration, and some stated that only a police officer was present. VBPD staff began notifying families of a death at approximately 9:00 p.m.and concluded at midnight.An assisting law enforcement agency facilitated one out-of-state notification at 1:00 a.m. Post-Event Incident Management While much of active assailant training focuses on response, incident management is similarly important.Specifically,for an event involving mass casualties,follow-up operations are essential, and include activities such as interviews,data analysis,evidence review,forensic analysis and reporting. Managing the continuing investigation has been challenging for the VBPD. The resource utilization and level of effort for any examination of a mass-casualty attack is significant. For example,as we are set to deliver this review,the VBPD continues to investigate this crime.While the basics are now known to law enforcement,key information is still being processed.The FBI is still analyzing the crime scene and the shooter's personal digital records. The VBPD has conducted hundreds of interviews,yet others remain on the interview list.As various agencies gain access and insights into an enormous pool of data with either direct or potential relevance to the attack, new information continues to emerge that informs our understanding of this tragedy and, in some cases, reframes our recreation of the timeline, events and the triggers that influenced it. The City of Virginia Beach's training on critical incidents is impressive.Consistent with what we see nationally,this training has been focused on the response to the incident and its immediate aftermath.As response policies and protocols evolve to the next level,the City needs to focus on resourcing,support and policies and protocols for immediate and long-term post-incident needs. The response to natural disasters,such as floods,have evolved to include mobilization of support resources concurrent with an active incident. The May 31,2019 event was unprecedented for the City of Virginia Beach.The subsequent investigation into the crime has significantly drained the VBPD's investigative resources.The ongoing investigation,coupled with the"normal"workload of the investigators,continues to ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 103 challenge the Department.The City would benefit by including post-incident scenarios in its training,and expanding policies and protocols designed to support those needs. For example,the command and control over the investigative response to a mass-casualty incident immediately, mid-term and long-term should be reviewed.VBPD did not have sufficient investigative staff working and contacted nearby Chesapeake Police Department, with which they have a previously established working relationship.They also had to rely upon call-ins,which consumed time. Established call-back protocols would have made this effort more efficient. Midway into the investigation,the VBPD hired back retired personnel to assist in the investigation to help ease the burden.While the efforts were focused on evidentiary review, some families of those killed said they had not been interviewed well into the investigation and felt that they had no information as to what was occurring. Establishing a specific liaison function - one that is linked with the investigation and able to brief families -would have improved this situation.The Family Liaisons identified below were more focused on support services, but some of the families felt they did not have sufficient or timely information regarding what was happening.Additionally, investigation continues into digital data, documents and other evidence. Ensuring the protocols and resource considerations for digital evidence support are in place would allow for better timing and progression of the criminal investigation. 3.3 Managing People and City Services Immediate Aftermath and Business Continuity In the wake of the incident,the City of Virginia Beach quickly sought to address the impact of the attack on its employees.City leaders also anticipated a gap in the delivery of city services provided by the employees in Building 2. One City official stated that this planning effort started shortly after the establishment of the EOC. The Emergency Operations Plan (EOP) includes a comprehensive overview of the response and recovery responsibilities of the various City departments relevant to the specific Emergency Support Functions(ESF).The EOP includes multiple functional groups and defined emergency support functions for recovery. However, it did not include detailed protocols or actions for a large-scale recovery following an active assailant event. www.hillardheintze.com 104 SECTION 3 AN EVALUATION OF MULTI-AGENCY COORDINATION,COMMAND AND CONTROL Interviewees informed us that although City personnel have significant experience in responding to and recovering from natural disasters,those events typically are forecasted days in advance. This provides necessary lead time to prepare for and mitigate the impact of the event. Unlike in cases involving natural disasters,which often come with significant advance warning and lead time for planning,the City was not as well equipped to mitigate an unanticipated emergency event, especially one that involved its own facilities and employees.On May 31,2019,the City did not have a specific Business Continuity Plan(BCP)for the City or Building 2. Response of the Facilities Management Office The City started to address the anticipated challenges in dealing with a traumatized and displaced workforce shortly after the attack occurred. In total,379 employees were assigned to Building 2 on the day of the tragedy.The City's Facilities Engineer was tasked by the City and created a Continuity of Operations Plan to ensure the essential mission and functions of Public Works were met.The plan began shortly after the attack and the team tasked with ensuring business continuity was operational the following day. The Facilities Engineer learned of the attack when his director contacted him and advised the municipal complex was on lock-down and told him to report to the EOC on June 1,2019. He arrived that morning to begin working on the business continuity and relocation plan. Upon arrival at the EOC,the Facilities Engineer met with the FBI to provide facility files for its review. He then instructed staff to open a memorial site at Building 11 to offer a location for grieving individuals while ensuring the integrity of the Building 2 crime scene. He then began work with his team,including management personnel from three departments,to start to develop the continuity plan. By Sunday,June 2,2019,the City Manager had approved a comprehensive Emergency Continuity of Operations Plan(ECO)to address business continuity.The Facility Engineer,at the direction of the City Manager,assembled and led the work group that began constructing the ECO on June 1, 2019.The team worked to identify work space and the technical considerations required to create viable temporary work locations. The employees from Building 2 were assigned across the City to nearly 30 different work locations. In many circumstances,the temporary work location consisted of just a laptop and a phone. Resources were strained in addressing this significant workload adjustment.While this relocation started June 1,2019,many of the Building 2 supervisors and employees did not have access to their phones,computers or work records. Supervisors and managers described how, ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 105 memisinow while dealing with their own issues from being involved in the incident,they were charged with setting up work space and assisting personnel with relocating.The immense task of retrieving personal and needed job-related items proved problematic and stressful for many of those involved.Throughout this process,employees faced the task of coping with their own feelings regarding the attack. A BCP helps to identify and mitigate risks in a less stressful manner during a traumatic event. Specifying the details of command oversight and specific tasks and roles associated with the relocation within the BCP would have allowed for an easier transition into recovery. Future Planning Anticipating gaps in services and staffing during emergencies,and especially mass-casualty events, is a challenge for any organization and community that has to respond to a tragedy.As of the date of this report,it still isn't clear whether all Building 2 employees will return to work or even choose to remain employed with the City.Workforce planning issues need to consider how and when roles will need to be staffed with replacements or new employees. Temporary work locations were identified and staff began the job of ensuring the availability of IT and other key resources to commence work. Some of the parties interviewed stated that the temporary work locations have not always been conducive to specific duties,such as posting call takers in one large, noisy room. Employees often have little-to-no privacy,and parking and access can be limited in the new locations. Many employees have been relocated to places that require a longer commute to and from their homes. Most of these issues are to be expected when dealing with emergency needs for a new temporary location. However,as time goes on, many relocated employees are becoming concerned about whether initially temporary changes will become permanent. Employees interviewed also raised the issue of safety and security at the temporary facilities in multiple locations. Employees report that they believe that security features have not been prioritized in the new work settings. Most of the new office spaces use an open floor plan.Access in the new locations is not always controlled,they emphasize. For many of the employees interviewed,the emotional impact of the shooting lingers. For those who survived by being locked in an office behind a door with a barrier placed against it,an open floor plan can provoke anxiety. As the City establishes and identifies new, permanent work locations,some of these safety and work/life balance considerations weigh heavily on the minds of its employees. www hi llardhe intze.com 106 SECTION 3 AN EVALUATION OF MULTI-AGENCY COORDINATION,COMMAND AND CONTROL ININNIIIIMME The data concerning the impact on City services provided by the employees from Building 2 is limited.The personnel from Building 2 provide significant services to the building and contractor trades.Without timely access to and delivery of permits and inspections,the work and livelihood of many in the City have been affected. Employees indicated that while the public was initially supportive,its members expect City services to be delivered in a timely manner.The public's patience and empathy has given way to aggravation by some and, in some cases,to verbal abuse. For a workforce already under duress,the inability to provide the expected levels of service is increasing levels of stress. Multiple variables contribute to the delays in services,some of which will not be rectified in the immediate future.These variables include the unfortunate loss of key supervisors and multiple employees with tenure and experience.As a result,the efficiency and effectiveness of the services provided by Building 2 employees have been hampered.Some employees have not returned to work,while others are essentially working part-time. Most are dealing with post-incident trauma that affects their work performance.As indicated previously,the temporary work space is not conducive to optimum work performance for some employees and this,too,weighs on overall efficiency.The lack of security,privacy and an efficient work space remain a concern and distractions for many employees. Post-Event Employee and Victim Engagement and Support Honor Guards/Family Liaisons The City has a system of Fire and Police Department members who are trained as Honor Guards. In this role,these personnel provide support for ceremonies, memorials and special events and attend funerals as representatives of the City. The City's Department of Public Safety assigned Honor Guards as Family Liaisons to the survivors and families of the victims involved in the shooting as a sign of respect and to help provide support and information following the horrible event. Anytime a victim's family needed contact or information,(e.g., payroll, health care benefits),the Family Liaison would connect them directly with the appropriate City personnel.The VBFD and VBPD coordinators would brief City leaders on issues and the progress in supporting the families. This service is provided following the death of active duty first responder,so the practice was familiar to the members of the Honor Guard. All Honor Guard members were volunteers and served,as requested,as flag bearers and/or pallbearers depending on each family's request.The Honor Guard roles and level of support varied ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 107 significantly based upon family preferences. Each victim's family is different,as some families have strong support networks nearby- immediate and extended family members,Church support and strong friendships -while others are more isolated and require more help and support.Some Honor Guard members were assigned to a family or survivor for a relatively short timeframe. These members aided with errands and answering questions.Other Honor Guard members supported the families at the funerals for their loved ones,stayed with the families in their homes for brief time periods and provided answers,information and emotional support. Some Honor Guard members provided ongoing support for several months with constant availability. The families became reliant upon their presence and the members serving as Honor Guards have demonstrated support and dedication to the families. Most families found comfort in their service and many felt honored by this assignment.The Honor Guard was able to provide direct information and direct points of contact to address the early issues of pay,insurance and funeral services.As time has progressed,some family members have found less information made available to them, primarily with respect to the active criminal investigation.The duration of the Honor Guard assignments exceeded what public safety leaders anticipated,although they recognize the value of the service and remain dedicated to providing support to the survivors and victims'families. However,the City has transitioned this role to a private charity to support family needs now and in the near future. Employee Services/VB Strong Center Recently,the City has partnered with Sentara Healthcare to open the VB Strong Center. Its goal is to foster the resilience of the community of the City of Virginia Beach through education, resources and direct support for anyone impacted by the May 31,2019 tragedy.Opened on October 29,2019,the Center is still establishing its services and how it provides care and support to the employees of Building 2,as well as others impacted by the tragedy. Ideally,any transition in the type and location of services will be structured and communicated to employees, highlighting the benefits of any such transition along with practical guidelines for employees. 3 RECOMMENDATIONS, 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. www.hillardheintze.com 108 SECTION 3 AN EVALUATION OF MULTI-AGENCY COORDINATION,COMMAND AND CONTROL 3 RECOMMENDATIONS 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 pre- planned 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 follow-up 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. 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 ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 109 3 RECOMMENDATIONS £° 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 role- focused 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. 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. www.hillardheintze.com 110 SECTION 3 AN EVALUATION OF MULTI-AGENCY COORDINATION,COMMAND AND CONTROL 111111111111111111111111111111 3 RECOMMENDATIONS 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. ©2019 HILLARD HEINTZE Section 4 An Appraisal of the City's Workplace Violence Prevention Capabilities The City of Virginia Beach:An Independent Review of the Tragic Events of May 31,2019 HILLARD iwp HEINTZE A JENSEN HUGHES COMPANY 112 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES u SECTION 4-AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES This section highlights where gaps are most evident and outlines program capabilities that need to be put into place in order to manage the risks associated with potential violence occurring on the City government's premises. In addition to studying the attack itself,the response in the minutes and hours that followed,and the actions the City took in the weeks and months afterward, the Hillard Heintze team also examined the City's readiness and ability to prevent this attack and others -specifically with respect to four critical areas. FOUR CRITICAL AREAS OF FOCUS 1 The physical and technical security measures in place in Building 2 2 The City HR Department's structure and operational model 3 The City's HR and workplace violence prevention policies 4 The need for a formal workplace violence prevention program ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 113 4.1 Physical and Technical Security Measures in Building 2 Facility Security Like other government entities and facilities,the City of Virginia Beach is challenged to ensure both open access for the public to key municipal services and also a secure work environment for its employees. Workplace violence prevention relies in part on building construction. Most buildings are not designed with active assailants in mind, but that mindset is changing as more and more spaces, from schools to government buildings,are affected by these tragedies. The City manages more than 200 buildings of various age,construction and purpose. Building 2, also referred to as the Operations Building,is part of the Virginia Beach Municipal Center. Only the IT Department remains working in Building 2.The building included work space on five levels.Areas unoccupied since the shooting include: Three primary floors Partially finished area in the attic or penthouse level Four City of Virginia Beach departments held primary offices in the building: IT Department on the basement level Planning on the 1st floor Public Utilities on the 2nd floor Public Works on the 3rd and part of the 4th floor The nature of the business conducted by the Planning, Public Utilities and Public Works Departments on the three primary floors required routine interaction with the public. Exterior doors are located on all four sides of the first floor.The North and South entrances served as the primary public and employee entrances. During the work week, both entrances automatically unlocked from 6:00 a.m.to 6:00 p.m.The two emergency evacuation stairwells for the building are located near the North and South entrances. Exterior doors on the East and West sides always remain locked. www.hillardheintze.com 114 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES An access control system(ACS)card issued by the City of Virginia Beach required appropriate authorization to operate the East and West doors.The use of an authorized ACS card was required on all the building exterior entrances after hours,on weekends and on holidays. The basement loading dock doors also automatically unlocked on a similar schedule to the North and South entrances.Two elevators were available for employee and public use from the basement to the third floor.Security officers assigned to fixed posts were not in place before the May 31,2019 attack. The City of Virginia Beach has not developed a formal written minimum-security standard for all City-owned or operated buildings. Department heads are When Building 2 was responsible for requesting,planning and funding constructed in the 1970s, security improvements. No single department or its design- consistent with individual is responsible for overall physical and most buildings of that era - technical security. Different departments or did not address the risk of subdivisions handle discrete portions of the Virginia an active shooter or Beach security program applicable to Building 2. assailant. Key and lock control falls under the Building Maintenance Division of Public Works. The City's ACS is the responsibility of the Public Works Facilities Manager's Office. Planning and implementation of the security video management system is the responsibility of one individual within the Department of Information Technology. This approach contributes to both actual and perceived gaps in the level of security at different facilities or within the same building.The City of Virginia Beach would benefit from an integrated security program that is managed through a single department with accountability residing with one individual. Physical and Technical Security The City of Virginia Beach's primary security technology platforms are United Technologies Lenel OnGuard for access control and Genetec Security Center for security camera video management. Building 2 has a Honeywell Notifier NFS-320 Fire Life Safety alarm.All three systems are considered leading security industry solutions. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 115 During our on-site assessment,we observed differences in various Building 2 departments' security.The ACS and visitor management system(VMS)used by the City of Virginia Beach are not integrated,and this was also the case in Building 2. Doors in Building 2 equipped with ACS controls include magnetic door-position switches designed to detect forced entry and doors left propped open. However,the system is not actively monitored, rendering any intrusion detection value ineffective. Panic buttons are not used in Building 2. Panic or emergency call buttons provide a method to alert others if a response is required. Fixed position buttons placed at key locations such as department reception desks and key administrative staff and manager offices - supplemented by marked and visible wall-mounted buttons - provide a method to notify a central monitoring location that assistance is required or to activate alert devices in the vicinity of the alarm. Access Control System All Virginia Beach employees and a limited number of individuals with recurring City-related work responsibilities are issued photo identification badges reflecting their name,department and photograph when hired by the City.City policy requires that the badges be worn anytime the individual is on City property.The employee's supervisor is required to specify the level of access the individual needs to complete his or her job functions on the identification request form. Managers are responsible for recovering badges when an employee is separated from City service or when a vendor completes City-related work. The Facilities Managers staff uses a daily log for card deactivation. Deactivation results in an individual's access card no longer providing access to any space previously authorized. Under the policies in effect on May 31,2019,the subject's two-week notice email would not have initiated an immediate ACS card deactivation.The subject provided two-week notice with his resignation,so access would have continued for that time frame that he remained employed. All Building 2 perimeter doors were equipped with card readers.The North and South entrances and basement loading dock door were programmed to unlock automatically at 6:00 a.m.and relock at 6:00 p.m.to accommodate public access. Movement within the common public hallways was unrestricted.The public hallway connecting the North and South stairwells separated the East and West halves of the 2nd floor. Only two of the four departments in the building used ACS controls to limit access from the common public hallways to employee work areas:the IT Department in the basement and the Public Utilities Department,which was the subject's work location,on the 2nd floor. www.hillardheintze.com 116 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES Figure 3:Diagram of Card Readers on 2nd Floor of Building 2 --- 1[Thriniism.--1•11.1170111 — — ip....... ....._77 __.... _ , r imPuipitsi _-__. ' EJ - ' I , _ ... r______,H-r-rTh'j_T . 2-01 1 't. , L II M .. �rl,._ is I lilt and. L "1r i , itai 10 le y - } 1 0_._ 11 s. M.i.la I tl, I_r7— e wa+MAw-mui*t w.e N 0 —•)0. 0ag.m..', ...p w ,. ..., w rro ,r.E h r.r.if--1Ir".t. MM. I 11: �. '''. r .1. ilwa I it •-'..- all J i JO — I oaili 1 Building 2-2nd Floor Card Readers Used in Attack ��i 2-01-2nd Floor,West side,South Hall,Business Unit N 2-05-2nd Floor,East side,South Hall.Engineering 2-04-2nd Floor,East side,North Hall Engineering a,#. Address.Rradrr Numbs- Key and Lock Control Authorized personnel seeking access rely on ACS credentials rather than hard keys on buildings equipped with ACS controls.The Facilities Management Office, Building Maintenance Division keeps master keys for all keyed doorways and makes keys for departments that request keys to the buildings that they occupy.Acquiring a hard key requires the employee's supervisor to ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 117 complete and submit a work order to the Building Maintenance Division.The City uses four primary keyways on a master system hierarchy. Building Maintenance Division staff estimate that over 20 additional secondary keyways are in use.The Facilities Management Office does not have a key control program to identify how many keys have been issued,or to whom they have been issued.As a matter of practice,when a department determines that one of their employees needs a key to a space occupied by that department, it sends over a representative to get a key made.As a result,the City does not know how many hard keys exist. Building 2 features several different types of door lock hardware.ACS-controlled exterior doors are equipped with magnetic locks. Interior ACS doors include magnetic locks and electric locks (e.g.,electric strike)on the Public Utilities and IT Department hallway doors.Several doors off the public hallway not used for routine employee access have both key-operated and manual push- button locks. Interior employee work spaces,including offices,are equipped with key-operated or push-button manual locks. The presence of numerous lock types requiring differing inputs to open(e.g.,authorized ACS badge, manual push button code and hard key)likely contributed to first responders'delay in entering the facility.A Knox Box designed for key storage is mounted on the exterior of Building 2.The use of this type of key storage device is a common practice to provide building access to responding Fire Department staff.The Building 2 Knox Box was not accessed prior to the subject's detention,as discussed previously in Section 3. Security Camera System The City of Virginia Beach uses Genetic Security Center as the primary VMS.Axis is the City's preferred camera provider. 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.Should an incident occur in an area with security camera coverage,stored images are reviewed after the event,as needed, by City personnel. Security camera coverage in Building 2 was limited to the IT Department and the hallway approaches in the basement where the Department was located. Security cameras are not placed on the other levels and therefore video did not capture the attack or the police response on the upper levels. Fire Life Safety A recently updated Honeywell Notifier NFS-320 fire panel protected Building 2. Blue Ridge Monitoring Company provided fire panel central station monitoring service.As discussed earlier, an employee inside Building 2 activated the fire alarm during the May 31, 2019 attack.The VBFD, Engine 5,was one of the first responders on the scene, based upon the active shooter dispatch. When the alarm was pulled,VBFD was already on scene and responders knew it was not a fire. www.hillardheintze.com 118 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES Our review of the ACS system badge activity logs confirmed that the ACS-controlled doors on the 2nd floor did not release upon fire alarm activation.Automatic release is not required because the doors equipped with ACS controls do not restrict access to the emergency evacuation stairwells. Door security is critical to prevent;an attacker from gaining entry by activating the fire alarm. Emergency Alert and Notification System The City of Virginia Beach has several mass notification systems available to notify staff and citizens of an incident and relay emergency information and instructions.The current emergency alert service is being replaced with a new alert platform.The existing program suffered from poor employee self-enrollment with a limited number of message groups and pre-programmed incident messaging capabilities.Conversion to the new alert platform is ongoing. How the City used the messaging systems on May 31,2019 is discussed further in Section 3. The City's VBAlert is part of the Rave Smart911 tool.This system is also an opt-in program and requires accurate input of at least one type of multimodal contact method - ideally a cellphone number though an email address is acceptable -to receive information.The City also used E Staff 911(EMS), P Staff 911 (police)and F Staff 911(fire)to send and link emergency call information with the computer-aided dispatch(CAD)incident number.This system provides the first responder recipient the information required to access incident information from any CAD terminal. On the day of the attack,the City HR Department's Communications Director sent an email to the "All Users"distribution group at 4:22 p.m.with the subject,"Urgent:Shelter in Place @ Mun.Ctr. until further notice."The email body stated,"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."The emails below were the only mass notification sent to employees on the Municipal Campus and in Building 2. A follow-up email was sent at 4:54 p.m.with the same subject line,stating in the email body,"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!" A third and final email was sent,still from the City HR Department's Communications Coordinator,at 5:55 p.m.with the subject"All Mun.Ctr. Employees can leave except for Bldg. 2 employees",stating in the email body,"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 ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 119 officials will inform Bldg.2 employees when it's safe to leave. Please drive safely when leaving.Thank you." Building 2 is not equipped with a public address(PA)system other than the capabilities incorporated into the fire alarm system.The fire panel PA was not used during the attack. Appropriate building-wide messaging using a PA system would have been difficult given the dynamic nature of the attack and the uncertainty about the number of assailants and their location. 4.2 The City HR Department's Structure and Operational Model The City HR Department relies upon its management units to address most employee HR needs. The majority of employee engagement is decentralized,including all performance improvement plans and discipline decisions that result in up to 40 hours of time off.Staff within the various departments are tasked with HR-related duties,but most are not trained in HR and most perform other duties.As outlined elsewhere in this report, under the decentralized approach to managing employees' performance and behaviors that could affect the workplace,there is no indication that HR had knowledge or received information directly from employees or third-parties of any concerns regarding the shooter's behavior in the workplace. We do,however, note concerns regarding the structure and approach of the City HR Department and how it engages with City employees and managers. It is not a cohesive relationship. The Role of an Effective HR Organization An effective Human Resources department(HR)assists both management and employees in addressing employee and workforce needs. HR serves a critical role in conflict resolution and performance improvement and in ensuring equitable practices and support for managers in addressing employee behaviors. Professional HR staff should be available to assist managers in evaluating performance reviews,to help identify professional development and performance issues and to develop policies,training and protocols for interventions that redirect problem employee behavior. Helping to align improvement plans and subsequent discipline is a key HR function. Finally,as discussed later in this chapter, HR is instrumental in developing and leading workplace practices focused on the prevention of workplace violence. www.hillardheintze.com 120 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES A Decentralized Organizational Structure The City HR Department's structure does not support viewing employee performance and behaviors holistically. HR is organized into four divisions: Learning& Development,Staffing& Compensation,Occupational Safety&Health and Employee Relations.The majority of employee HR engagement,however,is left to unit managers and their staff- most of whom are not trained or equipped to deal with problem employees. Each management unit has an HR Liaison who fulfills most of the basic HR functions within the unit.The annual performance evaluations,day-to-day engagement and workplace issues are addressed by staff not aligned with the City HR Department.The structure is not conducive to a comprehensive approach to employee management.The lack of ongoing,structured and direct engagement with managers and HR Liaisons creates gaps in information. Identifying and engaging with employees and their managers is difficult without a consistent,structured approach to employee satisfaction,development and performance. The Role of HR Liaisons Most of the City's departments include one or more individuals who are designated as HR Liaisons. In concept, HR Liaisons are to serve as conduits for employee needs from the department to the City HR Department and perform most of the HR functions at the unit level. However,in practice,the City HR Department and the HR Liaisons rarely interact with one another,and as a result, most of the HR functions for City personnel are driven at the unit level without professional HR guidance. HR Liaisons are full-time City employees tasked primarily with other functions who report directly to individual department management, not to HR.16 They vary widely in HR-related experience and training and most carry HR assignments in addition to full-time job duties. Not all of the assigned HR Liaisons have the experience or training to advise managers on employee issues. Additionally,with individual HR Liaisons acting autonomously,the overall HR function lacks consistency from department to department.The ability of a unit's HR Liaison to advocate on behalf of the employee affected by a manager's decision is also limited because the HR Liaison reports to the same chain of command. 16 The only exception is the Police Services Department,which has a dedicated HR Coordinator reporting directly to the Employee Relations Manager. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 121 These HR Liaisons are embedded throughout the organization in the following departments: in Aquariums/Museums,Agriculture,City Attorney,City Manager,Convention and Visitors Bureau (CVB),Cultural Affairs, ECCS(9-1-1/3-1-1), Economic Development, EMS, Finance, Fire, Housing, Human Services, Information Technology, Libraries, Management Services, Media& Communications, Parks& Recreation(PAR), Landscape, Planning, Police, Public Utilities, Stormwater/Wastewater, Public Works, Real Estate and Sheriff. Reliance on Direct Managers Rather than HR and Legal Experts The role of an effective HR department is outlined above - but it is most critical when engaging with difficult employees.The legal landscape is challenging- particularly for government employers.A range of statutes,administrative rules and regulations govern the workplace. In the City of Virginia Beach,managing these complexities falls primarily to direct managers rather than trained HR professionals.The City's use of non-HR experts to fill HR functions at the unit level is not limited to the HR Liaisons. Direct managers are tasked with making many decisions about employee matters.The City HR Department is not involved in most of these decisions and has little to no visibility in the ongoing issues within the various departmental units including disciplinary suspensions without pay up to 40 hours. Poor HR Visibility into Employee Performance The City HR Department is not structured to provide visibility into the progression of an employee's performance and therefore is often not engaged to identify early warning signs and prohibited behaviors.This lack of visibility also undermines HR's ability to identify strategies to mitigate the situation and intervene to address behaviors. Managers administer employee improvement programs based on their interpretation of the policies prescribing acceptable behaviors in the workplace, including areas such as sexual harassment,compliance with the Code of Ethics and workplace violence prevention.The employee's manager, not a City HR Department representative,is the one who determines whether performance aligns with the policies,where it is not compliant and whether discipline is warranted.This same manager then has the authority to implement discipline based upon this determination. Unit managers have the ability to administer discipline measures, including suspension of up to 40 hours,which is a significant financial impact for many employees.This entire process remains within the unit under the guidance,direction and determination of the unit manager. Managers can seek City HR Department assistance, but this is not seen as helpful and in www.hillardheintze.com 122 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES some cases is challenging for managers to engage or follow the advice,in part due to the lack of early engagement with the City HR Department in developing strategies. Structural Challenges for the City HR Department The reliance by the City HR Department on individuals outside their reporting structure creates confusion and inconsistency in managing employees.The units,through the HR Liaisons and direct managers, have wide latitude to address HR-related issues.This leads to the following outcomes: • Confusion among employees about the role of HR and who they need to engage with on issues • Perceptions that two different HR functions exist,"HR"and"City HR,"although employees work for one employer Conflicts of interest,both real and perceived,for HR Liaisons who are direct reports to operational managers addressing employee performance and other matters • Concerns that there is not a resource to assist employees who are facing challenges with their managers Managers who do not feel supported by the City HR Department _- City HR Department staff who feel they are not timely engaged to be able to support the needs of managers and employees Inconsistency across the Organization in How the City Addresses HR Issues Without a strong and unified HR function operating consistently and effectively throughout the City,the City's employees are more likely to be supervised inconsistently and ineffectively.It places significant responsibility on managers to both supervise and manage HR practices that may result in unnecessary confrontation and friction in addressing problem employees. Employees who believe they are not being treated fairly may feel they have little recourse to address what they perceive as unfair or abusive actions.This helps explain comments employees shared with the assessors that their concerns go unaddressed and that they have little to no options for"being heard."An independent HR function would ensure fair and equitable responses to inappropriate workplace behaviors and allow managers and employees to focus on performance. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 123 4.3 The City's Policies Related to Workplace Violence Prevention While many of the City's policies can be viewed as directly or indirectly impacting workplace violence prevention,threat assessment and the security and safety of the workplace,the majority of these can be categorized as falling principally within the following three domains: 1 Physical and Technical Security- Effective security requires the ability to control access to physical locations, monitor for compliance or crises and enhance intervention, mitigation and response. 2 Human Resource Management and Planning-Violence and its prevention is fundamentally about people,behaviors and culture. 3 Workplace Violence Prevention - Preventing an act of violence in the workplace is a highly specialized capability that depends in part on best-in-class protocols in HR management, physical security and technical systems, but extends well beyond them. Recruitment,Hiring and Background Investigations RELEVANCE TO THE MAY 31,2019 ATTACK Based on the evidence examined,the shooter did not exhibit any readily apparent issues before the City hired him that would have raised concerns and prompted either additional investigation or a decision not to extend him an offer of employment. SIGNIFICANCE OF THIS POLICY It's important to recognize that the hiring process -from recruitment through background investigation - is the earliest opportunity the City has to prevent future violence by ensuring it is bringing in candidates who meet the requirements of the position,with respect to knowledge, skills and experience but are also well-adjusted individuals who represent a good fit within the City's governing and administrative culture and environment. Careful candidate screening not only enhances the safety of the workplace through detection of concerning behaviors or violent history, but has also reduced turnover and deterred fraud. Advanced violence prevention programs involve an educated workforce led by HR professionals in collaboration with security and legal counsel who can cultivate a culture of caring within the organization.These programs educate people about how to address restraining orders, identify concerning behaviors and handle other troubling but non-violent situations that may occur in the workplace. Policies with punitive overtones, like"zero tolerance,"can make people resistant to www.hillardheintze.com 124 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES reporting concerning behaviors.When implemented properly,programs avoid creating a whistleblower mentality. Instead,they promote courtesy,respect and safety. EVALUATION OF CITY'S EXISTING POLICY AND PROCEDURES The City of Virginia Beach's hiring process is documented in the Recruitment,Applications and Employment Policy,which was last updated on November 28,2018. HR provides training on the hiring process to new supervisors four times each year and twice per year to tenured supervisors. The training includes information on incorporating behavior-based questions into the interviews and interviewing techniques.The HR Staffing and Compensation Division and the hiring department or manager coordinate the hiring process,wherein HR staff ensure the process follows HR and the City of Virginia Beach's Equal Employment Opportunity(EEO)policy. EEO policies are the responsibility of the Department of Human Resources Employee Relations Division.17 For example,this policy dictates that all candidates who receive a conditional offer of employment are required to submit to criminal background checks.The policy also prescribes that HR personnel must call the candidate's references,and the hiring manager needs to verify academic history,licenses and certifications.18 The criminal background check is conducted by the VBPD. The City follows good practice in requiring a successful completion of a criminal background check before allowing new employees access to the workplace. However,the validation of references and qualifications is also a significant step in ensuring workplace safety-a candidate should be truthful and the references should be able to provide insight to the hiring process.This critical step is left to the unit hiring manager-who may or may not be sufficiently versed in conducting this validation.Additionally,the decision for sufficiency remains within the unit. Many municipal employers provide for standardized background reviews within a single unit rather than relying upon multiple hiring managers to conduct background reviews. 17 https://www.vbgov.com/government/departments/human-resources/Pages/equal-employment-opportunity.aspx. 18 City of Virginia Beach.Recruitment,Applications and Employment Policy.Policy Number:1.01.Date of Adoption: November 11,1991.Date of Prior Revision:December 2008.Date of Current Revision:November 28,2018 ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 125 Code of Conduct RELEVANCE TO THE MAY 31,2019 ATTACK A Code of Conduct provides specific notice of required workplace behaviors.The City of Virginia Beach does not have a stand-alone Code of Conduct but relies,instead, upon a series of policies and protocols that address employee conduct. The City has a Code of Ethics, but it is focused on expectations with respect to public integrity more so than conduct or behaviors.As an example of a potential integrity issue,the subject had approved work to proceed without a contract and this resulted in a $3,027.48 payment order that was not approved for payment.The City's Finance and Purchasing Department identified that this was a legal violation,that the work could not be approved and therefore the funds could not be encumbered. However,the subject's managers told him this was not a problem and that they would handle this issue.A clearly defined and communicated Code of Conduct would identify not only the expectations but also the anticipated outcomes. SIGNIFICANCE OF THIS POLICY A Code of Conduct is a key component of ensuring appropriate workplace behaviors.This policy is a crucial factor in preventing workplace violence,serving to identify appropriate standards of conduct and allowing for consistent, impartial and timely efforts to address prohibited behaviors. A Code of Conduct allows the employer to address improper behaviors with consistent and fair interventions.The goal should be redirection of poor performance,with discipline as a later option. EVALUATION OF CITY'S EXISTING POLICY AND PROCEDURES The City does not have a formal,stand-alone document for its Code of Conduct. Instead, employee performance standards are addressed in other documented policies such as the City's Code of Ethics and individual policies,such as Weapons, Harassment or Workplace Discrimination. These policies include standards that are recognized as best practices. However,a single Code of Conduct serves as notice to all employees of the expected standards that the City holds for them. It also is a transparent way to ensure that the standards are consistently met and applied. www.hillardheintze.com 126 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES Grievances RELEVANCE TO THE MAY 31,2019 ATTACK The attacker perceived that he was not being treated fairly at work.We determined this through interviews with those he spoke to,through emails and verbal discussions with his supervisors and managers,and through some of his draft emails that he never sent. He perceived others were not treating him with the same level of fairness extended to coworkers with the same job description. After the subject received a Written Reprimand for Poor Performance on July 12,2018,he initiated the formal grievance process on the departmental level,completing the first three steps in the process. However,after initiating Step 3 - Department Director,the subject ultimately chose to end his grievance process in September 2018 and did not elect to move on to Step 4,in which he would have appealed his grievance to the Personnel Board. SIGNIFICANCE OF THIS POLICY The ability to grieve unfair employer actions gives voice to employees who feel that the employer has not recognized all of the facts involved in an employment issue and that the identified disciplinary action is not equitable or fair.Allowing for a consistent,documented and impartial grievance process allows the City to create an environment wherein an employee will not face "acts of retaliation because the employee has(i)used or participated in the grievance procedure; (ii)complied with any law of the United States or the Commonwealth,(iii)reported any violation of law to a governmental authority; (iv)sought any change in law before the Congress of the United States or the General Assembly,or(v)reported an incidence of fraud,abuse or gross mismanagement."19 It provides a level of checks and balances over employee responsibility and management authority. EVALUATION OF CITY'S EXISTING POLICY AND PROCEDURES The City's grievance policy is consistent with those of other employers, including governmental entities. It stipulates the need to"establish open communications between a supervisor and an employee for the resolution of grievances arising from employee concerns with his or her working environment."The policy's stated goal is to"obtain a complete understanding of employee concerns and to have them settled as soon as possible at the lowest possible supervisory level commensurate with a fair and equitable settlement."20 If an employee elects to grieve a matter, 19 City of Virginia Beach Grievance Policy and Procedure.Policy Number:4.04.Section 2.1.A.(4)Date of Adoption:1965. Date of Prior Revision:October 10,2011.Date of Current Revision:December 28,2016 20 City of Virginia Beach Grievance Policy and Procedure.Policy Number:4.04 Date of Adoption:1965.Date of Prior Revision:October 10,2011.Date of Current Revision:December 28,2016 ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 127 the Director of the City HR Department has the authority to determine if it is a matter for grievance.The steps for the grievance policy are clearly defined and consistent. Discipline RELEVANCE TO THE MAY 31,2019 ATTACK Hillard Heintze's review and assessment have confirmed that there were no significant,formal disciplinary actions involving the perpetrator. SIGNIFICANCE OF THIS POLICY It is a best practice for an employer to address concerning behaviors as early as possible.The key to a supportive approach is discerning the difference between prohibited behaviors(such as fighting or direct threats)and concerning behaviors(signs of depression,suicidal ideation, constantly blaming others or disruptive behavior that causes fear). Early intervention and redirection of concerning employee behaviors should be the focus of the City HR Department,including appropriate referrals to EAP and other corrective measures. Whenever employees consistently engage in warning behaviors or in prohibited behaviors,then discipline is an appropriate response. Discipline should be proportional and equitable. It allows the employer to maintain consistent standards in the workplace and ensure that actions of employees do not place other employees or the public at risk. Over the long term, punitive approaches are seldom effective in the early intervention of concerning behaviors or warning signs that may or may not have contributed to sub-par performance. However,when discipline is required,it's important to ensure a fair and impartial investigation. Establishing an independent investigation and a clear distinction between the investigation and the determination of discipline are good practices and grounded in transparency,independence and avoidance of potential bias. Inclusion of HR staff early in the process, particularly for significant discipline,ensures that policies and legal standards are met - as well as provides for a professional, unbiased approach into the investigation of the alleged misconduct. EVALUATION OF CITY'S EXISTING POLICIES AND PROCEDURES The City's discipline-related policies are well-documented.The unit manager is responsible for discipline up to suspensions of 40 hours.The City HR Department is responsible for overseeing significant disciplinary actions against employees,including dismissal,demotion, reductions in pay or suspensions over 40 hours.The policy is consistent in terms of documentation and approach for discipline. www.hillardheintze.com 128 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES The City's policy requires that,before imposing any discipline,supervisors must conduct an investigation -a fact-finding process.The extent and formality of the investigation depends on the individual circumstances of the policy violation,misconduct or performance issue.The fact- finding investigation is required to be conducted as soon as practicable 21 As noted above in this report,the City's supervisors are not trained to conduct employee investigations. Having untrained supervisors conduct their own investigations into allegations of employee misconduct,often without HR guidance or input,creates an opportunity for conflicts of interest and bias,particularly if the issues stem from operational requirements or unit rules and practices.Also,locating investigations within the specific work unit leads to weaker controls over confidentiality and challenges in providing an unbiased and independent investigation.Additional limitations of the City's policies and procedures follow. • The City's policies do not address how to effectively support and engage poorly performing employees, nor how City supervisors and managers should interact with the employees,collect insights and information,and help redirect these individuals. • The City HR Department does not have a formal designated role to ensure discipline is consistently and appropriately handled in accordance with the City's policies and standards.As a result,each unit follows its own standards and processes with wide variation across the City. • Supervisors are both investigator and adjudicator;they are responsible for conducting "fact-finding"investigations and for imposing discipline.This is not a good practice,as supervisory decisions not only affect the specific matter under review but also control the employee's overall work environment. Many pre-cursor behaviors for workplace violence are lesser violations of employee conduct standards. HR has no responsibility for maintaining visibility on these issues,as supervisors are only"encouraged"to consult with HR prior to taking any disciplinary action.The manager may be left to engage with employees exhibiting behavioral issues or poor performance without the skills or tools to help redirect that employee's activities. When a City employee perceives a lack of fairness by a manager,or if in fact there is an issue,an unhealthy dynamic develops as the manager both determines the outcome and penalty for workplace transgressions.The employees may feel they have no voice in their workplace or opportunity to engage a neutral party.While an employee retains the right 21 City of Virginia Beach Discipline Policy and Procedure.Policy Number:4.02 Dote of Adoption:May 12,1977 Dote of Prior Revision:October 2,2012 Date of Current Revision:April 25,2016 ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 129 to go to the City HR Department,this is not perceived as an option. Many we spoke with on this topic felt the City HR Department would not engage in lower-level issues. The City HR Department doesn't have a centrally located and standardized method for tracking all employee investigations and complaints.A database would provide a holistic view of the employee's performance within the unit and allow comparisons from a citywide perspective,thereby reducing any potential employee/manager bias. The bifurcation between Type A discipline(i.e.,dismissal,demotion or suspension for more than forty(40)consecutive working hours)and Type B(i.e.,all other types of discipline)is an arbitrary standard.Suspension without pay for up to 40 hours is a significant issue for most employees. For example, policy allows a wide latitude for supervisors to impose discipline without consulting with the City HR Department first if the discipline is a suspension of less than 40 hours. Policies should support procedural justice regardless of the length of suspension,and City HR should be involved to ensure consistent,appropriate standards are met for all investigations. Under the current policy,consistency is seemingly in place only for suspensions involving more than 40 hours.The policy states that"supervisors are encouraged to consult with the Department of Human Resources Employee Relations Division prior to taking any disciplinary action; however,supervisors,or the person in the supervisory chain authorized pursuant to departmental policy to impose a dismissal, demotion,administrative decrease or suspension for more than 40 hours,are required to contact the Department of Human Resources, Employee Relations Division or Director's Office prior to initiating such discipline for review and recommendation."22 i ermination of Employment RELEVANCE TO THE MAY 31,2019 ATTACK Our review of the City's policies and the documented employee performance issues did not identify any behaviors that would have resulted in the attacker's termination of employment based on his workplace performance. Other employees offered varying opinions as to whether the issue of the work the subject authorized without a signed contract and subsequent challenge with obtaining payment would potentially have resulted in the attacker's termination of employment. Most stated it would not. However,work conversations between coworkers and managers, 22 City of Virginia Beach Discipline Policy and Procedure Policy Number:4.02 Date of Adoption:May 12,1977 Date of Prior Revision:October 2,2012 Date of Current Revision:April 25,2016 www.hillardheintze.com 130 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES evidenced by the email messages and voicemails left for the subject,indicated that this issue was a concern for him. Unrelated to the attacker was the fact that another employee received notice of termination of employment on May 29,2019.Consistent with City policy,23 this individual was formally terminated from his employment on May 30, 2019.When the attack first erupted on May 31, 2019, many City employees initially believed this former employee to be the attacker.Other managers and employees in Building 2 indicated that they were not aware of the termination of employment of this other employee. However,those who did know said they learned of it through informal communication. Many employees had concerns that this other individual could commit an act of workplace violence and felt this issue was not addressed properly by management. SIGNIFICANCE OF THIS POLICY Termination of employment is a form of discipline,albeit one that requires a more formal practice and approach.When an employer moves to terminate employment,this is a critical juncture for the employee as the source of income will be terminated as well. For difficult employees,or those displaying inappropriate workplace behaviors,it also creates a risk factor. If an employee is not well-adjusted,the potential for violence increases. Understanding the issues leading to the determination that separation of employment is warranted is critical to ensuring appropriate management responses.This requires engagement by the City HR Department that provides a holistic view of the employee, including additional information,intelligence or evidence of the factors that would indicate an intent,motive or capability of committing an act of targeted violence. The term"targeted violence"is defined as any incident of violence in which a known or knowable attacker selects a particular target prior to his or her violent attack.24 Finally,for the employer,the protocols and practices that guide termination of employment need to meet legal guidelines, reduce risk of retaliation and ensure consistent,humane approaches.Given the personal,safety and legal risk associated with termination of employment,employers should ensure policies and procedures are clear and comprehensive,addressing safety, legal and employee issues through a coordinated and documented approach. Many HR departments disseminate a standardized termination of employment and/or suspension checklist that identifies key risk factors, policies and procedures to ensure a process for safely removing an employee. 23 City of Virginia Beach Separation from Employment Policy.Policy Number:6.01(A)Date of Adoption:July 1996 Date of Prior Revision:December 10,2012 Date of Current Revision:December 28,2015 24 1 See Fein,R.A.,Vossekuil.B.&Holden,G."Threat Assessment:An Approach to Prevent Targeted Violence."Research in Action.U.S.Department of Justice,Office of Justice Programs,National Institute of Justice:Washington,D.C. (September,1995),at 1-7.NCJ 155000 2 U.S.Department of Education. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 131 EVALUATION OF CITY'S EXISTING POLICIES AND PROCEDURES The City policy addresses three areas for termination of employment: Health,Administrative and Disciplinary.Our review focuses on the latter. When a disciplinary outcome may result in termination of employment,the managing department is required to consult with the City HR Department before initiating such discipline for review and recommendation.25 Approval rests with the City HR Department Director and action cannot be taken unless all of the mandatory contents of the dismissal letter are received. By the time the managing department has made a determination that termination of employment is the appropriate course of action,it is usually based upon a significant level of interaction with the local unit. Late engagement of the City HR Department does not allow for early intervention, redirection of employee behaviors or an informed assessment of the overall risk presented by an employee. Unit managers must provide a minimum of 24 hours written notice to the employee of the pre-disciplinary meeting advising of the proposed action,why discipline is proposed and the date and time of the meeting.The City has defaulted to this being a "24-hour notice to report" letter- meaning that the employee is to respond within 24 hours for the final determination. Many of the employees we interviewed said that they view the notice as synonymous with termination. The letter generally requires the employee to return to the unit of employment for the final notice. In a contentious situation,as is usually the case when terminating employment,this increases the risk for workplace violence.The employee has been investigated,disciplined and challenged by the same unit manager who is now informing them that they no longer have a job with the City. Full-time employees have the right to grieve a separation from employment due to misconduct or unsatisfactory work performance. Managers and supervisors are not trained to recognize and report individuals exhibiting concerning behaviors as early as possible or in advance of taking any disciplinary action against the employee. The City's policies do not describe a formal process for making and handling requests for police or outsourced security support for a meeting with an employee of concern.A best 25 City of Virginia Beach Discipline Policy and Procedure.Policy Number:4.02 Date of Adoption:Moy 12,1977 Date of Prior Revision:October 2,2012 Date of Current Revision:April 25,2016 www.hillardheintze.com 132 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES practice is to require personnel to contact local police in advance of any terminations or suspensions when they believe the behavior may escalate into violence. Substance Abuse,Drug Screening and Testing RELEVANCE TO THE MAY 31,2019 ATTACK We did not identify any information suggesting that the perpetrator had a substance abuse problem or that substance abuse contributed to the attack in any manner. However,substance abuse in the workplace is a concern for many employers given its effect on behavior. SIGNIFICANCE OF THIS POLICY Substance abuse policies are designed to ensure that drugs and substance abuse do not harm the workplace and employees.This abuse is heavily associated with several negative outcomes,such as mood swings,erratic behavior and violent tendencies,all of which can impact safety and productivity. Research has shown that such policies reduce the potential for workplace injuries and employee absenteeism and assure consistency in performance.26 For certain position classifications,federal and state law may require drug testing,such as for those operating heavy equipment.Additionally,substance abuse in the workplace contributes to risk of financial loss, employee injury and injury to other people. Finally,as part of an overall holistic approach to employee wellness,such policies provide for education,awareness and support for those employees facing substance abuse challenges. EVALUATION OF CI i Y'S EXISTING POLICY AND PROCEDURES The City of Virginia Beach instituted its Substance Abuse Policy 6.15 in 1990 and updated it on March 13,2019.Virginia Beach's drug screening and testing program has an overall wellness approach that seeks to promote the health,safety and well-being of City members and the public by eliminating illegal substance use and abuse from the workplace and to assist those members who have a drug or alcohol problem with rehabilitation.The policy is applicable to all City employees. Section 2.12 defines a "safety sensitive position,"but does not identify labor categories or job classifications that are considered safety sensitive.Section 2.13 describes safety sensitive duties focused primarily on those driving for the City as part of their duty or those actually driving City vehicles. 26 https://www.businessgrouphealth.org/pub/?id=f3151957-2354-d714-5191-c11a80a07294 0 2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 133 • The City policy determines when employees should be screened,such as during routine exams,after promotions and transfers,and based on reasonable suspicion,which is consistent with many such policies.To determine reasonable suspicion,the appropriate City personnel must fill out a checklist;two supervisors must conduct a dual review;and Occupational Safety and Health Services representatives must provide final authorization. This is a good practice as it requires review independent of a single supervisor,thereby reducing the chance for bias. • While employees need to disclose the use of prescription medication that could impair their work abilities,they need not disclose the drug or underlying condition to the supervisor. If concerned that prescription medication may impair driving,employees must inform their supervisor and report to OSHS for evaluation.This is a good practice as it allows an employee to retain privacy while still protecting the risk to the City regarding impaired driving. Consistent with best practice,the City encourages voluntary engagement with the Employee Assistance Program,and consistent with EAP policy 5.02,this action and treatment will not be shared without the employee's consent.Additionally,the City abides by a compassionate,"last-chance"protocol that emphasizes treatment and EAP engagement rather than termination of the individual's employment contract whenever possible. Failure to subsequently pass or take a test is deemed a failure and is grounds for termination of employment.This allows the employee to have full understanding of the risks of substance abuse in the workplace,while still supporting a rehabilitative approach for employees facing challenges. Workplace Harassment RELEVANCE TO THE MAY 31,2019 ATTACK Our assessors did not identify any evidence that the attacker was subject to or engaged in workplace harassment, including any indication that a manager was aware of a harassment allegation. SIGNIFICANCE OF THIS POLICY The City"prohibits any discrimination and harassment on the basis of race,color,sex, religion, national origin,disability,age, pregnancy or childbirth,genetics, military status, sexual orientation or gender identity.The City also prohibits discrimination and harassment in the interaction with all citizens,vendors,contractors,clients and customers on the basis of race,color,sex, religion, national origin,disability,age, pregnancy or childbirth,genetics, military status,sexual orientation www.hillardheintze.com 134 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES or gender identity."27 It's important to discern between promulgating policies on harassment as enumerated above and ensuring a holistic approach that includes a continuous training program of awareness and sensitivity to employees who are under duress who may perceive their environment as discriminatory. EVALUATION OF CITY'S EXISTING POLICY AND PROCEDURES The harassment policies at Virginia Beach reflect standard best practices used in both the public and private sectors.The City promptly investigates complaints of unlawful discrimination and harassment in accordance with the City's Equal Employment Opportunity Policy and Complaint Procedure, No.6.06. However,the initiation point for such complaints is often the HR Liaisons who are not all full-time City HR Department employees and most of whom report to a unit manager.They may not all be adept at identifying harassment behaviors since most are not fulltime professionals trained on how to handle these types of situations. Employee Assistance RELEVANCE TO THE MAY 31,2019 ATTAL[ The subject in this case had no record of self-engagement, nor was he referred to an EAP.28 In that his divorce was a personal matter that was not identified as affecting his work performance by his supervisor,any referral by a manager,as well as his attendance,would be voluntary under the existing policy.We did not find any direct evidence that suggests that,had the subject been referred to an EAP,the referral would have disrupted his pathway to violence.At least one of his supervisors was aware that he had undergone a significant life event- his divorce in September 2017. In the period immediately after the divorce he exhibited noticeable changes in his work performance,which might have been addressed through engagement with EAP. However,no informal or formal referral to the EAP was made.The policy requires that a manager complete a form for review by the City HR Department.This did not occur. During our interviews, representatives of the City as well as the City's EAP services confirmed to our assessors that EAP personnel have extensive expertise in the emotional, psychological and financial challenges of a divorce. 27 City of Virginia Beach Workplace Harassment Policy.Policy Number:6.13.Date of Adoption:April 1995 Date of Prior Revision:Not Applicable.Date of Current Revision:October 12,2015 28 City of Virginia Beach Employee Assistance Program.Policy Number:5.02.Date of Adoption:April 29.1988.Date of Prior Revision:Not Applicable.Date of Current Revisions:June 24,2015. m 2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 135 SIGNIFICANCE OF THIS POLICY An EAP is a critical component in a workplace violence prevention program -and an EAP referral can be an effective first step in disrupting inappropriate workplace behaviors as well as any potential pathway to violence. EAPs can provide unbiased advocacy and support for employees who are struggling with various work and personal issues and can represent a valuable resource for managers and supervisors trying to assist their employees. EVALUATION OF CITY'S EXISTING POLICY AND PROCEDURES The City provides an EAP through a third-party provider.Guidelines for using the EAP are outlined in the City's Employee Assistance Program Policy.According to the policy,supervisors have a few referral options,including: Informal Supervisory Referrals to address personal problems that may or may not be affecting job performance.The employee can voluntarily accept or reject the offer. Many supervisors are not trained on how to refer employees to EAP effectively. Formal Supervisory Referral used to assist the supervisor and the employee in taking steps to improve the employee's work performance.The employee can voluntarily accept or reject the offer. Mandatory Referral used in accordance with a last-chance agreement related to substance abuse or a violation of the Violence Prevention Policy.The employee is required to attend as part of the agreement. Representatives of the City and the City's EAP services stated that EAP counselors understand their"duty to warn" in cases of threats made by the employee. However, EAP counselors are not typically trained in behavioral threat assessment and therefore should not be relied upon to conduct assessments of workplace violence risk. A Duty to Warn: The Tarasoff Case Tarasoff v.Regents of the University of California (17 Cal.3d 425.551 P.2d 334,131 Cal.Rptr,14[Cal 1976I)was decided by the California Supreme Court in 1976. In 1974,the California Supreme Court stated in Tarasoff that The court further ruled that, "The discharge of this duty therapists have a "duty to warn" prospective victims that they are may require the therapist to ..,warn the intended victim at risk of falling prey to some violent act.The court issued its or others likely to apprise the victim of the danger,to subsequent ruling in 1976 and the ruling now reads that when a notify the police or to take whatever steps are therapist determines"that his patient presents a serious danger of reasonably necessary under the circumstances." violence to another,he incurs an obligation to use reasonable care to protect the intended victim." www.hillardheintze.com 136 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES The City HR Department's protocols to workplace violence should include specific protocols and policies around monitoring employee progress with the EAP.The formal protocol and policy should specifically address the need for confidentiality,but also clearly describe how and when the therapist is aware of the"duty to warn,"and the requirement for the City in responding to and managing such incidents. Privacy and Information Sharing RELEVANCE TO THE MAY 31,2019 ATTACK We found no evidence that any individuals withheld vital information or that concerns about sharing private information were a factor leading to the shooting.Assessors determined that personnel outside the attacker's immediate chain-of-command knew about issues involving his work performance.Additionally,there were employees who held a range of knowledge and information regarding events perceived as related to the attack- not all of which were true or substantiated - including employee performance issues and other issues that would center on private information. Some employees spoke about what they described as a lack of concern for privacy and confidentiality with regard to HR issues in the City's work units. Employees within Building 2 share strong working relationships with one another and many were aware of performance-related issues of co-workers that the City HR Department was perceived as not successful in addressing. For example,one employee engaged in disruptive behavior for years- behavior so well known that a significant number of Building 2 employees initially thought this individual was the shooter. Yet,other issues,such as disclosure of security information regarding building access or employment status,was not formally shared.. SIGNIFICANCE Of THIS POLICY The key to ensuring appropriate workplace standards is providing a professional environment that is equitable and supportive to all employees.Where there are issues in the workplace,trained management discretion and confidentiality is paramount to maintaining a civil work environment and providing appropriate corrective action.The actions of management must be unbiased, impartial and appropriate to the employee behaviors.Allowing ongoing office talk and rumors is not consistent with good workplace practice and contributes to hostility.Additionally,for some employees, particularly those at risk of harassment or suffering domestic violence,workplace privacy is usually an issue in reporting,and management should ensure that to the best of their ability,the practices in the workplace support an environment of reporting concerning information without fear of retaliation. m 2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 137 It is important to note that information sharing to prevent workplace violence provides overall awareness about the warning signs that allow for interventions.There are roadblocks to information sharing,including hesitation to get involved,assumption that it is someone else's responsibility,assumption that the behavior is an isolated incident, reluctance to be a tattletale or busybody and apprehension about getting a coworker in trouble. Policies need to be clear that it is not an invasion of privacy to report concerning situations that are observed by a well-trained workforce,and training needs to reinforce the value of reporting despite concerns. Information sharing, internally and externally,is key to a proactive workplace violence prevention program.Consistent with privacy and professionalism in addressing workplace behaviors, employers must identify how best to facilitate sharing of relevant information, regardless of source,and the ability to credit or discredit it. Establishing protocols and policies helps define exactly where,when, how and why information may be shared - through clearly defined public- safety exemptions to mandated disclosure regulations. Review and processing standards are key to ensuring the appropriate use and disclosure of otherwise private and protected information when risks to others manifest and take precedence. EVALUATION OF CITY'S EXISTING POLICY AND PROCEDURES The City needs to provide clear guidance through applicable policies, protocols and processes for recognizing and reporting issues regarding concerning workplace behaviors to ensure no gaps or omissions in addressing employee issues.The City does not have a single comprehensive policy addressing employee information, privacy and disclosure.This leaves employees and managers to guess what they can and cannot disclose regarding actions in the workplace. Moreover, legal issues can arise regarding rights to privacy,compliance with the organization's established policies and procedures,legal obligations under the ADA and other anti-discriminatory laws,due process requirements,obligations under the federal Fair Credit Reporting Act and related state statutes and evidence preservation and requirements under any employment agreements or handbooks. Policies that have privacy impact include some of the following. The Health Insurance Portability and Accountability Act(HIPAA):The City HR Department staff has an extensive understanding of the HIPAA regulations with respect to the privacy of an employee's health records.This knowledge is not as widely held by the HR Liaisons.The City HR Department needs to ensure its staff is aware of the public safety exceptions relative to employees. In some situations, privacy is outweighed by certain interests. For example,healthcare providers must disclose information about a person who presents an imminent threat to the health and safety of individuals and the www.hillardheintze.com 138 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES public. Providers can disclose information to law enforcement in order to locate a fugitive or suspect and are also authorized to disclose information when state law requires it.29 The Family Educational Rights and Privacy Act(FERPA):City HR Department personnel need to be aware of public safety exceptions to FERPA,as the employee base may include interns as part of an academic program. Like HIPAA, FERPA's basic rule favors privacy. Information from educational records cannot be shared unless authorized by law or a consenting parent,or if the enrolled student is 18 or older and provides consent. It is important to note that a student's behavior is often misinterpreted as an"academic record."This error can have tragic consequences.One of the more infamous examples was at Virginia Tech,where the shooter exhibited signs of troubling behavior,but the faculty did not share the information with law enforcement personnel because that information was erroneously considered part of the shooter's academic record.3o Policies Related to State Labor Laws:The City does not have a training program that informs managers about state labor laws,such as those regarding weapons in the workplace, mental health commitment and discrimination based on knowledge of domestic violence.A successful workplace violence prevention program can be greatly enhanced when managers have this knowledge. Policies on Information Sharing:The City could benefit from updated policies and enhanced protocols that prioritize information sharing on behaviors of concern. Like many organizations,it struggles with sharing information on employee issues across systems - especially given its decentralization.While employees have access to several communications channels and forums such as discussions with managers or engaging either EAP or Employee Relations,it's not easy for the City HR Department to gain a comprehensive and holistic perspective on information pertinent to workplace violence prevention. Policies on Workplace Violence Prevention Early Warning Signs: Policy 6.17 Violence Prevention Policy clearly describes prohibited behaviors and the associated reporting structure.This policy would be enhanced by an early intervention approach to workplace violence warning signs,including to whom these indicators should be reported. 29 Virginia Tech Review Panel.0 U.S.C.§1232g(b)(1)(E);Va.Code§22.1-287.Virginia law authorizes disclosure to law enforcement officers seeking information in the course of his or her duties,court services units,mental health and medical health agencies,and state or local children and family service agencies.2007 30 45 C.F.R.§160.103,definition of"protected health information." ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 139 Examples of early warning signs may include: • Behavioral changes • Irritability • Blaming others • Sleep disturbances • Withdrawal • Substance abuse Accidents Performance decline Physical complaints Examples of prohibited behaviors may include: • Causing physical injury • Making threatening remarks • Exhibiting aggressive or hostile behavior that creates a reasonable fear of injury • Stalking,threatening or harassing anyone with the use of the company's resources Intentionally damaging employer property or property of another employee Possession of a weapon while on company property or while on company business Committing acts motivated by,or related to,sexual harassment or domestic violence • Policies on Domestic Abuse and Protective Orders:As part of the City's early intervention approach to workplace violence, it should provide training and refined policies regarding domestic abuse warning signs and procedures on how to respond to protective or restraining orders involving employees, beyond suggesting the employee notify their supervisor. Criminal and Administrative Charges and Convictions RELEVANCE TO THE MAY 31,2019 ATTACK Our review of the subject's background identified no criminal activity that would have prevented him from working with the City. www.hillardheintze.com 140 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES SIGNIFICANCE OF THIS POLICY Criminal behavior is often an indicator for other workplace issues.Standards regarding what type of criminal conduct is grounds for employer action should be established in a documented policy that is clearly communicated to employees.Violent criminal activity increases the risk for workplace violence. Employees charged with a criminal offense should advise their employer of the nature of the charge and,if legally detained,should advise the employer where they were detained,the reason for the detainment and the length of the detainment,if known. In addition, employees should be required to notify their supervisor immediately after release from detainment. EVALUATION OF CITY'S EXISTING POLICY AND PROCEDURES The City's policy requires that full-time and part-time employees,volunteers and temporary service employees uphold the highest standards of conduct and that all workers obey federal, state and local laws in order to maintain the public trust.The City states that it holds all workers accountable and takes appropriate action upon notification that a City employee,volunteer or temporary services employee is charged with,convicted of, pled guilty to or had a judicial finding, e.g.,a deferred finding entered for any criminal or administrative offense.31 A Charge and Conviction Panel(Panel)is convened by the City HR Department and reviews all crimes that are a felony or any misdemeanor involving moral turpitude,criminal sexual assault, violence(including domestic violence), DUI,reckless driving or a barrier crime-defined as a crime which prohibits the hiring of an applicant or continued employment subject to federal, state or local law,rule, regulation and/or City departmental policies.The Panel then makes a recommendation to the City regarding suspension, restriction on service delivery or termination of employment. Self-reporting for workers charged with a criminal offense is a standard clearly articulated in policy,but in practice it can create an overreliance on the employee's integrity.Additionally, requiring reporting to the direct manager is challenging in a work environment that does not prioritize privacy and discretion. 31 City of Virginia Beach.CRIMINAL AND ADMINISTRATIVE CHARGE AND CONVICTION POLICY.Policy Number: 6.02 A Date of Adoption:September 14,1999 Date of Prior Revision:September 3,2010 Date of Current Revision: June 26,2013 0 2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 141 Resignation of Employment RELEVANCE TO THE MAY 31,2019 ATTACK The subject voluntarily resigned from his employment at Virginia Beach on the day of the shooting. He provided notice to his manager through email that his last day of work would be June 14, 2019. He complied with the policy requirements relative to notice.32 SIGNIFICANCE OF THIS POLICY Resignation policies allow for employers to have visibility over the reasons why employees are leaving their employment and help ensure ongoing security related to sensitive work documents, access to facilities and the timely resolution of any potential gaps in services. Policies and protocols,as well as training on procedures for managing voluntary separations,are key to work force continuity. It is also important to ensure that managers act consistently and appropriately when an employee has exhibited warning signs or prohibited behaviors.This would enhance the City's ability to recognize and report warning signs and, ideally,help prevent an act of workplace violence. EVALUATION OF CITY'S EXISTING POLICY AND PROCEDURES The City has a clearly stated policy that"all employees desiring to resign their employment with the City shall submit written notification of such intent to their employing authority.All notifications of resignation must include the actual date and hour the resignation is to become effective and be signed by the employee. Notifications of resignation may also include a reason for resignation.The department shall upload a copy of the written notification into the Human Resources Information System for inclusion in the employee's official personnel file."33 Resignation from employment is sometimes a risk factor for potential violence. Managers and supervisors need to be trained to recognize and report individuals exhibiting warning signs and prohibited behaviors as early as possible and always in advance of taking any disciplinary action against the employee.This requires that the City establish policies governing progressive discipline to inform employees and managers of the possible course of action regarding corrective discipline -and train supervisors on these policies.This transparency will help increase awareness as well as forecast possible next steps involving correcting undesired behaviors. 32 City of Virginia Beach Resignations Policy Number:6.12 Date of Adoption:December 10,1986 Date of Prior Revision: July 3,2008 Date of Current Revision April 25,2016 33 City of Virginia Beach Resignations Policy Number:6.12 Date of Adoption:December 10,1986 Date of Prior Revision: July 3,2008 Date of Current Revision April 25,2016 www.hillardheintze.com 142 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES The City policy is directed towards the administrative processing of a resignation and does not address security concerns,such as ensuring that employees whose employment contracts are terminated are not allowed into offices to visit former colleagues without proper notification or management authority. Workplace Violence Prevention RELEVANCE TO THE MAY 31,2019 ATTACK As previously stated,the subject did not exhibit significant risk factors that collectively would have suggested that he was on a pathway to targeted workplace violence. However,the workforce has not been trained in observing warning signs,nor did the City HR Department have a program in place to report concerning behaviors. SIGNIFICANCE OF THIS POLICY As we have stated previously,the City appears to use the term "workplace violence"with reference to someone with or without a weapon physically harming another employee. In actuality,"workplace violence"encompasses a broader range of behaviors and actions that,if recognized and addressed early,can prevent an act of violence and promote a more productive and safe work environment. Developing a broader definition for"workplace violence"and implementing the processes for recognizing and managing early warning behaviors are key to violence prevention. The behaviors noted in the figure below in and of themselves do not mean that the person is the next potential suspect in committing workplace violence,but if not addressed,the issues could escalate. Early reporting is critical to enable early intervention,provide aid to the individual of concern and prevent violence. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 143 Figure 4:The Spectrum of Workplace Violence Fatal Attack Physical Violence ��♦� Stalking Multi-level threat Dumestic Violence ' � interventions, 4.7 Nish Risk monitoring and management Stated Threats Angry Threat Outbursts Assessment and 11111 iI{ Psychological Evaluation of Bullying Risk OC Mild Bullying Pr. Reporting, < employer V� IETIMMI interventions �y i Violent Ideation � Disrespectful Early reporting of Rude warning signs Concerning Inappropriate Behavior EVALUATION OF CITY'S EXISTING POLICY AND PROCEDURES The City has a workplace violence prevention policy(Policy 6.17)but it has not been updated since it was adopted in July 2001. It addresses prohibited behaviors such as direct threats and physical harm. It also prescribes the responsibility of members and employees to report potential violations of the policy and the existence of protective orders. www.hillardheintze.com 144 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES While the policy refers to prohibited "acts and behaviors,"it does not reference warning signs and behaviors that employees need to be alert to if they are to report things such as signs of domestic abuse or untreated depression. The policy focuses on punitive rather than positive actions. Research has shown that some bystanders fear their reports could lead to immediate and harsh repercussions for the individual in question without due process and could result in retaliation against them personally. Behaviors of concern,if left unchecked,can escalate into threatening behavior such as harassment and intimidation,threats or sabotage,and possibly assaults or even homicide. Focusing on behaviors of concern and how the City can address these situations can prevent situations from escalating. Not only have these efforts been successful when other entities have established these programs, but morale also increases dramatically when an employer demonstrates its care and concern for employees. A policy that promotes a proactive approach to violence prevention is more effective when it encourages employees to report issues of concern early,before they escalate. Research has shown that people often have vital pieces of information,but for various reasons - including fear of retaliation and getting someone in trouble - do not share it.Often after an incident,we learn that key information was available but never provided to the right people or was withheld due to misunderstandings about rules and laws governing privacy.Some employees don't report concerns for fear of retaliation or when they feel it is not their business or responsibility. The policy also states the supervisor is responsible for investigating suspected workplace violence violations as well as imposing disciplinary action.Supervisors are directed to notify the City HR Department"of any matter that involves a violation or potential violation of this policy,"though the policy does not indicate when that notification should be made.This is a clear vulnerability, as managers are typically not trained in workplace violence prevention nor should they operate autonomously without consulting subject-matter experts.The manager should work in close collaboration with the City HR Department when dealing with warning signs, but they need to be trained. Zero Tolerance RELEVANCE TO THE MAY 31,2019 ATTACK The City describes acts and behaviors of prohibited conduct in its violence prevention policies. This information - presented in a sample list of prohibited behaviors - describes the actions the City considers unacceptable and subject to significant discipline up to and including termination. However,it does not contain all the actions that would be deemed concerning under policy, O 2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 145 whether engaged in by an employee,contractor or visitor on premises or in close proximity to the workplace. SIGNIFICANCE OF THIS POLICY The prohibited behaviors listed in the violence prevention policy reflect those behaviors also prohibited under best practices. Employees who believe they are being or have been subjected to an act or behavior that violates this policy are" structed to report the incident to their supervisor immediately. If the supervisor is the party who is engaging in the improper conduct,employees should report the incident to their department director or to the Director of Human Resources (or a designee). EVALUATION OF CITY'S EXISTING POLICY AND PROCEDURES In addition to defining prohibited behaviors,the City should also focus on reporting and managing behaviors and situations of concern. Not having a process in place to deal with low-risk but inappropriate behaviors also contributes to untreated mental health issues that, if left unchecked, could potentially escalate to an act of targeted violence. Weapons RELEVANCE TO THE MAY 31,2019 ATTACK The attacker left Building 2 and retrieved his weapons from his parked vehicle on government property. He then shot two people in the parking lot and reentered the building and shot many of his coworkers.The City of Virginia Beach has a firearms policy that prohibits the possession of firearms in the workplace.The attacker's actions are one reason why such policies exist,as they are intended to reduce the risk of such attacks. Some employees suggested, however,that had they been allowed to have weapons in the workplace,they might have been able to limit the harm done in the attack. SIGNIFICANCE OF THIS POLICY Many employers ban weapons in the workplace as a risk factor for violence.Some employers and employees believe that the availability of armed defense would limit such attacks. Notwithstanding this difference of opinion, it is a known correlation that most of the mass casualties in the workplace are caused by firearms. Regardless of the policy approach of the employer, it should be clearly delineated and enforced. Policies should identify expectations of privacy in the workplace, highlighting those areas subject to search for weapons in the event of a report or complaint that an employee may have a weapon in the workplace.Additionally,if there is a workplace ban on weapons, policies should consider the breadth of these restrictions and ensure www.hillardheintze.com 146 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES that all employees are trained on how to report knowledge of personnel possessing weapons at the workplace,its basis and how the policy will be enforced. EVALUATION OF CITY'S EXISTING POLICY AND PROCEDURES The City has a zero-tolerance policy that prohibits individuals from possessing,brandishing or using any weapon while(a)working;(b)acting as a representative of the City; (c)in a City-insured vehicle;and/or(d)on City property.There are two exceptions to this policy:(1)Where the possession,brandishing or use of the weapon is a condition of the member's employment with the City; is a condition of providing services to the City; or has been authorized by their supervisor and(2)Storing a lawfully possessed firearm and ammunition in a locked private motor vehicle while on City property,as determined in the Code of Virginia§ 15.2-915. City policy states that"members who become aware or have reason to believe that this policy is being violated shall,to the extent possible,immediately report the incident to their supervisor at the time it is occurring. If a member reports information in good faith in accordance with this policy, [he] shall not be subject to retaliation or discipline by the City solely for making the report."34 As mentioned previously,it is important for employees to feel comfortable and supported in reporting concerning behaviors.Stressing the fact that an employee who reports information shall not be subject to retaliation or discipline is in line with a successful enforcement of a weapons ban policy as it prioritizes safety concerns. The policy specifically addresses searches and states that an employee may be asked to consent to a search of their person based upon reasonable suspicion. It also states that the City reserves the right to search property under control of a member. It is better practice to identify that employees have no privacy rights in their workspace or in the use of City-owned spaces or equipment. Visitor Management RELEVANCE TO THE MAY 31,2019 ATTACK. The attacker was an employee in Building 2 and as such had free access to the secured employee floors.Therefore,visitor management was not an issue. Building 2 did not use access control through the two doors it uses to provide public access during business hours on the main floor. These doors were open at the time of the shooting,as the shooting occurred during business 34 City of Virginia Beach Weapons Policy Number:6.18 Date of Adoption:July 16,2001 Date of Prior Revision:None Date of Current Revision:July 18,2012 2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 147 hours. Building 2 did not have a formal reception area or security desk on the main floor. Individuals entering Building 2 were not required to show identification or a building access pass until an unauthorized individual reached the employee-only access areas,where there were access controls requiring an employee access card.Access control on the employee floors was an issue for the police response as they tried to enter the non-public doors and floors but did not have access cards that allowed them entry. SIGNIFICANCE OF THIS POLICY Another important component of an effective workplace violence prevention program is a strong policy governing visitor management and access limitation.This includes security in the reception and lobby areas. It is challenging for a public institution to limit access to public buildings. However, many municipalities have moved to a layered security system,one that supports public access for appropriate locations and limits access to only employees in others. 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 their public buildings. EVALUATION OF CITY'S EXISTING POLICY AND PROCEDURES The City does not have a comprehensive risk-based policy addressing facility security and visitor management. The City appropriately used access control for restricted employee-only areas. However, consideration should be given to more restrictive movement, based upon an employee's work area and role. Further,access control should be available to Emergency Communication&Citizen Services to manage in the event of an emergency like the one that occurred on May 31,2019. Public safety responders should also have access or train to ensure they know how to access a controlled facility in the event of an active assailant or public safety need. A risk assessment should be conducted for buildings open to the public to determine whether such access is necessary to support the public's needs and, if so,which countermeasures and tactics need to be engaged to control access and improve security.While it may not be practical to engage lobby staff for more than 200 City buildings,the City should conduct a review of public access to each facility - and,where appropriate,implement visitor management practices based upon the public access need and the potential risk to overall safety. Minimally,for those areas with open public access,and depending on the facility, physical security improvements should consider whether visitors need to provide identification or sign in. Use of physical security measures may be an option for locations with high-risk issues and would include having personnel maintain a Do-Not-Admit List,informed and updated by the Security and the www.hillardheintze.com 148 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES City HR Departments as well as others,as necessary,with the names of individuals who may represent a risk to the organization or should not be allowed to enter the facility for a wide range of reasons. For example,employees who have applied for or obtained a protective or restraining order should be strongly encouraged to disclose it to their supervisor or HR personnel. After becoming aware of a protective restraining order,the City HR Department can discreetly and confidentially take appropriate action,such as posting a picture of the person against whom the restraining order was filed at the appropriate stations.They can also arrange to help ensure the at-risk employee's security with escorts to and from the office. Earlier in this report,we discuss the option of installing panic alarms and discuss the surveillance coverage of cameras.These are methods that contribute to security for buildings and employees. Maintaining visitor logs,even as a method to provide services based upon order of entry,helps the security and management teams monitor who is in the building or has accessed the premises through the reception system in the past. Risk-based security policies include training for personnel to ensure awareness of suspicious activity,including suspicious calls.Such policies should also drive strict adherence to employee access and control card policies. Meeting with Difficult Employees RELEVANCE TO THE MAY 31,2019 ATTACK Even though the subject never filed a formal workplace grievance in accordance with City policy, his supervisors and managers were aware of the attacker's beliefs of unfair treatment,primarily through(1)his performance evaluations,(2)his grievance process and(3)the emails related to the grievance and performance evaluation that he sent to his supervisor and managers on his view that the work reprimand was unfair. Managing employee concerns and difficult meetings and conversations with employees are key components of any robust workplace violence prevention program. SIGNIFICANCE OF THIS POLICY Conflict management is a key skill for managers.A priority goal of any workplace violence prevention program is to assist employees who may be in crisis by enhancing employee safety and identifying opportunities for early intervention.Supervisors should not ignore or justify ongoing inappropriate behavior or safety concerns. Further,effective managers engage with employees and are able to ensure not only appropriate behavior and performance, but can also help coach, 0 2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 149 mentor and direct employees to foster a healthy work environment and positive job satisfaction levels. Knowing when and how to engage an employee or report a concern is a collective effort to ensure employees work in a safe and secure environment. For example,a manager fearing the employee's response to negative news may request security support just prior to meeting with the individual. Deciding the date,time and place of these types of meetings is also critical and should be decided by a team of well-trained HR and management personnel. Because the City does not have training in place for managing difficult terminations,these situations can lead to a crisis response,lost productivity and increased risk for those who are engaged to manage the situation. EVALUATION OF CITY'S EXISTING POLICY AND PROCEDURES We did not identify any clear policy guidance for engaging or conducting meetings with difficult employees. In addition,the City does not provide managers with training on this topic. The City has an open-door policy,which is intended to facilitate the ability of employees to consult with their immediate supervisor on any problem that affects their attendance,work performance and job satisfaction. Having such a policy in an organization can be a best practice - when supported by assurances of confidentiality and non-retaliation -and can help ensure the successful implementation of a workplace violence prevention program. However,the City's policy places the burden on the employee,who must make contact with every level of supervision within his or her chain of command when utilizing the open-door policy.35 For an employee already facing workplace difficulties this may be a barrier to effective communication. Supervisors should be trained to alleviate any apprehension that an open-door policy for employee concerns will jeopardize a coworker in any way.The objectives are to help ensure the safety of the workplace, provide individuals exhibiting the behaviors of concern, in some cases, with appropriate assistance and support,and preventing them from bringing harm to others or themselves.The policy should also emphasize that the City will not retaliate against any individual involved in reporting the concern. 35 Virginia Beach POLICY 4.05:No date. www.hillardheintze.com 150 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES It is important to emphasize to all employees never to assume that it is someone else's responsibility to report concerning behaviors or situations even if they do not directly affect the ability of employees to attend work and perform their jobs satisfactorily. Termination/Separation Checklist RELEVANCE TO THE MAY 31,2019 ATTACK The subject resigned his employment on the same day of the attack. Management responded via email - but apparently took no further formal action that day. SIGNIFICANCE OF THIS POLICY Use of a Termination/Separation Checklist is a key component of a workplace violence prevention program - especially on the last day of employment. Employee turnover is a given in any organization. Ensuring consistent engagement practices for separation of employment improves security over property and documents,employee wellness and appropriate management actions. For difficult employees,ensuring consistent practices,including notification of resignation as well as termination,allows for timely identification and engagement in any risk issues.A decentralized approach to managing employee discipline can often lead to late notification of the actions of potential problem employees.This response can also lead to inconsistent practices and either hasten a potentially violent individual farther up the path toward violence or result in missed opportunities to intervene in this escalation. EVALUATION OF CITY'S EXISTING POLICY AND PROCEDURES The City HR Department should continue to manage employee contract resignations and terminations. Managers should share any information received about resignations in a timely manner. As part of the employment separation process,the City should develop a Termination/Separation Checklist that may include responsibility for actions such as the following: Collect door keys Collect security card and key fob Collect desk keys ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 151 Clear office and remove personal belongings L Collect City car keys Collect City phones Secure City desktop computer or laptop Discontinue wireless service account Change voicemail Terminate access control 4.4 The Need to Establish a Workplace Violence Prevention Program The City of Virginia Beach's investment in workplace violence prevention capabilities before the May 31,2019 attack was generally limited to its violence prevention policy. It did not- nor does it now- have an established workplace violence prevention program capable of identifying and mitigating potentially violent situations.These programs are critical to managing the potential risks for violence within a workforce as large as that of the City of Virginia Beach.We have outlined below many of the key elements the City needs to incorporate in order to establish a successful workplace violence program. Leadership:The Importance of Championing Workplace Violence Prevention The City of Virginia Beach has a workplace violence prevention policy, but we found no evidence that the City's leadership has actively focused on workplace violence prevention as an integral component of addressing the risks to its personnel and operations. Under an effective workplace violence prevention program structure, City leaders are vocal champions for workplace violence prevention. Management is able to communicate goals and objectives of such a program clearly and often, not only by acknowledging the risks of workplace www.hillardheintze.com 152 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES violence but also by demonstrating their commitment to building a foundation for consistent reporting,risk assessment and program development. Given the tragedy of May 31,2019,Hillard Heintze is confident City leaders will take on the recommendations contained in this review and develop an active workplace violence prevention plan.While the City's leaders are generally not directly involved in the day-to-day operations of workplace violence prevention activities,they must provide leadership that makes it clear to employees and residents that it is committed to safe workplaces.This includes commitment and support to ensure that the appropriate HR personnel lead the investigation and manage employee issues related to behavioral concerns and matters essential to the City's violence prevention policy. Behavioral Threat Assessment:The Capability to Identify,Assess and Manage Risk Behavioral threat assessment is the process of collecting and analyzing relevant information pertaining to a subject who may pose a threat to the organization's personnel or assets.Threat assessment is recognized as a best practice to reduce the risk of targeted violence.The City does not have a behavioral threat assessment capability that includes a documented process to evaluate situations related to concerning employee behavior or potential threats from a holistic perspective. Research into the thinking and behaviors of a person who commits an act of violence in the workplace suggests that most attacks are preceded by discernible behaviors as the perpetrator plans or prepares for the attack."These behaviors are referred to as"attack-related behaviors." The decentralized HR process in the City of Virginia Beach limits the effective collection of such information,as each individual unit manages the employee performance issues,often without the City HR Department's direct engagement. We find that the subject would not normally have risen to a formal review given the level of behaviors. However,it was widely known and reported that another employee demonstrated significant workplace threat behaviors that essentially were unresolved for a period of more than two years. Interviews with coworkers demonstrated a challenging work environment and increasing perceptions that this employee was capable of violence. 36 USSS-Mass Attacks in Public Spaces,2018 0 2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 153 In fact,shortly before the shooting,this employee stated that it would not be surprising if "someone came in and shot up the place." Many employees felt that the management response to this challenging individual was inadequate and spoke to the difficulties in dealing with this employee.On May 30,this individual's employment with the City was terminated,which in part led to the confusion over who the active shooter was on May 31, 2019.This incident is raised as an indicator of the importance of managing risk in the workplace - not only for long-term safety, but for overall workplace health,employee confidence in management and the ability to redirect inappropriate behaviors. Threat Assessment Teams:A Critical Component of Behavioral Threat Analysis We confirmed that no single City of Virginia Beach entity is tasked with tracking and analyzing employee behaviors holistically and as a matter of workplace violence prevention.This is a significant gap in the workplace violence prevention capabilities that needs to be rectified to help address escalating behaviors and prevent future incidents. The City needs to establish an interdisciplinary team to identify,assess and manage potentially concerning behaviors and employees to mitigate these gaps,commonly called a Threat Assessment Team(TAT).The TAT should have formal documentation that includes team processes,team structure,team meetings and recordkeeping guidelines. Establishing a TAT is a recognized best practice in behavioral threat analysis.TATs are recommended by various expert organizations, including the following. U.S. Department of Homeland Security U.S. Department of Labor U.S. Occupational Safety and Health Administration ASIS International Association of Threat Assessment Professionals(ATAP) One of the most recent endorsements of a TAT concept occurred during a 2015 symposium in which the Federal Bureau of Investigation(FBI) Behavioral Analysis Unit(BAU) reiterated the importance of having a single function tasked with these duties,stating that a "lack of knowledge www.hillardheintze.com 154 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES about threat assessment and management itself,about risk factors and warning signs"was the "most fundamental barrier"to a successful violence prevention program.37 The FBI's BAU strongly recommended this practice at the same symposium,stating,"By far the most valuable prevention strategy identified was the threat assessment and management team. The good news is that every organization and community has the potential to stand up or access such a team."38 The successful practices and lessons learned through public institutions of higher education readily transfer to the municipal environment. By using a combination of investigative skill and multi-disciplinary collaboration,a systematic approach can often gather the information and evidence necessary to make a comprehensive assessment of the threat an employee or other individual may pose.This assessment then informs the mitigation strategy developed by the team. Figure 3:Typical Threat Assessment Team Structure Ad Hoc Members Local Law Enforcement Senior Leadership 2 Employee Crisis and Risk Assistance Management Programs MAP' Personnel Threat Assessment Team(TAT) Legal Core Member ecuritY Threat Assessment Occupational Curt Membst Safety and Health Experts and Personnel • Licensed Clinical Psychologists Union Leaders Public Relations and Communications 37 Federal Bureau of Investigation Behavioral Analysis Unit—National Center for the Analysis of Violent Crime.Making Prevention a Reality:Identifying,Assessing,and Managing the Threat of Targeted Attacks.2015 3B Ibid. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 155 The City of Virginia Beach has a framework to follow in implementing a TAT. Largely based on lessons learned from the Virginia Tech mass shooting in 2007,Virginia State Law now states that "each public institution of higher education shall establish policies and procedures for the prevention of violence on campus, including assessment of and intervention with individuals whose behavior poses a threat to the safety of the campus community."39 This legal guidance provides the opportunity to develop a TAT that can readily address concerns over workplace violence. Within the City of Virginia Beach,this team could include representatives of HR, Legal and Facilities in addition to a manager with knowledge of the situation and the department's HR Liaison.Ad hoc members may include representatives such as senior leadership, EAP personnel, threat assessment experts and licensed clinical psychologists,local law enforcement,crisis and risk management personnel,occupational safety and health personnel,union leaders and public relations and communications experts. Each team member would have a specific role and responsibility in serving the TAT. However, each would also bring a perspective that allows for an informed,holistic response to potential workplace violence risks.A coordinated approach to assessment, review and intervention, based on shared knowledge of all of the interactions with the employee, is a best practice predicated upon reducing workplace violence. 39 2008,cc.450,533,§23-9.2:10;2010,cc.456,524;2013,c.710;2014,cc.793,799;2016,c.588.The chapters of the acts of assembly referenced in the historical citation at the end of this section may not constitute a comprehensive list of such chapters and may exclude chapters whose provisions have expired. www.hillardheintze.com 156 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES Figure 4:Threat Assessment Team Workplace Violence Prevention Response Protocol Threat Assessment Team(TAT) Workplace Violence Prevention Response Protocol NotSitation of incident of Concern Every known incident or report of concerning behavior related to workplace violence will activate the TAT response protocol detailed below. 0 _ 11111=1 HR or other TAT delegates collect background information and initiate assessment that establishes the appropraite level of concern and response. ir Determine Level of Concern and Activate Appropriate ---- Response The Level of Concern may be escalated or de-escalated at any point in response to various situational changes. 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Activate Erne+gancy Prcioaoit. et focal two el b i' rea tagom ant of RR Rote/to Onw WIC).Mar.eptrwm ream • tenrrwemeld - i/mlteelotud.mr,ta I !WrmatimcillePte Ipatlt tom,,Apt moo lr 1 - invh t IIiti.M M fl A 14 111MHt 1Mt Yi t•S Y i 4 t rY tr+ 7 • 51NMJvStMyJ1*t.r Axv9aM, I+IntAY on/dXA alhmsaasu i+:y./atrlr .;04,a ,,n€£ i Itryt.mli rrrlrrral In thicars to coast*of*ia41,4, a-stC+`PitigPr�� cnmo tkp MintlydoM. nlxrnpMemrt advns i tki4(‘heu+.alg.m,,,l,r Ie•ekPessocnnist ryrtx'+rcm ati 11 ttratawe ri.rwilh n5 WAJace bvlta.n, t litailtt.mphrym.ni I nMNMl ha.lsp^nulmceuana ms Imahu aciwau f Document and Report 0 2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 157 Complaint Categorization:The Need for a Central,Standardized System The City does not have a centralized database for interactions involving its employees.While this is a challenge for many municipal organizations,this particular vulnerability is further exacerbated by the decentralized HR process. Identifying and tracking complaints and their respective investigations in a consistent,standardized manner across departments within an organization can facilitate early intervention and thus help prevent any escalation to violence.A systematic and carefully documented case file approach ensures that baseline information about a subject's behaviors at a certain point in time is available whenever needed.40This allows visibility into potential escalation and effective de-escalation of employee behaviors and warning signs. Categorization No single system traces warning behaviors or actions taken in support of workplace violence prevention.The City HR Department does not ensure consistent identification and reporting of HR matters using categorization codes. Little oversight and visibility occur at the unit level,leaving determinations of serious misconduct to local unit standards. Employee behaviors span a range of actions and little is done to ensure consistent identification of the issues,the City's response and the appropriate outcomes. The City should categorize incidents to conduct an assessment that may pose a threat to the workplace.These categories include: 1 Inappropriate Behaviors or Communications - Incidents involving intimidating words or gestures,such as harassment causing emotional distress and serving no legitimate purpose, confrontation, phone harassment,obscene phone calls,stalking,verbal abuse and any behaviors that cause individuals to be concerned for their safety. 2 Domestic Violence - Incidents involving individuals who have or have had an intimate relationship that has become volatile. 40 ASIS International and SHRM(Society of Human Resource Management)have jointly determined that"workplace violence prevention and intervention program should include a system of centralized record keeping,making sure that all reports made under the workplace place violence prevention policy are recorded and tracked.A system of centralized record keeping becomes especially important in large organizations,where offenders can at times move to various positions within an organization.Record keeping will also allow for ongoing monitoring of incidents to identify high risk areas within the workplace,or customers,clients or patients who repeatedly demonstrate problematic behavior...this information,if contained in physical files,should be kept secured;likewise,strict security measures should be applied to all data stored electronically."ASIS/SHRM.American National Standard.Workplace Violence Prevention and Intervention.Page 19,Section 6.2.7.2011. www.hillardheintze.com 158 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES 3 Physical Violence- Physical contact resulting in minor or no injuries,including that which has induced fear and apprehension of physical or other harm in another person but without immediate danger of such harm being inflicted. Investigative Subjects:Three Types The City's workplace violence prevention program should also document the various categories of individuals who may pose a threat of violence.These include the following: Employee or Hired Contractor-The individual is a current or previous City employee or one of its contracted service providers. Resident with Domestic Situation -The individual has a personal relationship with the targeted employee and does not have an established relationship with the workplace. Visitor or Resident Seeking City Services or Information-The individual is not an employee and is seeking City-provided service or information or has another legitimate reason to be on the premises. Tracking The City maintains various employee record-keeping systems for documenting HR activity across the organization, but these are incomplete and often stand-alone. For example,our request for HR records required several layers of review and confirmation to ensure the record held by the City was complete.The official City HR Department record is housed online in a system and focuses primarily on administration rather than risk prevention.The City HR Department system does not document or track behaviors of concern that are unrelated to discipline,including knowledge of personal crises or behavioral warning signs,such as those for untreated mental illness.This information in this system is inadequate to meet the Department's and City's needs for violence prevention. Much of the employee interaction,including all discipline involving suspension for periods up to 40 hours,is maintained within the individual departments.These personnel records are paper- based and stored in file cabinets. Individual managers, HR Liaisons and some City HR Department staff also keep information and notes on paper and on their computers that may or may not be entered into the official City HR Department records. Developing a comprehensive employee record is challenging,as no one is assigned record-keeping duties and each file maintained is subject to the standards and practice of the local HR Liaison and unit. The City needs to begin to aggregate its data and record-keeping. Ensuring the City HR Department is involved in the early stages of discipline or poor performance will allow consistent identification and review of employee behaviors across the City.A record-keeping practice that establishes numeric and alpha identifiers will assist in creating a database with sufficient metadata ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 159 HR employees or HR Liaisons can access before interacting with employees.This metadata for the HR Liaisons and the City HR Department's ongoing verification of data will help the City better catalogue employees'behaviors,identify early warning signs and build familiarity with the response systems more effectively. This database should not be mixed in with other HR databases.ASIS International and the Society of Human Resource Management(SHRM)have jointly determined that: "...workplace violence prevention and intervention program should include a system of centralized record keeping,making sure that all reports made under the workplace place violence prevention policy are recorded and tracked.A system of centralized record keeping becomes especially important in large organizations,where offenders can at times move to various positions within an organization. Record keeping will also allow for ongoing monitoring of incidents to identify high-risk areas within the workplace,or customers,clients or patients who repeatedly demonstrate problematic behavior... this information, if contained in physical files,should be kept secured;likewise,strict security measures should be applied to all data stored electronically."41 Training and Education:Workplace Violence Prevention Awareness We confirmed that the City does not train employees on their role in helping to identify behaviors and information that can help the City prevent an act of workplace violence.Training employees at all levels of the organization is vital to implementing and sustaining an effective violence prevention program.Communicating the mission of the organization's workplace violence prevention program helps employees understand that the primary goal of the program is to enhance the safety of the entire organization, not to discipline,arrest or otherwise punish individuals. If employees understand the goal of the program,they are more likely to share information. The City should establish training that includes instruction by expert researchers and practitioners on the background and fundamentals of threat assessment,with a key focus on the four critical functions of threat assessment: Identification of those who may pose a threat 41 ASIS/SHRM.American National Standard.Workplace Violence Prevention and Intervention.Page 19,Section 6.2.7. 2011. www.hillardheintze.com 160 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES • Investigation to uncover all facts surrounding those who may pose a threat Assessment of the facts to determine whether the threat appears to be valid Management of those who are assessed as possibly posing a risk The City should target key stakeholder groups and customize training for each of them,as described below. The training curriculum for all City employees should stress the importance of"see something,say something"and the collective responsibility of the entire workforce in preventing workplace violence.The training should address Warning Signs and Prohibited Behaviors specifically reflective of the City's policy,how to report situations anonymously and stress the importance of the EAP to deal with life stressors,such as debt,divorce and illness. Upon completion,course participants should know what to look for and how to report concerning behaviors and situations. MANAGERS AND SUPERVISORS The curriculum for personnel who oversee the work of other employees should highlight their critical role in identifying and responding appropriately to disturbing,disruptive or threatening behavior and how to recognize the warning signs of potentially violent behavior. How to manage difficult meetings and how to report concerning situations to HR is critical in this training.The establishment of the City TAT should also be described in detail. INTERNAL THREAT ASSESSMENT TEAM As the most specialized area of training,the curriculum addressing this smaller group of experts should first present the latest research and principles in the areas of threat assessment and violence prevention and then explore how to share information among members of the Threat Assessment Team and other resources within the limits of information sharing and confidentiality. This training increases participants'ability to conduct threat assessment interviews, including exploring key questions that need to be answered.Topics such as basic principles of threat assessment,interviewing techniques and leveraging the City's resources should be discussed. Realistic scenarios that occurred or are likely to occur at the City should also be explored as part of employees'decision-making process. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 161 4.5 Survey Conducted of City of Virginia Beach Stakeholders Survey of Building 2 Employees We surveyed employees whose work location was Building 2 on May 31,2019.The survey was designed to(1)gain insight into issues such as workplace violence training and awareness, employee satisfaction and management,and physical security of those deeply affected by the attack,and (2)give all Building 2 employees the opportunity to provide their opinions,comments and concerns to our team.This was not intended to be a scientific survey,but rather an opportunity for Building 2 employees to be heard,given the May 31, 2019 tragedy's direct impact on their lives. We sent out 451 requests to complete the survey and received 226 responses(a 50-percent return rate). From the responses emerged the following four themes: 1 Workplace violence training and prevention 2 Employee satisfaction and safety 3 City executive,leadership and management 4 Physical security Additionally,the respondents'answers and specific comments added insight to our findings throughout this report.The following is a summary of the most significant and consistent themes. Workplace Violence Issues These questions addressed workplace violence prevention regarding policy,training and preparedness in the work environment as well as individual and supervisory knowledge and capabilities should violence in the workplace occur. Workplace Violence(WPV)Preparedness Twenty-one percent of respondents said that managers have engaged them on how to address workplace violence(WPV), 29 percent said they felt prepared to handle a threat or threatening situation if it were to occur in the workplace and 66 percent did not know the process for reporting concerning situations, incidents or threats of violence. www.hillardheintze.com 162 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES Less than 20 percent of respondents stated they have been informed about the department or unit's violence prevention policy for handling potentially violent situations, and 34 percent responded that prior to the May 31,2019 attack,the City had clear policies and practices concerning workplace violence. A minority of respondents(24 percent)reported they are better prepared to handle a violent situation in the workplace today than prior to May 31,2019. Policy and Training Of the respondents,only 17 percent knew about standard procedures in place to identify, evaluate and inform workers about specific high-risk clients,situations or locations. Most respondents(89 percent)agreed that employees should have training on workplace violence prevention.Three percent disagreed and 8 percent did not have an opinion. Nearly one fourth of respondents(22 percent)reported they have been trained to engage with hostile or poorly performing employees,and 20 percent reported being trained on WPV prevention. Employee Satisfaction and Safety These questions addressed how employees perceived being treated -whether they were met with dignity and respect by other employees, managers and City leadership. Dignity and Respect in the Workplace Respondents overwhelmingly reported that other employees treated them with dignity and respect,with 77.5 percent agreeing,9.5 percent disagreeing and 13 percent responding in a neutral manner. « A significant majority of respondents reported that their managers treated them with dignity and respect,with 68 percent agreeing,21 percent disagreeing and 11 percent responding neutral to that statement. Most respondents reported that the City managers and executives treated them with dignity and respect,with 55 percent agreeing,25 percent disagreeing and 20 percent responding neutral to that statement. These responses reflected our Building 2 interviews,where most employees discussed a supportive work environment with their peers and supervisors but were more negative in their perception regarding departmental and City executive issues. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 163 Management Issues • When asked if the respondent believed their manager would act in a timely and appropriate manner when reports of WPV are made, 55 percent agreed they would,20 percent disagreed they would and 25 percent did not know. • When asked if the respondent believed the City executives would act in a timely and appropriate manner when reports of WPV are made,42 percent agreed they would,40 percent disagreed they would and 18 percent did not know. • Most respondents(71 percent)agreed they were comfortable reporting situations, incidents or threats of violence to their manager, but only 48 percent said the same about the City HR Department. Security ▪ When asked if they felt secure in their workplace, 55 percent of the respondents said they did at least most of the time.When asked to consider how they felt before May 31, 2019, 71 percent said they felt secure in their workplace at least most of the time. The two most common concerns raised by respondents were a lack of physical security to prevent unauthorized access to non-public office areas and the lack of a secure infrastructure(e.g.,offices,doors and hiding places)to protect them in an active assailant situation. The majority of respondents that identified as belonging to Engineering felt secure in their workplace prior to and after May 31,2019. Supervisors • Almost 74 percent of the respondents who identified as currently supervising employees have not been trained on WPV prevention,and over 55 percent have not been trained to monitor or regulate the activity of others. Most respondents(68 percent)have not been trained on how to engage with hostile or poorly performing employees.Almost 82 percent of these respondents identified that no procedures were in place regarding high risk clients,situations or locations. Less than half of respondents(41 percent)who identified as supervisors felt that the City HR Department support was available when engaging with hostile or poorly performing employees,while 31 percent answered it was not and 27 percent felt that support was available sometimes. While almost 78 percent of the respondents identified that they were able to effectively engage with their employees since May 31, 2019,74 percent responded that they did not receive any additional support in helping to manage employee issues since May 31, 2019. www.hillardheintze.com 164 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES However,60 percent of these respondents did feel that management provided additional support to address work challenges since the date of the attack. Survey of City of Virginia Beach Residents by People Element During our public session and employee listening sessions,the discussions were often dominated by statements,paraphrased here,as referring to the City of Virginia Beach as a toxic environment, its workers as unhappy and its leadership as incompetent and malicious.Our assessors found, however,that the public statements did not align with the results of a series of annual surveys conducted by the City in which employees consistently reported high levels of satisfaction. When the early surveys were presented in the public forum,several people voiced concern that the City would retaliate against those who spoke truthful negative comments and therefore the survey results were invalid. It should be noted that we heard these comments for this survey as well as the Building 2 employee survey conducted by our team.At no point did Hillard Heintze share any information regarding specific responses with any member of the City government and its various departments and units. Although evidence to support these beliefs was limited,the public outcry as well as the voices at the Community and Public Listening Sessions were significant.Subsequently,the City approved the commissioning of a completely independent survey in order to validate its prior survey findings. Hillard Heintze contracted with People Element,a professional survey company,to conduct the survey.To further ensure anonymity,the survey was contracted with the stipulation that no individual responses could be shared outside the People Element team.This company administered all portions of the survey without direct data access or disclosure to either the City or Hillard Heintze.The completed survey report was received by Hillard Heintze on October 21, 2019.The survey in its entirety is contained in Appendix 6.6. Key Findings Reported levels of employee satisfaction declined in the current(Fall 2019)survey compared to the one in Spring 2019. The overall mean score for the current survey is 3.6,compared to the Spring survey overall mean of 3.8. Every item present in both surveys demonstrated a marked decrease in the current survey. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 165 The key categories measured by the current survey are shown below by highest to lowest mean score: Culture&Climate 3.8 Value&Ethics 3.8 Communication 3.8 Training&Development 3.7 Work Environment 3.6 Recognition 3.5 Leadership 3.3 Areas of High Perception The City received the highest ratings for items in the newly added category Culture&Climate. While this category cannot be compared to the previous survey,the highest-rated items in Culture &Climate are shown below: "I am motivated to go beyond what is normally expected of me to help the City be successful"(4.0) "My work gives me a sense of personal accomplishment"(4.0) "I plan to be with the City at least 1 year from now"(4.0) The City received the second highest ratings for items in the category Values& Ethics,though all items showed a decrease when compared to the previous survey.The highest-rated items in Values& Ethics are shown below: "I understand how my job impacts the City's mission and goals"(4.4) "I am treated with respect by my immediate supervisor"(4.1) "I am treated with respect by my coworkers"(4.0) Other notable highly rated items came from the categories of Work Environment& Communication: Work Environment- "My department accommodates my needs when I have a personal matter to attend to"(4.2) www.hillardheintze.com 166 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES • Communication - "I keep myself informed by reading various forms of internal publications/communication(Because You Asked, Member Update,beachnet,e-mail, Benefits e-bulletin,etc.)"(4.0) • Communication - "I often initiate(begin)communication about my job with my immediate supervisor"(4.0) Areas of Low Perception The City received the lowest ratings for items in the category Leadership.The lowest rated items in Leadership are shown below: • "The City Manager's/Deputy City Managers'decision-making is based on the City's Organizational Values"(3.1) • "The City Manager and Deputy City Managers help to create a culture of learning and development"(3.2) "Our managers'decision-making is based on the City's Organizational Values"(3.3) The City received the second lowest ratings for items in the category Recognition.The lowest rated items in Recognition are shown below: • "Overall, I am satisfied with the City's compensation(salary, health care, retirement,leave, etc.)"(2.8) "I am satisfied with the advancement opportunities that I have within the City"(2.9) "My coworkers regularly give encouragement and praise to one another"(3.6) Other notable low rated items came from the categories of Work Environment,Training& Development,and Culture&Climate: Work Environment- "I believe the results of this survey will be used to make my department an even better place to work"(2.8) Work Environment- "My coworkers are held accountable for the quality of their work" (3.1) Work Environment- "The managers in my department work to build a trusting work environment"(3.1) Culture&Climate - "I don't consider looking for a new job elsewhere"(3.3) Training&Development- "When problems occur,our managers try to understand what happened,then find solutions rather than simply placing blame"(3.3) ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 167 Additional Findings The additional safety items added to the current survey were both rated lower than the overall survey average of 3.6. However,they were not among the lowest 15 items rated.The additional safety items with their respective scores are shown below: • "Proper steps are taken to ensure employee safety"(3.4) • "I feel safe at work"(3.57) Interpreting Respondent Scores The survey company determined that the findings show that every item in the current survey has decreased to some extent since the Spring.Without raw data from the Spring 2019 survey,the survey company could not statistically determine if the differences between the previous(Spring 2019)and current(Fall 2019)survey are significant.Also,given the results,there was insufficient evidence to support that having a third-party entity confidentially administer the survey impacted the results. The additional questions,including those on safety,added to the Fall 2019 survey were shown to be slightly below the overall survey average but not among the lowest 15 items rated.The other additional items added to the Fall 2019 survey were intended to provide a measure of employee engagement.The survey company determined that, based on its current survey practices within similar populations to that of the City of Virginia Beach and its use of a consistent measure of engagement across its client population,the City of Virginia Beach's employee engagement level is "below average."The company based this on its experience that current employee populations tend to use more of the high end of the 1-5 Likert Scale, producing quartile bands with higher ranges of scores than one might expect by simply reading the survey scale. The Value of Establishing a Public Advocate or Ombud Employee Concerns about HR Processes Among the most common themes emerging from our interviews, meetings and listening sessions involving City employees was trust-and whether the City HR Department and others were capable of responding quickly and effectively to any internal workplace concerns raised by employees on a wide range of issues. Many of the concerns raised related to what some described as"toxicity" in the workplace or unfavorable treatment regarding policy and practices and their interpretation by various government offices on the City of Virginia Beach campus. In spite of the various reporting avenues www.hillardheintze.com 168 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES available to employees, many questioned whether individual and inter-office issues were being properly handled. Interviewees reported that an HR Liaison or Office Administrator is often the first line of HR reporting within their office,as was the case in Building 2.A significant number commented that the guidance provided was inconsistent-depending on the person consulted and the issue at hand,among other factors. Some employees interviewed said they had sought guidance and assistance from the City HR Department for interpretations of policy and help with particular issues and were frustrated with the process and results.Others said they did not know or understand that their internal HR Liaison was not the final arbiter of an issue or that they could have taken the same issue to the City HR Department for possible resolution or further guidance. In addition to those who reported not knowing they had outside avenues of assistance, many vocal stakeholders stated that none of the current reporting structures were helpful and could not or would not address underlying HR- related issues regarding policy violations on the City of Virginia Beach campus. How a City of Virginia Beach Public Advocate Can Help One of the ways municipalities,government agencies and universities have addressed similar concerns is by creating an autonomous Public Advocate or Ombudsman Office to hear, review, address,solve and direct employees'issues and concerns to the correct office or division within the City or elsewhere. Following on the heels of universities,more government agencies are now establishing stand-alone offices dedicated to stakeholder advocacy with a direct reporting line to executive leadership in order to bypass the influence of other departments and functions. Public advocates and ombudspersons have been successful in leveraging organizational neutrality and collaborative problem-solving to address individual,group and agency-wide concerns that are raised in confidence.The Public Advocate or Ombudsman is often a trained professional with years of experience in handling HR,legal and other workplace concerns,including policy interpretation. In addition to directly serving as a vehicle for employees to raise concerns confidentially,she or he also serves as a conduit for the agency to identify trends and help the administration address underlying issues raised by employees.Typically,these issues involve policies, procedures or practices that various groups and offices view as problematic, misunderstood, misinterpreted or applied in a manner that does not reflect the organization's mission,values and principles. We believe that establishing a City of Virginia Beach Public Advocate's Office would improve morale and commitment across the workforce.Such an office would help the City gain and maintain trust and give voice to employee concerns. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 169 The Public Advocate's Office is not an island unto itself,and it would work collaboratively with other offices and reporting avenues already established within the City. Its role is to be a neutral point for anyone working in the City to raise concerns and to help address these concerns by being knowledgeable about resources, policies and other offices best quipped to address specific situations.This office is not a substitute for HR, Legal or an Inspector General. Instead, it is a supplement to the City to assist with resolving employee concerns that may not have been brought to light otherwise.There are several key types of these offices,each with unique aspects. Should the City accept this recommendation,the function of the office would need to be clearly defined and function in a transparent manner. Types of Internal Offices Dedicated to Resolving Employee Issues Executive- Receives complaints concerning actions and omissions of the agency and its officials,employees and contractors,and works to hold the entity or its programs accountable or works to improve performance. Traditional Ombudsman- Is established by statute or some other official means to resolve problems through formal investigations,usually in addition to informal reviews, and issues formal reports;some classical ombudsmen have decision-making authority. Organizational - Is established by statute or management decision; performs neutral fact- finding; and informally addresses problems concerning the organization's actions, policies or regulations(governmental). Advocate- Evaluates complaints, problems and issues objectively, but advocates for fair process on behalf of specific individuals or groups(e.g.,a long-term care Ombudsman). 4.6 Community Forums and Employee Meetings: Out-of-Scope Issues Raised The Hillard Heintze team held two community forums and two employee meetings to provide employees and community members an open forum to ask questions and raise concerns regarding Building 2 and the May 31,2019 shooting. Several significant issues were raised repeatedly in all four sessions that were out of scope of the review of the May 31, 2019 shooting and not arising from the employees in Building 2. Few issues brought forward in the forums were directly related to Public Utilities/Public Works Departments.A substantial number of the comments made were specifically regarding the City HR Department.Additionally, unless noted below,the issues of toxicity and racism voiced at the public meetings rarely were heard during our interviews.Also,while mentioned in the comments of the survey,they did not represent a significant finding in the survey. www.hillardheintze.com 170 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES Issues raised during these community forums and employee meetings included the following: a Mistreatment and bullying, retaliation and humiliation by supervisors,managers and department leadership,with the work environment often being described as toxic. ffi Mistrust of City leadership, most notably the former city manager,which was also a common theme during the interviews. t. Lack of a trusted and independent office to which employees can report concerns, complaints and issues confidentially with confidence that their issues will be evaluated by an impartial professional,such as an ombudsman,empowered with addressing, investigating,meditating and resolving employee issues. • Concern that the City HR department was disconnected from what was occurring in the divisions,which was also a common theme during the interviews. • Mistrust in the findings and confidentiality of City's findings in,for example,surveys,data collection and confidential employee files. Concerns regarding City survey findings being linked back to their unique IDs/work emails and retaliation potentially occurring based on honest feedback provided. Concerns about racism and the lack of hiring and promotion opportunities afforded to minorities. Representatives from the City of Virginia Beach Interdenominational Ministers Conference attended all public meetings and presented a list of questions(Appendix 6.5)that was also sent to City leadership. We note that these issues were not within the scope of our review. For the most part,the employees in Building 2 did not raise these issues in interviews or in surveys and definitely did not raise these issues to the level heard at the public meetings. In addition, management practices did not play a role in the shooting. However,there were public comments at each of the meetings held regarding the impact of toxicity,retribution by supervisors, racism and poor working environments.They were significant in terms of volume and in terms of the issues raised.They were public and this team listened. For this reason,we have provided this appendix to the report. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 171 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 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 as-built 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. www.hillardheintze.com 172 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES 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 • 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 City-issued 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. 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 ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 173 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 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. www.hillardheintze.com 174 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES 4.18 Negative Performance Evaluations: Restructure how the City HR Deparment 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. 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 ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 175 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 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. www.hillardheintze.com 176 SECTION 4 AN APPRAISAL OF THE CITY'S WORKPLACE VIOLENCE PREVENTION CAPABILITIES 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, role and responsibility for such reporting are and what outcome reporting requirements should attach to the report.42 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. 42 Reporting Fraud,Waste.&Abuse.https://www.vbgov.com/government/departments/city-auditors- office/Pages/report-fraud-abuse.aspx.Accessed 10/24/19 ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 177 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. 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. www.hillardheintze.com 5 Section 5 The Challenges to Recovery, Resiliency and Prevention on the Path Ahead The City of Virginia Beach:An Independent Review of the Tragic Events of May 31,2019 ---,,,,A4,7„., : . „„,,,,--;-o,,,,,-;.r,-,--..t",,:,-4:.':-,r,--,fi:-.---, ,i,,----- ---4,,,,,,,;-.-,;:.----- 7/..," ______''''.r'44P'''''-4.001,4,V6011 -1*- ..- .4 . ., , m __, - iiilottititi,„4,T.4- r .--• ' ' '. `'..k ,� v �. „ +sex H I LLARDlr H E I NTZE AJE N HUGHES COMPANY THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 179 SECTION 5 -THE CHALLENGES TO RECOVERY,RESILIENCY AND PREVENTION ON THE PATH AHEAD For the City of Virginia Beach, like other communities,workforce recovery and continuity of operations planning are critical components of the response to an attack like this one, or any critical incident. Best practice now starts the recovery phase almost concurrently with the initial response to the critical incident, which reflects the true meaning of"workforce resilience" - an organization's ability to respond to and overcome threats confronting its workforce. We know that a workforce faced with a critical incident will be affected in many ways and will face difficult challenges, including post-traumatic stress, burnout and fatigue. It is thereby critical to plan for the support of the workforce and ensure key service delivery can continue during and after the response to critical incidents. www.hillardheintze.com 180 SECTION 5-THE CHALLENGES TO RECOVERY,RESILIENCY AND PREVENTION ON THE PATH AHEAD 5.1 Recovery and its Impact on Employees and Victims Managing Future Challenges This report will help inform the path ahead. It has identified key issues employees faced before the tragedy as well as challenges the City needs to address in the months and years ahead. Today, Building 2 stands surrounded by fencing,and the top three floors remain unoccupied. It is a reminder that despite the events of May 31,2019,the workforce is supported by a strong foundation. The impacts on leaders and employees have been substantial;some survivors may never to return to work,while others may address the stressors and issues that continue to challenge them well into the future. However,every person to whom we spoke -employees,coworkers,first responders and City residents -talked about focusing on recovery. Even those who faced significant horror and danger met with us-to share information and contribute to changes that will help protect stakeholders in the future.The task of following through on these rests with the City and with its employees. Effective recovery incorporates an operational continuity plan that allows key services to continue after a critical incident.The City of Virginia Beach began this work on the day of the tragedy; however,this planning continues today,as recovery is an ongoing process. A key component of recovery is to establish workforce resilience.This term refers to the City's ability to respond to and support the needs of the workforce.The more employees are supported, the easier it is to maintain continuous operations in the event of a crisis. Many employees have been working relentlessly since the tragedy,but as time progresses,the potential for burnout increases. As part of the recovery process,the City will need to support and address the complications of post-traumatic stress and compassion fatigue among first responders and employees. It will be critical to engage employees and help both supervisors and managers assess which employees are having difficulties in their return to work.Working together,the City and its employees can identify future needs and the best way to help the workforce in the near-term. As the City moves forward,difficult decisions will need to be made regarding positions, accommodations and support services. Establishing the structures now,with education and training for employees and their supervisors and managers,will help everyone understand the framework for recovery. It will be particularly important to provide external support for ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 181 supervisors and managers to help them develop the leadership skills necessary to work through what has been a horrific event for all. Virginia Beach is strong-and the employees of Building 2 demonstrated that on May 31, 2019 and continuing through today. Each faces a different struggle that may or may not be visible in the workplace. Developing a plan with professional guidance and input will allow the City to support its employees and to set the structures and guidance necessary to move forward. 5.2 Recovery and its Impact on City Services to the Community - Returning to Business A walk through the municipal campus demonstrates that business in Virginia Beach and the provision of key City services continues.We outlined the focus and drive that allowed key City services to resume fairly quickly after the tragedy,despite a traumatized and displaced workforce. The City is to be commended for its rapid response to ensure that the provision of essential services was able to resume. The future focus should be on ensuring that the continuation of operations plan considers the challenges of a mass casualty event and its mitigation.The City should focus future emergency response planning on redundancy in City building sites and operations,and it should evaluate blended resourcing and support functions across the City to establish a layered response to any potential critical incident in the future. An established plan that is transparent and goal-focused will allow both the employees and those individuals who rely upon City services from the departments of Building 2 to move forward. There will be tough decisions, but as the City moves into recovery and beyond,focusing on the service and support needs of the community will provide a good start. www.hillardheintze.com Section 6 Appendices The City of Virginia Beach:An Independent Review of the Tragic Events of May 31,2019 HILLARD HEINTZE A JENSEN HUGHES COMPANY THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 183 APPENDICES These Appendices provide an additional resource to ensure that this report can be easily read and understood by anyone — a City of Virginia Beach community member or otherwise — who is seeking insight into the events of May 31. 2019. www.hillardheintze.com 184 SECTION 5-THE CHALLENGES TO RECOVERY,RESILIENCY AND PREVENTION ON THE PATH AHEAD Appendix 6.1 - Acknowledgements Hillard Heintze sincerely thanks the community of Virginia Beach for the support provided to our review.We met community members,employees,government stakeholders and others who were supportive of our team and aided the work. Hundreds of people in Virginia Beach generously gave their time and resources to our review,including helping us gather key information and facts, accommodating our team with access to City facilities,and being available and willing to participate in the interview process. Each party with whom we met demonstrated a commitment to transparency and providing survivors answers to the May 31,2019 tragedy. Hillard Heintze is grateful to the over 200 employees and citizens who spoke with us during an interview or provided information to the team,as well as those who participated in the four listening sessions.We specifically thank the following Virginia Beach City personnel and work units for their support of the review and interest in providing us the data,information and time needed to conduct the review. CITY AUDITOR'S OFFICE • Mr. Lyndon S. Remias,CPA,CIA,CRMA,CGAP • Ms. Gretchen Hudome,CIA,CRMA • Ms. Rosana Clark CITY OF VIRGINIA BEACH OFFICES City Manager Police Department •• Public Utilities Fire Department Business Division Emergency Medical Services • Director's Office Office of Emergency Management • Engineering Division Emergency Communication& • Facilities Management Citizen Services • Information Technology Occupational Safety and Health • Real Estate Services • Technical Services Health&Human Services Finally,we thank the families and the survivors for their assistance-their courage and fortitude throughout this review was truly inspiring. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 185 Appendix 6.2 - About the Review Team's Experts The strength and relevance of this report's key findings and recommendations depend on the credibility,qualifications and experience of the review team and its individual members. For the benefit of the reader,a short description of each team member's background is provided below. More detailed background can be found at www.hillardheintze.com. ARNETTE F.HEINTZE,CHIEF EXECUTIVE OFFICER Arnette transformed a small, high-performing cadre of senior experts into a globally recognized security risk management and investigations firm.Under -Ts,' leadership,the expanding Hillard Heintze team is systematically setting new best practices in security and investigations across the board - a track record that has quickly and dramatically expanded the firm's client list to include a "Who's Who"of Fortune-ranked corporations with leading positions in their industries - across the country and, in many cases,worldwide. Based on nearly three decades of experience working at the highest levels of federal,state and local law enforcement, Arnette has an exceptionally strategic perspective on security.As a U.S.Secret Service Special Agent and a senior agency executive,Arnette planned,designed and implemented successful security strategies for U.S. Presidents,world leaders,events of national significance and the protection of the nation's most critically sensitive assets. KENNETH A.BOUCHE,CHIEF OPERATING OFFICER As Hillard Heintze's Chief Operating Officer, Ken has helped the firm's CEO transform a small team of seasoned professionals into one of the leading # security risk management firms in the world. Ken has advised clients across many industries and sectors on how to align their security strategies with their corporate strategies to improve efficiencies and effectively mitigate risk. He currently guides the performance of the firm's operations from end-to-end, across all six of its practices. Ken's depth of experience in the justice and homeland security space includes serving as a member the IJIS Institute's Board of Directors from 2009 to 2013 and chairing the Global Justice Information Sharing Initiative from 2001 to 2006. He served as a national leader in improving America's information-sharing capacity and implementing post-9/11 intelligence reforms. Ken dedicated 23 years to the Illinois State Police(ISP).As Colonel and CIO, he was responsible for modernizing and standardizing the agency's technology functions. He oversaw the delivery of critical real-time information to more than 1,000 police agencies and 40,000 police and justice end-users on a 24-hour basis. www.hi Ilardhe intze.com 186 SECTION 6 APPENDICES DEBRA K.KIRBY,ESQ.,SENIOR VICE PRESIDENT,OPERATIONS Ire Debra has been a lifelong champion for change and improved policing practices in the U.S.and in Ireland.She served as Deputy Chief Inspector of Garda Siochana Inspectorate,an agency tasked with making policy and practice recommendations for An Garda Siochana,the national police force of Ireland, directing a range of improvements for policing in Ireland.She retired as the highest-ranking female in a major city police department,having developed expertise in labor management; officer-involved shooting investigations and policies;criminal investigations; large-scale demonstrations and emergency preparedness;and,internal affairs and accountability.She was a change agent in critical organizational change programs,including district reduction,introduction of the first independent civilian police review for officer use of force;and establishing protocols and policies around issues such as prisoner treatment;stop and frisk;officer involved shootings and other risk areas.She currently serves as the Project Director for Hillard Heintze's collaborative reform efforts in addition to leading other law enforcement consulting engagements.She holds a Master of Arts in Homeland Security from the Naval Postgraduate School and a Juris Doctor from the John Marshall Law School in Chicago. MATTHEW W.DOHERTY,SENIOR VICE PRESIDENT,THREAT+VIOLENCE RISK MANAGEMENT Assessing the potential for danger and preventing targeted violence against our nation's leaders and U.S. corporations has been the cornerstone of Matt's ` career.As the Senior Vice President leading the Threat+Violence Risk I Management practice at Hillard Heintze and the retired U.S.Secret Service Special Agent in Charge of the National Threat Assessment Center, Doherty is a nationally recognized workplace violence prevention and program development expert.Credited with saving lives by intervening on domestic abuse,terminations,severe mental illness and other critical situations in today's workforce, Matthew advises federal agencies and private-sector organizations by gathering and assessing information about persons or groups who may have the interest, motive,intention and capability of violence. He has conducted training on threat assessment and targeted violence prevention for law enforcement personnel,schools and Fortune 500 companies. Featured in numerous magazines, newspapers and news media for his insights on insider threats,assassinations and school shootings, Matthew is a sought-after speaker and interview subject on targeted violence incidents and prevention efforts. He is a member of ASIS International,the Association of Threat Assessment Professionals(ATAP),and the Society for Human Resource Management(SHRM). ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 187 iimmi • ROB DAVIS,SENIOR VICE PRESIDENT,LAW ENFORCEMENT CONSULTING Rob is a highly regarded and innovative national leader in policing and public safety with extensive experience assessing federal,state and local law ,h, enforcement agencies across the U.S. Rob served in a variety of capacities Aduring his 30 years'career with the San Jose Police Department, including as the Chief of Police for seven years. During his time as chief, Rob also served as the President of the Major Cities Chiefs Association. He provided consulting services for the U.S.State Department,traveling on numerous occasions to Central and South America to provide training in community policing methods addressing gang prevention, intervention and suppression.Since retiring from San Jose, Rob has been involved in numerous assessments of police departments across the nation,including serving as the Project Director for Hillard Heintze's Department of Justice Collaborative Reform Initiative for Technical Assistance contract. JENNIFER L.MACKOVJAK,SENIOR VICE PRESIDENT,INVESTIGATIONS Jennifer is a highly seasoned civil and criminal investigator with extensive U.S. r and international public and private sector credentials.Jennifer leads and i , directs critical investigative tasks related to formulating and executing case f strategies,investigative plans and tactical initiatives; analyzing litigation and } other public filings; and gathering intelligence through human-source interviews, media reports,social networking sites and online database research. Her experience gives her a keen understanding of the rigor,objectivity and persistence required to preserve the integrity of critical investigative findings. DR.MARK BRENZINGER,PSY.D.,VICE PRESIDENT,THREAT+VIOLENCE RISK MANAGEMENT p (-I\ Mark Brenzinger, Psy.D., is a licensed clinical and forensic psychologist with more than 20 years of experience. Mark has conducted thousands of indirect • threat assessments and direct violence risk evaluations and with adult and adolescent male and female subjects.As a Licensed Sex Offender Evaluator specializing in psychosexual risk evaluations, he has conducted more than 1,000 evaluations and provided expert court testimony. He has worked with clients that range from Fortune-ranked enterprises and mid-sized corporations to government agencies, academic institutions and private individuals. www.hillardhe intze.com 188 SECTION 6 APPENDICES MARCIA THOMPSON,VICE PRESIDENT,LAW ENFORCEMENT CONSULTING As a Vice President within our Law Enforcement Consulting practice,she provides oversight, management and technical assistance on various law enforcement assessments,trainings and reviews. Marcia has served as a law enforcement administrator within the Department of Safety at the University of 4 Chicago Police Department,where she oversaw professional standards, accreditation,compliance,training, records management, recruitment,field training,in-service training, leadership development,succession planning,community engagement, youth outreach and the community advisory committee in support of the universities transparency and inclusion initiative. Marcia is a Virginia Supreme Court certified mediator as well as a collaborative problem-solver,change management facilitator,and equal employment opportunity (EEO)and civil rights professional. For many years, Marcia has served as a federal fact finder, EEO counselor,trained EEO investigator and hearing officer, providing neutral hearings and drafting administrative appellate determinations. CASS W.LEATON,SENIOR DIRECTOR,SECURITY RISK MANAGEMENT Cass is one of this country's leading physical and technical experts in developing comprehensive security plans and countermeasures for the protection of our nation's most critical infrastructure as well as high-profile individuals and the venues they visit.Cass managed the physical security for all U.S.Secret Service lb facilities in 12 states and Canada. He is affiliated with the Great Lakes Bomb Technicians, National Centrex Users Group and the DMS-100 Users Group and is an alumnus of the Center for Creative Leadership and National Intelligence Academy. CHAD M.MCGINTY,SENIOR DIRECTOR,SECURITY RISK MANAGEMENT 414 Chad brings nearly three decades of law enforcement, public safety,emergency preparedness and security leadership experience to his role as Senior Director at Hillard Heintze.Chad served in the Ohio State Highway Patrol for nearly 28 41- years,starting as a Trooper in 1989 and later serving as Sergeant, Lieutenant ,r�' and Captain before joining the Senior Staff as Major,Commander of Field Operations in 2014. He concluded his tenure by coordinating and leading the crowd control/field force response for the 2016 Republican National Convention in Cleveland, Ohio.Chad implemented a sophisticated staging and response for 1,400 field force officers from 18 different agencies and 15 states. ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 189 JOANN UGOLINI,CFE,CPP,PSP,SENIOR DIRECTOR,THREAT+VIOLENCE RISK MANAGEMENT JoAnn leads and contributes to multiple client service teams as an expert in open source database research,security risk analysis,threat assessment and fraud investigations.With more than 20 years of professional security - experience,JoAnn is a Certified Fraud Examiner and has been board certified in security management and physical security. Before joining Hillard Heintze, JoAnn served as the Manager of Business Risk Intelligence at Abbott Laboratories.She co-developed a customized risk-mapping tool,which compiles and organizes risk data.JoAnn was the lead analyst on projects which analyzed open source intelligence and threat monitoring tools.JoAnn also served as Abbott Global Security's expert on threat assessment and management.Additionally,JoAnn conducted hundreds of internal and external threat and fraud investigations.JoAnn is currently the Programming Director on the board of InfraGard,and served for two years as the Committee Chairperson of Abbott Women Leaders in Action. ANDREW K.DAVIS,CFE,SENIOR DIRECTOR,INVESTIGATIONS -- Since joining Hillard Heintze in 2012,Andrew has been entrusted with a range of critical assignments -from supporting the firm's Senior Vice President on 4-40 security risk assessments of Fortune 500 global security programs and executive protection planning to his current responsibility:overseeing a team of associates dedicated to one of the firm's largest clients and leading the company's high-volume due diligence background investigation projects. He also participates in complex investigations,security assessment projects and emergency operations plans.Additionally,Andy has earned the Certified Fraud Examiner designation awarded by the Association of Certified Fraud Examiners. MARK GIUFFRE,CFE,CAMS,CPP,DIRECTOR,LAW ENFORCEMENT CONSULTING With 30 years of experience serving in the U.S. Drug Enforcement Administration(DEA), Mark is a globally recognized expert in narcotics investigations,interdiction, border security,transnational crime groups and i synthetic opioids. He has developed and provided training programs and instruction to federal,state, local,tribal and foreign law enforcement officials. In addition, he is trained,experienced and certified in financial,fraud and asset forfeiture investigations. Mark retired as an Assistant Special Agent in Charge of the DEA Chicago Office where he was responsible for narcotics investigations, money laundering investigations, intelligence and enforcement in five Midwestern states. Earlier in his career, Mark was stationed at the American Embassy in Bangkok,Thailand for seven years,with travel and assignments to 37 other nations. www.hiliardheintze.com 190 SECTION 6 APPENDICES MICHAEL DIRDEN,ESQ,SENIOR ADVISOR,LAW ENFORCEMENT CONSULTING Michael joined Hillard Heintze following a long and successful career with the Houston Police Department.As the Executive Assistant Chief of Police, Michael provided leadership and oversight for the department's Investigative,Strategic and Field Operations,including accountability for Patrol Operations,Traffic Enforcement,the Mental Health Division,Apartment Enforcement and Differential Police. TIFFANY BOSTROM,SENIOR ANALYST,THREAT+VIOLENCE RISK MANAGEMENT lit .---' As Senior Analyst,Threat and Violence Risk Management,Tiffany conducts day-to-day research and analysis of open source information from social media platforms and other online media sources. She writes reports and supports clients with time-sensitive intelligence related to workplace violence rt. prevention,background investigations, behavioral threat assessments,crisis management and executive protection.Tiffany received her Master's Degree in Forensic Psychology from the Chicago School of Professional Psychology.Tiffany volunteers as a member of the programming committee for InfraGard,an organization that serves as a partnership between the FBI and members of the private sector.Tiffany has also received formal training on the Workplace Assessment of Violence Risk(WAVR-21),which is a structured guide for assessing workplace and campus targeted violence. TALIA BEECHICK.ASSOCIATE DIRECTOR,INVESTIGATIONS .. . Since joining Hillard Heintze's investigative team in 2017,Talia has completed hundreds of individual and corporate investigations with a > ; focus on public records research and open-source intelligence.Talia's work within Hillard Heintze's investigative and threat assessment practice areas has helped clients make more informed business decisions, provided key insights relating to ongoing civil litigation and revealed information or patterns of behavior critical to keeping them safe. NATALIE FOl1TY.PROJECT MANAGEMENT SENIOR SPECIALIST Natalie is an accomplished project manager with key experience within the I criminal justice system including jails,task forces and private sector security 14 services.As Project Management Senior Specialist,she specializes in overseeing,conducting and developing extensive operational protocols and procedures,including those pertaining to case management and report preparation. Natalie has managed multiple large-scale projects with an emphasis ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 191 on creating tangible deliverables designed to satisfy the diverse needs of stakeholders. Prior to joining Hillard Heintze, Natalie served as Project Manager,Strategic Operations Center at the Cook County Sheriff's Office where she conducted comprehensive investigations and critical incident reviews,as well as created and implemented an early intervention system for officers. Natalie holds a Bachelor of Science degree from Loyola University Chicago. KRIS MOHANDIE,PH .,ABPP, EXTERNAL PEER REVIEWER Dr. Kris Mohandie is a clinical, police,and forensic psychologist with 30 years experience in the assessment and management of violent behavior. He has contributed to the published scholarly literature with coauthored publications pertaining to mass homicide and other extreme violence events. He has interviewed many violent offenders including mass and serial murderers. He regularly consults to, and testifies in homicide cases and during his tenure at the LAPD responded on scene as a psychologist consultant to the crisis negotiation/SWAT team. His true crime book, Evil Thoughts:Wicked Deeds was released November 2019. www.hillardheintze.com 192 SECTION 6 APPENDICES Appendix 6.3 - Summary of Recommendations 2 - RECOMMENDATIONS 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 pre- designated 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 THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 193 2 - RECOMMENDATIONS 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: 6 Emergency dispatch 7 Text message 8 Email 9 Mobile app push notification 10 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 194 SECTION 6 APPENDICES 2 - RECOMMENDATIONS 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.43 3 RECOMMENDATIONS 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 pre- planned 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 follow- up 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. 43 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 195 mes NDATI2NS 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 role- focused 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 196 SECTION 6 APPENDICES 1111111111111111111111111111111111 3 RECOMMENDATIONS 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. 4.1 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 197 4 RECOMMENDATIONS 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 as- built 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.hi Ilardheintze.com 198 SECTION 6 APPENDICES 110111111111111111111111111 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 City- issued 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 THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 199 memirmswis 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 200 SECTION 6 APPENDICES 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 201 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.hillard heintze.com 202 SECTION 6 APPENDICES 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, 0 2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 203 role and responsibility for such reporting are and what outcome reporting requirements should attach to the report.44 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. 44 ReportingFraud,Waste,&Abuse.htt s://www.vb ov.com/ overnment/de artments/ci p g g p ty-auditors- office/Pages/report-fraud-abuse.aspx.Accessed 10/24/19 www.hillardheintze.com 204 SECTION 6 APPENDICES 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 205 Appendix 6.4 - List of Acronyms and Abbreviations ACS Access control system ECCS Emergency Communication and ADA Americans with Citizen Services Disabilities Act ECO Emergency Continuity ATAP Association of Threat of Operations Plan Assessment Professionals EEO Equal Employment Opportunity ATF Bureau of Alcohol, Tobacco,and Firearms EMS Emergency Medical Services BAU Behavioral Analysis Unit EOC Emergency Operations Center BCP Business Continuity Plan EOP Emergency Operations Plan CAD Computer-aided dispatch ESF Emergency Support Functions CCTV Closed-circuit television FAC Family Assistance Centers CMCI Criminal Mass Casualty Incidents FBI Federal Bureau of CPD Chesapeake Police Investigation Department FERPA Family Educational Rights and Privacy Act CVB Convention and Visitors Bureau FRC Family Reunification Center DCM Deputy City Manager GUI Graphical user DEM Department of interface Emergency Management HIPAA Health Insurance Portability and DHS Department of Accountability Act Homeland Security HR Human Resources DV Domestic violence Department EAP Employee Assistance ICS Incident Command Program System www.hillardheintze.com 206 SECTION 6 APPENDICES Abbreviation Definition Abbreviation Definition IDS Intrusion detection VSP Virginia State Police system WAVR-21, Workplace Assessment JIC Joint Information 3rd Edition of Violence Risk Center MOU Memoranda of Understanding OEM Office of Emergency Management OSHS Occupational Safety and Health Services PA Public address[system] CCP or Charge and Conviction 'Panel' Panel PAR Parks and Recreation PIP Performance Improvement Plan RTF Rescue Task Force SHRM Society of Human Resource Management SWAT Special Weapons and Tactics TAT Threat Assessment Team VBFD Virginia Beach Fire Department VBIMT Virginia Beach Incident Management Team VBPD Virginia Beach Police Department VBSO Virginia Beach Sheriff's Office VMS Visitor management system ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 207 Appendix 6.5 - Questions Submitted by the Virginia Beach Interdenominational Ministers Conference The following is a list of questions the Virginia Beach Interdenominational Ministers Conference requested Hillard Heintze ask during the course of our investigation.We have provided these questions verbatim. 1 What percentage of Virginia Beach(VB)employees are female? 2 What percentage of VB employees are African American? 3 What percentage of VB employees are minorities not counting African Americans? 4 In this instance,are female being counted as minority 5 How many VB employees are considered exempt or supervisory in their roles? 6 How many exempt/supervisory employees are female? 7 How many exempt/supervisory employees are African American? 8 How many exempt/supervisory employees are minorities not counting African Americans? 9 How many African American VB employees were in some form of disciplinary action at the time of the incident?What percentage of the overall African American staff did this represent? 10 How many Caucasian VB employees were in some form of disciplinary action at the time of the incident?What percentage of the overall Caucasian staff did this represent? 11 How many VB employees were fired for cause in the last 36 months? 12 How many of these terminations were for African American employees? 13 How many of these terminations were for female employees? 14 How many VB employees retired in the last 36 months? 15 How many of these retirements were for African American employees? 16 How many of these retirements were for female employees? 17 Were any of these retirements'forced'? 18 How many promotions were there over the last 36 months? 19 What percentage of these promotions were for African American employees? 20 What percentage of these promotions were for female employees? www.hillardheintze.com 208 SECTION 6 APPENDICES 11111111111111111111111111111111111 21 What supervisor training was accomplished for any of the newly appointed supervisors? 22 What training plan(s)are required at all supervisory levels? 23 Who writes the performance reviews for supervisors and managers in Building 2? 24 What criteria qualifies a supervisor's performance as satisfactory? 25 Over the last 36 months,how many exempt/supervisory roles were filled from outside candidates rather than internal promotions? 26 At what level are hiring and firing decisions made within the VB city staff? 27 At what level are promotion decisions made within VB city staff? 28 Does the immediate supervisor decide if a front-line employee is promoted? 29 Are exit interviews required and if so by whom? 30 If an employee decides to quit or retire,what is the process for determining the last work date for the employee?At what level of leadership is this process managed? 31 How are employee complaints managed and tracked within the city? 32 Are all persons involved in the complaint interviewed and by whom? 33 Is there a different process if the complaint is against the employee's immediate supervisor? 34 What instructions do employees have if they have difficulty or dissatisfaction with their immediate supervisor? 35 How many employees were fired over the last 36 months after having first filed a complaint? 36 What emails(un-redacted)did the shooter send to or receive from VB employees over the last 24 months? 37 Did any of these emails involve disciplinary action? 38 When was last performance review performed on the shooter and how was he rated? 39 What is the normal evaluation performance intervals(annually,semi-annual,etc.)? 40 What performance level was the shooter's last three evaluations? 41 Was he on a disciplinary plan? 42 Who decides if an employee is going to put on a disciplinary plan? 43 What role does HR play in this process? 44 How does an employee get off of a disciplinary plan? 45 Who is responsible for having career development conversation with employees to discuss upward mobility? ©2019 HILLARD HEINTZE THE CITY OF VIRGINIA BEACH:AN INDEPENDENT REVIEW OF THE TRAGIC EVENTS OF MAY 31,2019 209 immommo 46 How many immediate supervisors did the shooter have over the last 36 months? 47 How long did he report to each of them? 48 Did he train any persons that were promoted and were any his immediate supervisor? 49 What was the tenure with the City for these supervisors? 50 If he wasn't on a disciplinary plan,why did the publicly disclosed email not attempt to convince him to stay? 51 Why did this same email refer to a two-week notice of separation as if the subject had been discussed before? 52 Who determined this two-week notice of separation and when was it communicated to the shooter? 53 Are there pay disparities that exist between Caucasian,African American,female and other minority employees? If not,what's the proof? www.hillardheintze.com 210 SECTION 6 APPENDICES IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII Appendix 6.6 - Survey of Virginia Beach Residents by Third-Party Survey Firm 0 2019 HILLARD HEINTZE City of Virginia Beach Workplace Survey Comparison Report . w • .i'� k . o t _ ,db 1 ili ,. “. r slip '• M"•ili�• sl - • •. mow. • . •R 1 44 ;i s+ €fkA r i • • • October 21 , 2019 Created by: People Quinton Barrett _, _ OD Business Partner Pe quinton(Cr�,peopleelement.com element 303.389.9012 CONTENTS BACKGROUND & METHODOLOGY 3 ANALYTICAL SUMMARY 4 KEY FINDINGS 5 KEY FINDINGS SUMMARY 7 CITYWIDE AVERAGE SCORES 8 CITYWIDE TOP & BOTTOM SCORES 12 DETAILED FINDINGS: VALUES & ETHICS 14 LEADERSHIP 18 COMMUNICATION 22 TRAINING & DEVELOPMENT 26 RECOGNITION 30 WORK ENVIRONMENT 34 CULTURE & CLIMATE 38 CITYWIDE ENGAGEMENT LEVEL 41 CITYWIDE ENGAGEMENT BENCHMARKED 42 APPENDIX A: PRE-SURVEY COMMUNICATIONS PRE-SURVEY EMAIL 44 SURVEY INVITATION 45 APPENDIX B: FINAL SURVEY FINAL SURVEY 47 ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 2 BACKGROUND & METHODOLOGY Hillard Heintze contracted People Element to conduct a confidential workplace survey to better understand City of Virginia Beach employee perceptions. The survey will assist by informing an independent investigation into the VA Beach incident occurring May 31st, 2019. Beginning in 2002, the City of Virginia Beach has conducted biennial surveys to assess employee perceptions and satisfaction with their employment. The results of the research are typically used to develop and update action plans at the City and departmental level. The current survey (Fall 2019) was administered months after the last Employee Satisfaction Survey (Spring 2019) with the goal of assessing employee perception differences since the May 315t, 2019 incident. The fact that the survey was being administered by a third party to ensure confidentiality was communicated to the City's employees to encourage candid feedback. The key categories usually measured by the survey include: A. Values & Ethics B. Leadership C. Communication D. Training &Development E. Recognition F. Work Environment People Element administered a slightly modified version of the same survey to provide comparison data. The only changes made to the survey were the addition of two safety related items added to the existing Work Environment category and seven items added via a new Culture & Climate category. The Culture & Climate category also includes items People Element uses to provide a measure of employee engagement to further understand employee perceptions. All City Members (Full & Part Time) were eligible to participate in the survey (approximately 7,500). Data was collected from September 24th to October 12th, 2019. Invitation emails were sent to 6,678 Members, and an anonymous survey link was distributed to employees without a City of Virginia Beach email address. Prior to launching the survey, a pre-notification email was distributed by the City of Virginia Beach to all employees with emails. A flyer with an anonymous survey link was distributed to employees without emails. A reminder email with the survey link and cut-off date was sent to non-responders throughout data collection. A total of 3,159 evaluations were completed (3,116 by email,43 by anonymous link) representing a participation rate of 42%. ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 3 ANALYTICAL SUMMARY The total sample size (n=3,159) yields a 1.33% margin of error at the 95% level of confidence, meaning that there is a 95% level of confidence that the actual result lies within 1.33 percentage points (in either direction) of the result our sample produced. Members were segmented into various sub-groups based on self-selected demographics/background information. Significance testing (Mann-Whitney U test) at the 95% confidence level was conducted to detect differences among these segments. When applicable, these findings are noted. People Element was not provided with raw data from the previous (Spring 2019) survey. Instead a summary of the data was provided with mean scores rounded to one decimal. For this reason, significant differences in item scores could not be determined reliably. However, category and item comparisons are included in the analysis. Unless otherwise indicated, questions were asked of all respondents (n=3,159). All quantitative items were measured on a 1-5 agreement scale in which 1=strongly disagree and 5=strongly agree. Due to rounding, percentages may not add to 100%. ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 4 KEY FINDINGS High Level Overview When compared to the previous (Spring 2019) survey the current (Fall 2019) survey showed a decrease in employee satisfaction. • The overall mean score for the current (Fall 2019) survey is 3.6, compared to the previous (Spring 2019) survey with an overall mean of 3.8. • Every item present in both surveys showed a marked decrease in the Fall 2019 survey. The key categories measured by the Fall 2019 survey are shown below by highest to lowest mean score: • Culture & Climate (3.8) • Value & Ethics (3.8) • Communication (3.8) • Training & Development (3.7) • Work Environment (3.6) • Recognition (3.5) • Leadership (3.3) Areas of High Perception The City received the highest ratings for items in the newly added category Culture & Climate. While this category cannot be compared to the previous survey, the highest rated items in Culture & Climate are shown below: • I am motivated to go beyond what is normally expected of me to help the City be successful (4.0) • My work gives me a sense of personal accomplishment (4.0) • I plan to be with the City at least 1 year from now (4.0) The City received the second highest ratings for items in the category Values& Ethics. Though all items showed a decrease when compared to the previous survey. The highest rated items in Values& Ethics are shown below: • I understand how my job impacts the City's mission and goals (4.4) • I am treated with respect by my immediate supervisor (4.1) • I am treated with respect by my co-workers (4.0) Other notable highly rated items came from the categories of Work Environment & Communication: • Work Environment - My department accommodates my needs when I have a personal matter to attend to (4.2) • Communication - I keep myself informed by reading various forms of internal publications/communication (Because You Asked, Member Update, beachnet, e-mail, Benefits e- bulletin, etc.) (4.0) • Communication - I often initiate (begin) communication about my job with my immediate supervisor (4.0) ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 5 KEY FINDINGS - CONT. Areas of Low Perception The City received the lowest ratings for items in the category Leadership. The lowest rated items in Leadership are shown below: • The City Manager's/Deputy City Managers' decision-making is based on the City's Organizational Values (3.1) • The City Manager and Deputy City Managers help to create a culture of learning and development (3.2) • Our managers' decision-making is based on the City's Organizational Values (3.3) The City received the second lowest ratings for items in the category Recognition. The lowest rated items in Recognition are shown below: • Overall, I am satisfied with the City's compensation (salary, health care, retirement, leave,etc.) (2.8) • I am satisfied with the advancement opportunities that I have within the City (2.9) • My co-workers regularly give encouragement and praise to one another(3.6) Other notable low rated items came from the categories of Work Environment, Training & Development & Culture & Climate: • Work Environment- I believe the results of this survey will be used to make my department an even better place to work(2.8) • Work Environment- My co-workers are held accountable for the quality of their work (3.1) • Work Environment - The managers in my department work to build a trusting work environment (3.1) • Culture & Climate - I don't consider looking for a new job elsewhere (3.3) • Training & Development - When problems occur, our managers try to understand what happened, then find solutions rather than simply placing blame (3.3) Additional Findings The additional safety items added to the Fall 2019 survey were both rated lower than the overall survey average of 3.6. However, they were not among the lowest 15 items rated. The additional safety items with their respective scores are shown below: • Proper steps are taken to ensure employee safety (3.4) • I feel safe at work (3.57) The City's engagement level was measured with People Element's engagement index items included in the Culture & Climate category. This was a new addition included in the Fall 2019 survey. The City's overall engagement level is 39%with most of the survey population being disengaged to some extent. People Element benchmark data shows the City of Virginia Beach engagement level to be 19% lower than the engagement benchmark. This is based on a year's worth of People Element engagement data. The benchmark data is not industry specific but calculated using a variety of industries. ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 6 KEY FINDINGS SUMMARY The findings show that every item in the current survey has decreased to some extent since the Spring. Without raw data from the Spring 2019 survey, People Element cannot reliably determine if the differences between the previous (Spring 2019) and current (Fall 2019) survey are significant. Also, there is not enough evidence to support that having a third party confidentially administer the survey impacted the results. The additional safety items added to the Fall 2019 survey were shown to be slightly below the overall survey average but not among the lowest 15 items rated. The other additional items added to the Fall 2019 survey were intended to provide a measure of employee engagement. As People Element uses a consistent measure of engagement across its client population it was determined that the City of Virginia Beach's engagement level is below average. ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 7 CITYWIDE AVERAGE SCORES I understand how my job impacts the City's mission and goals. 4.4 My department accommodates my needs when I have a personal matter to attend to. 4.2 I am treated with respect by my immediate supervisor. 4.1 I am treated with respect by my co-workers. 4.0 I plan to be with the City at least 1 year from now 4.0 I am motivated to go beyond what is normally expected of me to help the City be successful 4.0 My work gives me a sense of personal accomplishment 4.0 I keep myself informed by reading various forms of internal publications/communication(Because You Asked, Member... 4.0 My immediate supervisor works with me to help solve work related issues. 4.0 I often initiate(begin)communication about my job with my immediate supervisor. 4.0 I am proud to be a Member of my department. 4.0 My immediate supervisor provides me the time needed to obtain training to enhance my skills. 4'0 My immediate supervisor considers my ideas related to my work. 3.9 My immediate supervisor values my talents and the contributions that I make. 3.9 My immediate supervisor encourages effective teamwork in our 3 9 department. My co-workers go beyond what is expected of them to serve others (e.g.customers,citizens, Members). 3'9 Members are willing to share information and/or their 3.9 knowledge with one another. My co-workers contribute to a quality work life in my department. 3'8 I have the necessary tools,equipment,and materials needed to perform my job properly. 3'8 ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 8 CITYWIDE AVERAGE SCORES - CONT. My immediate supervisor does what(s)he says (s)he will. 3.8 I have the authority to carry out my job responsibilities effectively. 3'8 When problems occur, my immediate supervisor tries to understand what happened,then finds solutions, rather than... 3.8 My immediate supervisor compliments and/or praises me when I perform my job well. 3'8 I receive the proper training to perform my job well. 3.8 I feel proud to work for the City 3.8 My immediate supervisor provides me with useful ongoing feedback about my job performance. 3'7 The City's Member Communications Program (Because You Asked,Citywide emails, Member Conversations, Member... 3'7 I am treated with respect by the managers in my department. 3.7 I am involved in improving the work processes in my department. 3'7 My immediate supervisor works to build a trusting work environment. 3'7 My department is concerned about Member health and safety. 3.6 The City values diversity based on age,gender, race, religion, 3.6 disability,sexual orientation,etc. Training dedicated to diversity and inclusion are important to my work experience. 3.6 My co-workers regularly give encouragement and praise to one - another. 3.6 My department's managers/supervisors apply policies&rules 3.6 fairly to me. My department looks for ways to improve our services. 3.6 My co-workers take the initiative to learn and grow. 3.6 I feel safe at work 3.6 My Department Director encourages effective teamwork in our department. 3.6 ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 9 CITYWIDE AVERAGE SCORES - CONT. The City does not tolerate discrimination based on age,gender, 3.6 race, religion,disability,sexual orientation,etc.and treats this... I would recommend the City as a good place to work 3.5 I would recommend the City of Virginia Beach as a good place to 3.5 work. The managers in my department encourage effective teamwork. 3.5 The City effectively promotes inclusion and diversity. 3.5 Proper steps are taken to ensure employee safety 3.5 Overall, my department does a good job communicating City issues that affect me. 3.4 The amount of work expected of me is reasonable. 3.4 I am in a work environment where I feel included and valued. 3.4 I have opportunities to contribute to decisions that directly affect my job. 3.4 The managers in my department communicate our department's goals and objectives so I can easily understand... 3.4 My Department Director communicates the City's goals and objectives so I can easily understand the direction of the City. 3.4 My Department Director's decision-making is based on the City's Organizational Values. 3.4 The managers in my department are committed to improving 3.4 processes. Our managers'decision-making is based on the City's Organizational Values. 3.3 The managers in my department do what they say they will. 3.3 When problems occur,our managers try to understand what happened,then find solutions rather than simply placing blame. 3.3 I don't consider looking for a new job elsewhere 3.3 The managers in my department work to build a trusting work environment. 3.2 The City Manager and Deputy City Managers help to create a 3.2 culture of learning and development. My co-workers are held accountable for the quality of their 3.1 work. ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 10 CITYWIDE AVERAGE SCORES - CONT. The City Manager's/Deputy City Managers'decision-making is based on the City's Organizational Values. 3.1 I am satisfied with the advancement opportunities that I have within the City. 2'9 I believe the results of this survey will be used to make my department an even better place to work. Overall,I am satisfied with the City's compensation (salary, health care, retirement,leave,etc.) ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 11 CITYWIDE TOP & BOTTOM SCORES I understand how my job impacts the City's mission and goals. 4.4 My department accommodates my needs when I have a personal matter to attend to. 4.2 I am treated with respect by my immediate supervisor. 4.1 I am treated with respect by my co-workers. 4.0 I plan to be with the City at least 1 year from now 4.0 I am motivated to go beyond what is normally expected of me to help the City be successful 4'0 My work gives me a sense of personal accomplishment 4.0 I keep myself informed by reading various forms of internal publications/communication(Because You Asked, Member... 4.0 My immediate supervisor works with me to help solve work related issues. 4.0 I often initiate(begin)communication about my job with my 4.0 immediate supervisor. The managers in my department do what they say they will. 3.3 When problems occur,our managers try to understand what happened,then find solutions rather than simply placing... I don't consider looking for a new job elsewhere The managers in my department work to build a trusting work environment. The City Manager and Deputy City Managers help to create a culture of learning and development. My co-workers are held accountable for the quality of their work. The City Manager's/Deputy City Managers'decision-making is based on the City's Organizational Values. I am satisfied with the advancement opportunities that I have within the City. I believe the results of this survey will be used to make my department an even better place to work. Overall,I am satisfied with the City's compensation (salary, health care, retirement,leave,etc.) ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 12 DETAILED FINDINGS ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 13 VALUES & ETHICS - RESULTS Values & Ethics overall category mean has decreased from 4.0 (Spring 2019) to 3.8 (Fall 2019). All items within Values & Ethics showed a decrease. Items with the largest decrease are shown below: • The City does not tolerate discrimination based on age, gender, race, religion, disability, sexual orientation, etc. and treats this issue with great importance. (.40 Decrease) • The managers in my department encourage effective teamwork. (.30 Decrease) • The City effectively promotes inclusion and diversity. (.30 Decrease) • My department's managers/supervisors apply policies & rules fairly to me. (.30 Decrease) • The City values diversity based on age, gender, race, religion, disability, sexual orientation, etc. (.30 Decrease) I understand how my job impacts the City's mission and goals. 4.4 I am treated with respect by my immediate supervisor. 4.1 I am treated with respect by my co-workers. 4.0 My immediate supervisor encourages effective teamwork in our 3.9 department. My co-workers go beyond what is expected of them to serve others (e.g.customers, citizens, Members). 3.9 I am treated with respect by the managers in my department. 3.7 The City values diversity based on age,gender, race, religion, 3.6 disability,sexual orientation,etc. Training dedicated to diversity and inclusion are important to 3.6 my work experience. My department's managers/supervisors apply policies&rules fairly to me. 3.6 My department looks for ways to improve our services. 3.6 My Department Director encourages effective teamwork in our 3.6 department. The City does not tolerate discrimination based on age,gender, 3.6 race,religion,disability,sexual orientation,etc.and treats this... The managers in my department encourage effective teamwork. 3.5 The City effectively promotes inclusion and diversity. 3.5 ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 14 VALUES & ETHICS - COMPARISON I understand how my job impacts the City's mission and goals. 4.4 I am treated with respect by my immediate supervisor. 4.1 I am treated with respect by my co-workers. 4.2s 4.0 My immediate supervisor encourages effective teamwork in our department. My co-workers go beyond what is expected of them to serve others(e.g.customers,citizens, Members). I am treated with respect by the managers in my department. 3,7 The City values diversity based on age,gender, race, religion,disability,sexual orientation,etc. 3.6 Spring 2019 Training dedicated to diversity and inclusion are important 3.8 ■Fall 2019 to my work experience. 3.6 My department's managers/supervisors apply policies& rules fairly to me. My department looks for ways to improve our services. 3.6 My Department Director encourages effective teamwork in our department. The City does not tolerate discrimination based on age, 4,t..F gender,race,religion,disability,sexual orientation,etc.... 3.6 The managers in my department encourage effective teamwork. The City effectively promotes inclusion and diversity. 3.5 ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 15 VALUES & ETHICS - BY SEGMENT The chart below shows significant differences by segment. Asterisks represent a group that is significantly higher than their counterpart within the current (Fall 2019) survey data. Job Category Tenure Age Ethnicity Gender Non-Sup Sup >1 year <1 year <55 55+ Non- White Male Female White n=1877 n=948 n=316 n=2517 n=2023 n=786 n=876 n=1906 n=1239 n=1558 I understand how my job impacts the 4.3 4.5* 4.4 4.3 4.5* 4.3 4.4 4.4 4.4 4.4 City's mission and goals. I am treated with respect by my co 4.0 4.1 4.0 4.1 4.1* 4.0 4.0 4.1 4.1* 4.0 workers. I am treated with respect by my 4.1 4.2 4.1 4.4* 4.1 4.1 4.0 4.1* 4.1* 4.1 immediate supervisor. I am treated with respect by the managers 3.6 3.8* 3.6 4.2* 3.8* 3.6 3.6 3.7* 3.6 3.7* in my department. The City does not tolerate discrimination based on age,gender,race,religion, 3.5 3.7* 3.5 4.0* 3.6 3.5 3.3 3.7* 3.7* 3.5 disability,sex My department's managers/supervisors 3.5 3.8* 3.6 4.1* 3.7* 3.6 3.5 3.7* 3.6 3.6 apply policies&rules fairly to me. My department looks for ways to improve 3.5 3.8* 3.6 3.8* 3.8* 3.5 3.5 3.7* 3.5 3.7* our services. The City values diversity based on age, gender,race,religion,disability,sexual 3.6 3.8* 3.6 4.0* 3.7 3.6 3.4 3.7* 3.7 3.6 orientation, My immediate supervisor encourages 3.8 4.0* 3.9 4.1* 3.9 3.9 3.8 3.9* 4.0* 3.8 effective teamwork in our department. My Department Director encourages 3.5 3.7* 3.5 4.0* 3.7* 3.5 3.5 3.6 3.6 3.6 effective teamwork in our department. The managers in my department 3.4 3.6* 3.5 3.9* 3.6* 3.4 3.4 3.5 3.5 3.5 encourage effective teamwork. My co-workers go beyond what is expected of them to serve others(e.g. 3.8 4.0* 3.9 3.9 3.9* 3.8 3.8 3.9 3.9* 3.8 customers,citizens,Me Training dedicated to diversity and inclusion are important to my work 3.6 3.7* 3.6 4.0* 3.7* 3.6 3.8* 3.5 3.5 3.8* experience. The City effectively promotes inclusion and 3.4 3.6* 3.4 3.8* 3.6* 3.4 3.2 3.6* 3.5 3.4 diversity. Average 3.7 3.9 3.7 4.1 3.9 3.7 3.7 3.8 3.8 3.8 *Asterisk denotes significant difference between segments ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 16 VALUES & ETHICS - QUALITATIVE DATA Each category in the Fall 2019 survey is paired with an open-ended question asking the respondent to provide additional comments if desired. Respondents that chose to provide additional comments often did so due to a criticism they wanted to share. The most prominent topics within the qualitative data from Values & Ethics were Environment, Supervision & Leadership. • Environment comments most commonly referred to criticism of Diversity& Inclusion and being treated with respect as an employee. • Supervision comments showed a mix of positive/negative sentiment regarding supervision. • Leadership comments often outlined criticism of upper management. However, the level of management was not always specified in the comments. Please provide any additional comments regarding Values and Ethics that may not have been covered above Topics Frequency Environment 27% Supervisor 16` Leadership 12% People _-8% System&Resource Management 7% Growth&Development -5% Onboarding&Training -5% Compensation&Benefits _3% Job/Workload _3% Recognition _3% Communication -2% Work life/Schedule -2% ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 17 LEADERSHIP - RESULTS Leadership overall category mean has decreased from 3.6 (Spring 2019) to 3.3 (Fall 2019). All items within Leadership showed a decrease. Items with the largest decrease are shown below: • The City Manager's/Deputy City Managers' decision-making is based on the City's Organizational Values. (.30 Decrease) • The City Manager and Deputy City Managers help to create a culture of learning and development. (.30 Decrease) • Our managers' decision-making is based on the City's Organizational Values. (.30 Decrease) • The managers in my department are committed to improving processes. (.30 Decrease) The managers in my department communicate our department's goals and objectives so I can easily understand the 3.4 direction of my department. My Department Director communicates the City's goals and objectives so I can easily understand the direction of the City. 3.4 My Department Director's decision-making is based on the City's 3.4 Organizational Values. The managers in my department are committed to improving 3.4 processes. Our managers'decision-making is based on the City's 3.3 Organizational Values. The City Manager and Deputy City Managers help to create a 3.2 culture of learning and development. The City Manager's/Deputy City Managers'decision-making is 3.1 based on the City's Organizational Values. ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 18 LEADERSHIP - COMPARISON The managers in my department communicate our 3.6 department's goals and objectives so I can easily understand the direction of my department. 3.4 My Department Director communicates the City's goals =.6 and objectives so I can easily understand the direction of the City. 3.4 My Department Director's decision-making is based on the City's Organizational Values. The managers in my department are committed to Spring 2019 improving processes. •Fall 2019 3.4 Our managers' decision-making is based on the City's .6 Organizational Values. 3.3 The City Manager and Deputy City Managers help to 3.5 create a culture of learning and development. 3.2 The City Manager's/Deputy City Managers'decision- making3.4 is based on the City's Organizational Values. 3.1 ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 19 LEADERSHIP - BY SEGMENT The chart below shows significant differences by segment. Asterisks represent a group that is significantly higher than their counterpart within the current (Fall 2019) survey data. Job Category Tenure Age Ethnicity Gender Non- Non-Sup Sup >1 year <1 year <55 55+ White Male Female White n=1866 n=948 n=313 n=2510 n=2018 n=781 n=874 n=1898 n=1238 n=1549 The City Manager and Deputy City Managers help to create a culture of 3.1 3.4* 3.1 3.5* 3.3* 3.1 3.2 3.2 3.1 3.2* learning and development. The managers in my department are 3.3 3.5* 3.3 3.7* 3.5* 3.3 3.3 3.4* 3.3 3.4* committed to improving processes. My Department Director communicates the City's goals and objectives so I can 3.3 3.5* 3.3 3.7* 3.5* 3.3 3.4 3.4 3.3 3.5* easily understand the direction of the City. The managers in my department communicate our department's goals and 3.3 3.5* 3.3 3.8* 3.5* 3.3 3.4 3.4 3.3 3.4* objectives so I can easily understand the direction of my department. The City Manager's/Deputy City Managers' decision-making is based on the City's 3.1 3.3* 3.1 3.6* 3.3* 3.1 3.1 3.1 3.0 3.2* Organizational Values. My Department Director's decision-making is based on the City's Organizational 3.3 3.5* 3.3 3.8* 3.5* 3.3 3.4 3.4 3.3 3.5* Values. Our managers'decision-making is based 3.3 3.5* 3.3 3.8* 3.5* 3.3 3.3 3.4* 3.3 3.4* on the City's Organizational Values. Average 3.2 3.4 3.3 3.7 3.5 3.2 3.3 3.3 3.2 3.4 *Asterisk denotes significant difference between segments ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 20 LEADERSHIP - QUALITATIVE DATA Each category in the Fall 2019 survey is paired with an open-ended question asking the respondent to provide additional comments if desired. Respondents that chose to provide additional comments often did so due to a criticism they wanted to share. As the category was specific to Leadership, the most common topics that emerged were Leadership &Supervision. Other prominent topics within the qualitative data from the category were Environment, System & Resource Management & Communication. • Environment comments most commonly referred to criticism around Leadership's understanding and promotion of organizational values. • System & Resource Management comments were commonly critical of the quality of service provided by the City and the ability to effectively implement and follow policy. • Communication comments were commonly critical of communication from Leadership. Please provide any additional comments regarding Leadership that may not have been covered above Topics Frequency Leadership 23% Supervisor Environment 18% System&Resource Management 6% Communication 5% Compensation&Benefits -4% Growth &Development -4% People -4% Recognition -3% Job/Workload _2% Onboarding&Training _2% Work life/Schedule _2% ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 21 COMMUNICATION - RESULTS Communication overall category mean has decreased from 3.9 (Spring 2019)to 3.8 (Fall 2019). All items within Communication showed a decrease. Items with the largest decrease are shown below: • The managers in my department do what they say they will. (.30 Decrease) • My immediate supervisor does what (s)he says (s)he will. (.30 Decrease) I keep myself informed by reading various forms of internal publications/communication (Because You Asked, Member 4.0 Update, beachnet,e-mail, Benefits e-bulletin,etc.). I often initiate(begin)communication about my job with my immediate supervisor. 4.0 My immediate supervisor considers my ideas related to my work. 3'9 My immediate supervisor does what(s)he says(s)he will. 3.8 The City's Member Communications Program (Because You Asked,Citywide emails, Member Conversations, Member 3.7 Update,etc.) keeps me well-informed. Overall, my department does a good job communicating City issues that affect me. 3.4 The managers in my department do what they say they will. 3.3 ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 22 COMMUNICATION - COMPARISON I keep myself informed by reading various forms of internal publications/communication (Because You Asked, Member Update,beachnet,e-mail, Benefits e-bulletin, etc.). 4.0 I often initiate(begin)communication about my job with my immediate supervisor. 4.0 My immediate supervisor considers my ideas related to my work. 3.9 4.1 ■Spring 2019 My immediate supervisor does what(s)he says(s)he will. 38 •Fall 2019 The City's Member Communications Program(Because 3.9 You Asked, Citywide emails, Member Conversations, Member Update,etc.) keeps me well-informed. 3.7 Overall, my department does a good job communicating 3.6 City issues that affect me. 3.4 The managers in my department do what they say they 3.6 will. 3.3 ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 23 COMMUNICATION - BY SEGMENT The chart below shows significant differences by segment. Asterisks represent a group that is significantly higher than their counterpart within the current(Fall 2019) survey data. Job Category Tenure Age Ethnicity Gender Non-Sup Sup >I.year <1 year <55 55+ Non- White Male Female White n=1872 n=947 n=315 n=2513 n=2020 n=784 n=873 n=1904 n=1239 n=1553 Overall,my department does a good job 3.4 3.6* 3.4 3.7* 3.6* 3.4 3.4 3.5 3.4 3.5 communicating City issues that affect me. The City's Member Communications Program(Because You Asked,Citywide 3.7 3.8 3.7 3.9* 3.8* 3.7 3.7 3.7 3.5 3.8* emails,Member Conversations,Member Update,etc.)keeps me well-informed. My immediate supervisor considers my 3.8 4.1* 3.9 4.1 3.9 3.9 3.8 4.0* 3.9 3.9 ideas related to my work. My immediate supervisor does what(s)he 3.8 3.9 3.8 4.1* 3.9 3.8 3.7 3.9* 3.9 3.8* says(s)he will. The managers in my department do what 3.3 3.5* 3.3 3.8* 3.5* 3.3 3.3 3.4 3.3 3.4 they say they will. I keep myself informed by reading various forms of internal publications/communication(Because You 4.0 4.1* 4.0 4.1 4.1* 4.0 4.0 4.0 3.8 4.1* Asked,Member Update,beachnet,e-mail, Benefits e-bulletin,etc.). I often initiate(begin)communication about my job with my immediate 4.0 4.1* 4.0 4.1 4.0 4.0 3.9 4.0 4.0 4.0 supervisor. Average 3.7 3.8 3.7 4.0 3.8 3.7 3.7 3.8 3.7 3.8 *Asterisk denotes significant difference between segments ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 24 COMMUNICATION - QUALITATIVE DATA Each category in the Fall 2019 survey is paired with an open-ended question asking the respondent to provide additional comments if desired. Respondents that chose to provide additional comments often did so due to a criticism they wanted to share. As the category was specific to Communication, one of the most common topics that emerged was Communication. Other prominent topics within the qualitative data from the category were Supervision, Communication & Leadership. • Supervision comments were commonly critical of the ability of supervisors to communicate effectively. • Leadership comments often outlined criticism of upper management. However, the level of management was not always specified in the comments. • Environment comments were commonly critical of the overall work environment and morale. Please provide any additional comments regarding Communication that may not have been covered above Topics Frequency Supervisor 28% Communication Leadership 11% Environment 8% System&Resource Management 6% Compensation&Benefits _3% Growth&Development _3% Job/Workload _3% People _3% Onboarding&Training -2% Recognition -2% Work life/Schedule -2% ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 25 TRAINING & DEVELOPMENT - RESULTS Training & Development overall category mean has decreased from 3.9 (Spring 2019) to 3.7 (Fall 2019). All items within Training & Development showed a decrease. Items with the largest decrease are shown below: • The amount of work expected of me is reasonable. (.30 Decrease) • When problems occur, my immediate supervisor tries to understand what happened, then finds solutions, rather than simply placing blame. (.30 Decrease) My immediate supervisor provides me the time needed to 4.0 obtain training to enhance my skills. Members are willing to share information and/or their 3.9 knowledge with one another. I have the authority to carry out my job responsibilities effectively. 3.8 When problems occur, my immediate supervisor tries to understand what happened,then finds solutions, rather than 3.8 simply placing blame. I receive the proper training to perform my job well. 3.8 I am involved in improving the work processes in my department. 3'7 My co-workers take the initiative to learn and grow. 3.6 The amount of work expected of me is reasonable. 3.4 When problems occur,our managers try to understand what 3.3 happened,then find solutions rather than simply placing blame. ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 26 TRAINING & DEVELOPMENT - COMPARISON My immediate supervisor provides me the time needed to 4.2 obtain training to enhance my skills. 4.0 Members are willing to share information and/or their ; 4.0 knowledge with one another. 3.9 I have the authority to carry out my job responsibilities effectively. 3.8 When problems occur, my immediate supervisor tries to understand what happened,then finds solutions, rather than simply placing blame. 3.8 ■Spring 2019 I receive the proper training to perform my job well. 3.8 ■Fall 2019 I am involved in improving the work processes in my department. 3.7 My co-workers take the initiative to learn and grow. 3.6 3.7 The amount of work expected of me is reasonable. 3.4 When problems occur,our managers try to understand 3.5 what happened,then find solutions rather than simply placing blame. 3.3 ©2019 People Element Hillard HeintzLLCe City of VA Beach Survey Comparison Page 27 TRAINING & DEVELOPMENT - BY SEGMENT The chart below shows significant differences by segment. Asterisks represent a group that is significantly higher than their counterpart within the current (Fall 2019) survey data. Job Category Tenure Age Ethnicity Gender Non-Sup Sup >1 year <1 year <55 55+ Non- White Male Female White n=1875 0=948 n=316 n=2515 n=2021 n=786 n=875 n=1905 n=1238 n=1557 I receive the proper training to perform my 3.7 3.9* 3.8 3.7 3.9* 3.7 3.7 3.8* 3.9* 3.7 job well. Members are willing to share information 3.8 3.9 3.9 4.0* 3.9 3.9 3.7 3.9* 3.9* 3.8 and/or their knowledge with one another. My immediate supervisor provides me the time needed to obtain training to enhance 3.9 4.1* 4.0 4.1* 4.1 3.9 3.9 4.0* 4.0 3.9 my skills. I am involved in improving the work 3.5 4.0* 3.7 3.8 3.8 3.7 3.6 3.7* 3.7 3.7 processes in my department. When problems occur,my immediate supervisor tries to understand what 3.8 3.9 3.8 4.1* 3.9 3.8 3.7 3.9* 3.9 3.8 happened,then finds solutions,rather than simply placing blame. When problems occur,our managers try to understand what happened,then find 3.2 3.5* 3.2 3.8* 3.5* 3.2 3.2 3.3* 3.3 3.3 solutions rather than simply placing blame. The amount of work expected of me is 3.4 3.4 3.4 3.8* 3.6* 3.4 3.4 3.5* 3.6* 3.3 reasonable. I have the authority to carry out my job 3.8 3.8 3.8 4.1* 3.9* 3.8 3.8 3.8 3.8 3.8 responsibilities effectively. My co-workers take the initiative to learn 3.6 3.6 3.6 3.7 3.7* 3.6 3.6 3.6 3.6 3.6 and grow. Average 3.6 3.8 3.7 3.9 3.8 3.7 3.6 3.7 3.7 3.7 *Asterisk denotes significant difference between segments ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 28 TRAINING & DEVELOPMENT - QUALITATIVE DATA Each category in the Fall 2019 survey is paired with an open-ended question asking the respondent to provide additional comments if desired. Respondents that chose to provide additional comments often did so due to a criticism they wanted to share. The most prominent topics within the qualitative data from Training & Development were Onboarding&Training, Supervision and Growth & Development. • Onboarding & Training comments showed a mix of positive/negative sentiment regarding training quality and availability. • Supervision comments showed a mix of positive/negative sentiment regarding supervision and their impact on training & development. • Growth & Development comments showed a mix of positive/negative sentiment regarding the ability to grow within the organization and the support provided. Please provide any additional comments regarding Training & Development that may not have been covered above Topics Frequency Onboarding&Training 22% Supervisor 16'F Growth&Development 10% Environment 8% Leadership 8% Job/Workload 7% System&Resource Management 6% People 5% Compensation&Benefits -4% Communication -3% Work life/Schedule _3% Recognition _2% ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 29 RECOGNITION - RESULTS Recognition overall category mean has decreased from 3.7 (Spring 2019) to 3.5 (Fall 2019). All items within Recognition showed a decrease. Items with the largest decrease are shown below: • I am satisfied with the advancement opportunities that I have within the City. (.30 Decrease) • My immediate supervisor provides me with useful ongoing feedback about my job performance. (.30 Decrease) My immediate supervisor values my talents and the 3.9 contributions that I make. My immediate supervisor compliments and/or praises me when I perform my job well. 3'8 My immediate supervisor provides me with useful ongoing 3.7 feedback about my job performance. My co-workers regularly give encouragement and praise to one another. 3.6 I am satisfied with the advancement opportunities that I have 11111111111111111 within the City. Overall,I am satisfied with the City's compensation (salary, health care,retirement,leave,etc.) 2"8 ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 30 RECOGNITION - COMPARISON My immediate supervisor values my talents and the 4.1`. contributions that I make. 3.9 4.0 My immediate supervisor compliments and/or praises t me when I perform my job well. 3.8 My immediate supervisor provides me with useful 4.0 ongoing feedback about my job performance. 3.7 i Spring 2019 ■Fall 2019 My co-workers regularly give encouragement and praise to one another. 3.6 I am satisfied with the advancement opportunities that 3.2 I have within the City. 2.9 Overall, I am satisfied with the City's compensation 2.9 (salary,health care, retirement, leave,etc.) 2.8 ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 31 RECOGNITION - BY SEGMENT The chart below shows significant differences by segment. Asterisks represent a group that is significantly higher than their counterpart within the current (Fall 2019) survey data. Job Category Tenure Age Ethnicity Gender Non- Non-Sup I Sup >1 year ( <1 year <50 50+ White White Male Female n=1873 n=947 n=315 n=2513 n=2019 n=785 n=874 n=1903 n=1237 n=1555 My immediate supervisor provides me with useful ongoing feedback about my 3.7 3.7 3.7 3.9* 3.8 3.7 3.7 3.7 3.7 3.7 job performance. My immediate supervisor values my 3.9 4.0 3.9 4.1* 3.9 3.9 3.8 3.9* 3.9 3.9 talents and the contributions that I make. My immediate supervisor compliments and/or praises me when I perform my job 3.8 3.9 3.8 4.0* 3.8 3.8 3.8 3.8 3.8 3.8 well. My co-workers regularly give 3.6 3.7 3.6 3.7 3.6 3.6 3.6 3.6 3.7' 3.6 encouragement and praise to one another. I am satisfied with the advancement 2.7 3.3* 2.9 3.3* 3.1* 2.8 2.8 3.0* 3.0 2.9 opportunities that I have within the City. Overall,I am satisfied with the City's compensation(salary,health care, 2.7 3.0* 2.8 3.1* 3.2* 2.7 2.9 2.8 2.6 3.0* retirement,leave,etc.) Average 3.4 3.6 3.4 3.7 3.6 3.4 3.4 3.5 3.5 3.5 *Asterisk denotes significant difference between segments ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 32 RECOGNITION - QUALITATIVE DATA Each category in the Fall 2019 survey is paired with an open-ended question asking the respondent to provide additional comments if desired. Respondents that chose to provide additional comments often did so due to a criticism they wanted to share. The most prominent topics within the qualitative data from Recognition were Compensation & Benefits, Supervision and Growth & Development. • Compensation & Benefits comments were mostly critical of compensation with benefits mentioned far less. • Supervision comments commonly referred to criticism of performance evaluations or lack thereof and the supervisor's ability or willingness to provide effective recognition. • Growth & Development comments were often equating advancement and recognition and critical of the employee's ability to advance within the organization. Please provide any additional comments regarding Recognition that may not have been covered above Topics Frequency Compensation&Benefits 19% Supervisor 16`-4 Growth&Development 11'% Recognition 11% Environment Leadership 6% Job/Workload -- 5% System&Resource Management 4% Work life/Schedule 4% Communication -3% People -3% Onboarding&Training _2 ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 33 WORK ENVIRONMENT - RESULTS Work Environment overall category mean has decreased from 3.8 (Spring 2019) to 3.6 (Fall 2019). All items within Work Environment showed a decrease. Items with the largest decrease are shown below: • My co-workers are held accountable for the quality of their work. (.40 Decrease) • I believe the results of this survey will be used to make my department an even better place to work. (.30 Decrease) • I have opportunities to contribute to decisions that directly affect my job. (.30 Decrease) • I am in a work environment where I feel included and valued. (.30 Decrease) • I would recommend the City of Virginia Beach as a good place to work. (.30 Decrease) • My department is concerned about Member health and safety. (.30 Decrease) Two additional items were added to the current survey (Fall 2019) relating to safety. The additional items are not included in the category average above to ensure a fair comparison. My department accommodates my needs when I have a...gingliminimmi My immediate supervisor works with me to help solve work... 4.0 I am proud to be a Member of my department. 4.0 My co-workers contribute to a quality work life in my... 3.8 I have the necessary tools,equipment,and materials needed... 3.8 My immediate supervisor works to build a trusting work... 3.7 My department is concerned about Member health and safety. 3.6 I feel safe at work 3.6 I would recommend the City of Virginia Beach as a good place... 3.5 Proper steps are taken to ensure employee safety 3.5 I am in a work environment where I feel included and valued. 3.4 I have opportunities to contribute to decisions that directly... 3.4 The managers in my department work to build a trusting work... 3.2 My co-workers are held accountable for the quality of their... 3.1 I believe the results of this survey will be used to make my... 2.8 ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 34 WORK ENVIRONMENT - COMPARISON My department accommodates my needs when I have a personal matter to attend to. 4.2 My immediate supervisor works with me to help solve work related issues. 4.0 I am proud to be a Member of my department. 4.1 4.0 My co-workers contribute to a quality work life in my 4.0 department. 3.8 I have the necessary tools,equipment,and materials -V.a "` 3,• needed to perform my job properly. 3.8 My immediate supervisor works to build a trusting work environment. 3.7 My department is concerned about Member health and safety. 3.6 Spring 2019 I feel safe at work 3.6 • Fall 2019 I would recommend the City of Virginia Beach as a good place to work. 3.5 Proper steps are taken to ensure employee safety 35 I am in a work environment where I feel included and valued. 3.4 I have opportunities to contribute to decisions that directly affect my job. 3.4 The managers in my department work to build a trusting work environment. 3.2 My co-workers are held accountable for the quality of their work. 3.1 I believe the results of this survey will be used to make my department an even better place to work. 2.8 ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 35 WORK ENVIRONMENT - BY SEGMENT The chart below shows significant differences by segment. Asterisks represent a group that is significantly higher than their counterpart within the current (Fall 2019) survey data. Job Category Tenure Age Ethnicity Gender Non- Non-Sup Sup >1 year <1 year <50 S0+ White White Male Female n=1875 n=948 n=315 n=2517 n=2022 n=786 n-876 n=1905 n=1238 n=1558 My department accommodates my needs when I have a personal matter to attend 4.1 4.3* 4.2 4.3* 4.3* 4.2 4.1 4.2* 4.2 4.2 to. My immediate supervisor works with me 4.0 4.1* 4.0 4.2* 4.1 4.0 4.0 4.0* 4.0 4.0 to help solve work related issues. My department is concerned about 3.5 3.8* 3.6 4.0* 3.8* 3.6 3.6 3.7* 3.7* 3.6 Member health and safety. I feel safe at work 3.5 3.7* 3.6 3.8* 3.6 3.6 3.4 3.7* 3.7* 3.4 Proper steps are taken to ensure 3.4 3.6* 3.4 3.7* 3.5 3.4 3.3 3.5* 3.6* 3.4 employee safety I am proud to be a Member of my 3.9 4.1* 4.0 4.2* 4.1* 3.9 3.9 4.0* 4.0 4.0 department. I have the necessary tools,equipment,and materials needed to perform my job 3.8 3.9* 3.8 3.9* 4.0* 3.8 3.7 3.9* 3.8 3.8 properly. I would recommend the City of Virginia 3.4 3.7* 3.5 3.9* 3.7* 3.4 3.5 3.5 3.4 3.5 Beach as a good place to work. My co-workers contribute to a quality 3.8 3.9* 3.8 3.9* 3.9 3.8 3.8 3.9* 3.9 3.8 work life in my department. My immediate supervisor works to build a 3.6 3.7 3.6 3.9* 3.7 3.6 3.6 3.7* 3.7* 3.6 trusting work environment. The managers in my department work to 3.1 3.3* 3.1 3.6* 3.4* 3.1 3.1 3.2 3.1 3.2 build a trusting work environment. I believe the results of this survey will be used to make my department an even 2.8 2.9 2.8 3.4* 3.1* 2.7 2.9* 2.8 2.7 2.9* better place to work. My co-workers are held accountable for 3.1 3.2 3.1 3.6* 3.3* 3.1 3.2 3.1 3.2* 3.1 the quality of their work. I am in a work environment where I feel 3.3 3.6* 3.4 3.7* 3.5* 3.3 3.3 3.5* 3.4 3.4 included and valued. I have opportunities to contribute to 3.3 3.7* 3.4 3.7* 3.5* 3.4 3.3 3.4* 3.4 3.4 decisions that directly affect my job. Average 3.3 3.5 3.3 3.7 3.5 3.3 3.3 3.4 3.4 3.4 *Asterisk denotes significant difference between segments ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 36 WORK ENVIRONMENT - QUALITATIVE DATA Each category in the Fall 2019 survey is paired with an open-ended question asking the respondent to provide additional comments if desired. Respondents that chose to provide additional comments often did so due to a criticism they wanted to share. As the category was specific to Work Environment, one of the most common topics that emerged was Environment. Other prominent topics within the qualitative data from the category were Supervision, Leadership & People. • Supervision comments showed a mix of positive/negative sentiment regarding supervision and their impact on the work environment. • Leadership comments often outlined criticism of upper management and their impact on work environment. However, the level of management was not always specified in the comments. • People comments showed a mix of positive/negative sentiment regarding coworkers and their impact on work environment. Please provide any additional comments regarding Work Environment that may not have been covered above Topics Frequency Environment 23% Supervisor 1 5% Leadership 10% People 9% System&Resource Management 7% Compensation&Benefits 5% Growth&Development 5% Job/Workload —4% Recognition —4% Communication _3% Onboarding&Training —3% Work life/Schedule _3% ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 37 CULTURE & CLIMATE - RESULTS Culture & Climate is an entirely new category added to the Fall 2019 survey. Culture & Climate showed the highest overall mean for any category at 3.8. I plan to be with the City at least 1 year from now 4.0 I am motivated to go beyond what is normally expected of me 4.0 to help the City be successful My work gives me a sense of personal accomplishment 4.0 I feel proud to work for the City 3.8 I would recommend the City as a good place to work 3.5 I don't consider looking for a new job elsewhere 3.3 ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 38 CULTURE & CLIMATE -- BY SEGMENT The chart below shows significant differences by segment. Asterisks represent a group that is significantly higher than their counterpart within the current (Fall 2019) survey data. Job Category Tenure Age Ethnicity Gender Non-SupSu >1 ear <1 ear <50 50+ Non- White Male Female n=1873 n=948 n=315 n=2514 n=2021 n=784 White n=1903 n=1239 n=1555 P Y Y n=876 I I feel proud to work for the City 3.7 3.9* 3.7 4.1* 4.0* 3.7 3.7 3.8 3.7 3.8 I would recommend the City as a good 3.4 3.7* 3.5 3.9* 3.7* 3.5 3.5 3.5 3.4 3.6* place to work I plan to be with the City at least 1 year 4.0 4.2* 4.0 4.1 4.1 4.0 3.9 4.1* 4.1* 4.0 from now I don't consider looking for a new job 3.2 3.4* 3.3 3.4 3.6* 3.1 3.1 3.3* 3.3 3.2 elsewhere I am motivated to go beyond what is normally expected of me to help the City 4.0 4.2* 4.0 4.2* 4.2* 4.0 4.0 4.1 4.0 4.1* be successful My work gives me a sense of personal 4.0 4.1* 4.0 4.1* 4.2* 4.0 4.0 4.1* 4.0 4.1 accomplishment Average 3.7 3.9 3.8 4.0 4.0 3.7 3.7 3.8 3.8 3.8 *Asterisk denotes significant difference between segments ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 39 CULTURE/CLIMATE - QUALITATIVE DATA Each category in the Fall 2019 survey is paired with an open-ended question asking the respondent to provide additional comments if desired. Respondents that chose to provide additional comments often did so due to a criticism they wanted to share. The most prominent topics within the qualitative data from Culture & Climate were Environment, Leadership and Supervision. • Environment comments were mostly critical of the City's overall work environment. • Leadership comments often outlined criticism of upper management and their impact on culture & climate. However, the level of management was not always specified in the comments. • Supervision comments commonly referred to criticism of supervision and their impact on culture & climate. Please provide any additional comments regarding Culture& Climate that may not have been covered above Topics Frequency Environment 20% Leadership 11% Supervisor 11% Compensation&Benefits 10% Growth&Development 8% Job/Workload 6% People _-5% Recognition --5% System&Resource Management 5n% Work life/Schedule -3% Onboarding&Training Communication •1% ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 40 CITYWIDE ENGAGEMENT LEVEL To gain a better understanding of employee perceptions at the City of Virginia Beach, People Element calculated the City's engagement level using an engagement index imbedded in the Culture & Climate category. The measurement is consistent with how People Element measures engagement for organizations within a variety of industries. The City's population was grouped by Actively Disengaged, Disengaged, Engaged, & Actively Engaged. Overall Engagement was calculated by adding the Engaged and Actively Engaged groups. The City's overall engagement level is 39%. This is much lower than People Element's engagement benchmark of 58%with a large portion of employees being disengaged to some extent. VA Beach Engagement Level — 39% 35.00% 30.00% 32.01% 29.26% 25.00% 20.00% 23.14% 15.00% 15.58% 10.00% 5.00% 0.00% Actively Disengaged Opportunity Group Engaged Actively Engaged ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 41 CITYWIDE ENGAGEMENT BENCHMARKED Engagement Benchmark - 58% 45.00% 40.00% 35.00% 38.18% 30.00% 32.01% 29.26% 25.00% 20.00% 22.29% 23.14% 19.71% 15.00% 15.58% 10.00% 5.00% 0.00% Actively Disengaged Opportunity Group Engaged Actively Engaged •VA Beach Spring 2019 People Element 2019 ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 42 APPENDIX A: PRE-SURVEY COMMUNICATION ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 43 PRE-SURVEY EMAIL Subject line: Upcoming Confidential Virginia Beach Workplace Survey Dear Virginia Beach team member, The Virginia Beach City Council selected Hillard Heintze to conduct a fully independent investigation into the May 31 tragedy to reinforce public trust and confidence. As part of this investigation, Hillard Heintze is partnering with People Element, a neutral, third-party, to conduct a confidential workplace survey with our employees to better understand perceptions.This will be completely confidential,and your individual responses will not be shared with either Hillard Heintze or the City of Virginia Beach. Your feedback is needed to better understand the quality of your work life. People Element will be administering the survey because your trust in this process is of the utmost importance and People Element is committed to protecting your confidentiality. Findings will be summarized, and trends will be reported to Hillard Heintze. People Element will not be reporting your individual survey responses.You are encouraged to be candid in your feedback. The survey will be available to take via email during the time frame below: September 23rd, 2019—October 13th, 2019 The survey will come from "insight@peopleeleement.com". Thank you in advance for your honesty and participation in this survey. ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 44 SURVEY INVITATION Subject Line:Confidential Virginia Beach Workplace Survey Dear<first name><last name>, We want your feedback to better understand the quality of your work life at the City of Virginia Beach. To reinforce public trust and confidence, the Virginia Beach City Council selected Hillard Heintze to conduct a fully independent investigation into the May 31st tragedy. This survey will inform the ongoing investigation. Hillard Heintze is partnering with us, People Element to ensure a skilled, neutral third-party conducts confidential surveys with employees to better understand your workplace perceptions. Your individual responses will not be shared with Hillard Heintze or the City of Virginia Beach under our contractual agreement. Your trust in this process is of the utmost importance to us and we are committed to protecting your confidentiality. Our findings will be summarized, and trends will be reported to Hillard Heintze; we will not be reporting your individual survey responses. We encourage you to be candid in your feedback. Please click on the link at the bottom of this message to complete your survey. Note—this link is specific to you; do not forward your link to anyone. We thank you in advance for your honesty and participation in this survey. Please click the link to complete your survey: <survey url> ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 45 APPENDIX B : FINAL SU RVEY ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 46 FINAL SURVEY Virginia Beach Employee Satisfaction Survey People Element The following series of statements are about aspects of your work life with the City of Virginia Beach and,specifically,your department. Please rate how much you agree with each statement by selecting the answer that best matches your response. Select"N/A" if you believe you have no direct knowledge to answer that particular statement(a response is required for each statement). "Co-workers"means"other Members in your department."Immediate supervisor is the person you directly report to. No Answer/ Strongly Disagree Neither Agree nor Agree Strongly Agree Does Not Apply Disagree Disagree N 1 2 3 4 5 Section A:Value&Ethics 1. I understand how my job impacts the City's mission and goals. 2. I am treated with respect by my co-workers. 3. I am treated with respect by my immediate supervisor. 4. I am treated with respect by the managers in my department. 5. The City does not tolerate discrimination based on age,gender, race, religion,disability, sexual orientation,etc. and treats this issue with great importance. 6. My department's managers/supervisors apply policies&rules fairly to me. 7. My department looks for ways to improve our services. 8. The City values diversity based on age,gender, race, religion,disability, sexual orientation,etc. 9. My immediate supervisor encourages effective teamwork in our department. 10. My Department Director encourages effective teamwork in our department. 11. The managers in my department encourage effective teamwork. 12. My co-workers go beyond what is expected of them to serve others(e.g. customers,citizens, Members). 13. Training dedicated to diversity and inclusion are important to my work experience. 14. The City effectively promotes inclusion and diversity. 15. Please provide any additional comments regarding Values and Ethics that may not have been covered above Section B: Leadership(Organizational Values refers to*Quality Customer Service;Teamwork; Leadership&Learning; Integrity; Commitment; Inclusion&Diversity) 16. The City Manager and Deputy City Managers help to create a culture of learning and development. 17. The managers in my department are committed to improving processes. 18. My Department Director communicates the City's goals and objectives so I can easily understand the direction of the City. 19. The managers in my department communicate our department's goals and objectives so I can easily understand the direction of my department. 20. The City Manager's/Deputy City Managers'decision-making is based on the City's Organizational Values* 21. My Department Director's decision-making is based on the City's Organizational Values* 22. Our managers'decision-making is based on the City's Organizational Values* 23. Please provide any additional comments regarding Leadership that may not have been covered above ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 47 FINAL SURVEY - CONT. Section C:Communication 24. Overall, my department does a good job communicating City issues that affect me. 25. The City's Member Communications Program(Because You Asked,Citywide emails, Member Conversations, Member Update, etc.) keeps me well-informed. 26. My immediate supervisor considers my ideas related to my work. 27. My immediate supervisor does what(s)he says(s)he will. 28. The managers in my department do what they say they will. 29. I keep myself informed by reading various forms of internal publications/communication(Because You Asked, Member Update, beachnet,e-mail,Benefits e-bulletin,etc.). 30. I often initiate(begin)communication about my job with my immediate supervisor. 31. Please provide any additional comments regarding Communication that may not have been covered above Section D:Training&Development 32. I receive the proper training to perform my job well. 33. Members are willing to share information and/or their knowledge with one another. 34. My immediate supervisor provides me the time needed to obtain training to enhance my skills. 35. I am involved in improving the work processes in my department. 36. When problems occur,my immediate supervisor tries to understand what happened,then finds solutions, rather than simply placing blame. 37. When problems occur,our managers try to understand what happened,then find solutions rather than simply placing blame. 38. The amount of work expected of me is reasonable. 39. I have the authority to carry out my job responsibilities effectively. 40. My co-workers take the initiative to learn and grow. 41. Please provide any additional comments regarding Training&Development that may not have been covered above Section E: Recognition 42. My immediate supervisor provides me with useful ongoing feedback about my job performance. 43. My immediate supervisor values my talents and the contributions that I make. 44. My immediate supervisor compliments and/or praises me when I perform my job well. 45. My co-workers regularly give encouragement and praise to one another. 46. I am satisfied with the advancement opportunities that I have within the City. 47. Overall, I am satisfied with the City's compensation(salary, health care, retirement,leave,etc.) 48. Did your supervisor meet with you in the past 12 months to review your annual performance evaluation? ❑Yes No 49. Please provide any additional comments regarding Recognition that may not have been covered above ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 48 FINAL SURVEY - CONT. Section G:Culture&Climate 50. I feel proud to work for the City 51. I would recommend the City as a good place to work 52. I plan to be with the City at least 1 year from now 53. I don't consider looking for a new job elsewhere 54. I am motivated to go beyond what is normally expected of me to help the City be successful 55. My work gives me a sense of personal accomplishment 56. Please provide any additional comments regarding Culture&Climate that may not have been covered above Section H:Background Information 57. How long have you been employed by the City of Virginia Beach? ❑ Less Than 1 year ❑ 1-2 years ❑ 3-4 years ❑ 5-9 years ❑ 10-14 years ❑ 15 years or longer 58. How long have you worked in your current department? ❑ Less Than 1 year ❑ 1-2 years ❑ 3-4 years ❑ 5-9 years ❑ 10-14 years ❑ 15 years or longer 59. Do you work full or part time? ❑ Full-Time ❑ Part-Time 60. What is your age? ❑ Less than 25 years of age ❑ 25—34 years of age ❑ 35—44 years of age ❑ 45—54 years of age ❑ Aged 55 or over 61. What is your gender? ❑ Male ❑ Female 62. What is your job category? ❑ Supervisor/Manager ❑ Non-supervisor/Non-manager 63. What is your ethnic background? ❑ White ❑ Black or African American ❑ Hispanic or Latino ❑ Asian ❑ Native Hawaiian or Other Pacific Islander ❑ American Indian or Alaska Native ❑ Two or More Races(a person having origins in two or more minority race categories above, not Hispanic or Latino) ❑ Other 64. If you answered Other to the previous question, please specify ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 49 FINAL SURVEY - CONT. Section I: Department/Division Information(For the following questions,select the department/division in which you work,or select None and move to the next group. If you do not see your division, choose your department.) 65. Select your department/division. ❑ None ❑ Agriculture ❑ Aquarium&Museums ❑ Budget I Management Services ❑ Circuit Court Clerk's Office ❑ City Attorney's Office ❑ City Clerk's Office ❑ City Managers Office/Cultural Affairs Office ❑ City Treasurers Office ❑ Commissioner of the Revenue's Office ❑ Commonwealth's Attomey's Office 66. Select your department/division. ❑ None ❑ Communications Office ❑ Convention&Visitors Bureau ❑ Economic Development ❑ Emergency Communications&Citizen Services ❑ Emergency Management Office ❑ Emergency Medical Services ❑ Finance ❑ Fire Administration/Services ❑ Fire Operations ❑ Health 67. Select your department/division. ❑ None ❑ Housing&Neighborhood Preservation ❑ Human Resources ❑ Human Services/Administration ❑ Human Services/Detention Center ❑ Human Services/MH/SA ❑ Human Services/Developmental Services ❑ Human Services/Adult&Family Services ❑ Human Services/Financial Assistance ❑ Human Services ❑ IT/Data&Information Mgmt 68. Select your department/division. ❑ None ❑ IT/CGIS/Technology Services/Business Ctr./Mail ❑ IT/Systems Support/Telecommunications ❑ IT/Enter.Arch&Planning ❑ Libraries ❑ Office of the City Auditor ❑ P&R/Landscape Mgmt./Asset Mgmt./Special Zones Mgmt. ❑ P&R/Landscape Mgmt./Operations&Maintenance ❑ P&R/Landscape Mgmt./Maintenance Management ❑ P&R/Programming&Operations/Recreation Centers ❑ P&R/Programming&Operations/Out-of-School Time ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 50 FINAL SURVEY - CONT. 69. Select your department/division. ❑ None ❑ P&R/Programming&Operations/Fusion ❑ P&R/Programming&Operations/Parks&Natural Areas ❑ Parks&Recreation(P&R) ❑ Planning ❑ Police/First Precinct ❑ Police/Second Precinct ❑ Police/Third Precinct ❑ Police/Fourth Precinct ❑ Police/Special Operations ❑ Police/Detective Bureau 70. Select your department/division. ❑ None ❑ Police/Special Investigations ❑ Police/Support ❑ Police ❑ Public Utilities/Engineering ❑ Public Utilities/Operations&Maintenance ❑ Public Utilities/Business ❑ Public Utilities ❑ PW/Technical Services&Engineering ❑ PW/Operations&Highways ❑ PW/Building Maintenance 71. Select your department/division. ❑ None ❑ PW/Fleet Management ❑ PW/Waste Management ❑ Public Works(PW) ❑ Real Estate Assessor's Office ❑ Sheriffs Office ❑ STiR ❑ Voter Registration&Elections ©2019 People Element LLC Hillard Heintze City of VA Beach Survey Comparison Page 51 . w •>- *w wxw Q ! : -- - ,. ...u....:-.�,�.e.'•' :.:-'.- 'r+�,.ems, ...�'^^' d »�...,.tee... m .v ., • KK •.. <. � �.. ,� ,ran a..„ HILLAPD • HE I NTZ E hiilardhemtze com A JENSEN HUGHES COMPANY