An in-depth look into the full report of the independent investigation into the Virginia Beach Municipal Center shooting

Timeline

Hillard Heintze compiled a timeline of key events in the shooter's life before the attack.

From April 1996 to April 2002, the shooter was a member of the Virginia Army National Guard and assigned to units in Norfolk in Hampton. He was honorably discharged from the National Guard.

He graduated from Old Dominion University in May 2002 and accepted an engineer position at Lewis and White.

After a year, he resigned from Lewis and White and accepted a Project Engineer position at MSA Engineering.

Five years later, he was laid-off. Someone close to the shooter said he had complained about the lack of promotion and perceived racism at MSA Engineering. He was then married and accepted a Project Engineer III position at Draper Aden Associates.

In July 2008, five months later, he resigned. He accepted the position of Engineer II for the city of Newport News.

He resigned from Newport News in January 2010.

The shooter started working at Virginia Beach as an Engineer II in February 2010.

He bought a home in Virginia Beach in January 2012. In September 2012, he received the "Thumbs Up" Award. He was given the "Excellence in Service" Award in April 2014.

The shooter received the "Team Participation" Award in May 2015 and the "Excellence in Service" Award again in December 2015.

In April 2016, he applied for and got a concealed handgun permit. Three months later, in July of that year, he bought an H&K USP45C 45 ACP pistol and a JRC JRCV067138 45 ACP carbine rifle.

He began regularly visiting gun websites on his phone in August 2016.

In September 2016, the shooter separated from his wife, the first images of weapons appear on his phone and he bought a Glock 21 45 ACP pistol.

He submitted a certification for a suppressor in October 2016.

In December 2016, an issue regarding missing contractor check's on the shooter's project.

From 2011 to 2017 the shooter received annual evaluations and was rated as "meets standards."

In January 2017 a manager documented the mishandling of checks in a letter. Afterward, he emailed his supervisor that his work was above average, but his salary didn't show that.

His wife moved out of their home in June 2017. That same month, he emailed his supervisor that he was assigned a project above his paygrade. He was then placed on a Performance Improvement Plan for deficiencies in his project management skills. The shooter said he felt "singled out" for his unsatisfactory work performance.

In August 2017, he told his lawyer to file for divorce. He successfully completed his Performance Improvement Plan. Also that month, his suppressor registration was completed.

A month later, his divorce was finalized and he texted someone close to him "finally got my suppressor today."

In December 2017 he bought a Bond Arms Backup Derringer 45 ACP pistol and started to decrease the amount he spoke to his mom.

He began talking more to his ex-wife in February 2018.

In April 2018, he received another "Thumbs Up" Award.

The shooter bought a second Glock 21 45 ACP pistol in June 2018.

The following month, he was given a written reprimand for poor performance expectations as well as a Letter of Performance Expectations. He submitted a verbal grievance with his supervisor about the reprimand, to which his supervisor verbally responded.

He received an "Improvement Required - Performance Improvement Plan Required" due to poor performance during his annual evaluation in August 2018. He submitted a written grievance to his supervisor and to the Department Head to remove the reprimand.

That same month, he complained in a response to his annual evaluation that he is being discriminated against by being assigned projects that were above his paygrade and drafted an email that expressed concerns he was being "sandbagged."

After a meeting with his Department Head in September 2018, he emailed the Department Head stating that he was clearly being discriminated against and asked for the reprimand to be removed. He was told the reprimand would remain and chose to end his grievance and to not to appeal to the Personnel Board.

The next month he stopped communicating with his mother and his ex-wife.

In January 2019, he used his Smart TV Guide to visit a news report about the Orland Square Mall shooting.

He visited gun conversion kit websites in March 2019.

On April 3, 2019, he drafted one work email about his perceptions of his professional relationships and stressors and another that reflected irrational and suspicious beliefs.

He browsed a premier body armor website and looks at body armor and ballistic plate on April 7, 2019. The next day, he looked at level 3A ballistic body armor panels.

On April 10, 2019, he got an email that confirmed the delivery of his purchased body armor. Two days later, he bought a Ruger rifle.

On May 20, 2019, he searched for maps of Building 2 and the Municipal Center on his computer.

He set a message on his computer on May 23, 19 that he would be out of the office from May 24 to the 28. A day later, he bought three rifle gun magazines and a rifle case.

On May 28, 2019, he emailed the Contracts Unit asking to expedite payment for a $3,027.48 contractor invoice, which the funds had not been properly assigned for.

A Contracts Specialist emailed the shooter back on May 29, 2019 asking for justification for and additional information about the purchase order and told him to email the City Procurement Officer with the request.

He emailed the Procurement Officer asking for help to resolve the issue. The Procurement Officer left him a voicemail about the issue telling him he made an unauthorized purchase and violated City ordinance.

The Procurement Officer followed up with an email that stated he did not properly follow policies and procedures and that full documentation about his purchases would be required.

The shooter played the voicemail for his supervisor and then emailed his supervisor on how he would respond to the Procurement Officer.

Another employee received a pre-dismissal letter from supervisors and a Virginia Beach police officer was posted at Building 2 as a precaution.

On May 30, 2019, the employee received a termination letter and was escorted out of the building by a supervisor.

The shooter then said he was too upset to meet with the Procurement Officer and would pay the $3,027.48 from his personal checking account to correct the error.

That night, he placed a 54-second phone call from his cell phone to his desk phone. He then called his ex-wife, in which he was apologetic, and his mother, where he discussed issues at work and his insomnia, but was overall upbeat in tone.

On the day of the shooting, the shooter left his home at 6:58 a.m. and arrived at work at 7:16 a.m.

At 7:21 a.m., he swiped his card for entry into the 2nd Floor Engineering North Hall in Building 2 and started up his computer at 7:23 a.m.

From 10 a.m. until 10:30 a.m. he searched the internet for Building 2 maps, the ECCS and Municipal Center Building Map. 

The shooter then emailed his supervisor his resignation, referring to personal reasons, at 10:31 a.m. Fifteen minutes later, his supervisor responded saying he hoped the personal reasons would be resolved and confirmed that the shooter's last day would be June 14.

At 10:49 that morning, the shooter's supervisor forwarded the resignation email to other managers copying the shooter on the forwarded email.

The shooter swiped his card to enter the 2nd Floor East Engineering South in Building 2 at 10:52 a.m.

At 11:25 a.m. he confirmed with his supervisor that June 14 would be his last day via email.

From 11:23 a.m. until 11:33 a.m. the shooter sent routine work emails.

He again swiped his card to enter the 2nd Floor Engineering North Hall at 11:58 a.m. then 10 minutes later swiped into the 2nd Floor Engineering South in Building 2.

At 1 p.m. he again swiped his card for entry into Building 2's 2nd Floor Engineering South. Four minuted later he left the building with two co-workers and drove to three project sites for routine inspections. They remained out of the building until 3:11 p.m.

At 3:55 p.m. he sent routine work emails and then was seen brushing his teeth in the second-floor bathroom at 3:57 p.m.

Between 4 p.m. and 4:05 p.m., he entered the south entrance of Building 2 and a witness heard gunshots, saw him with a gun in his hand and a man bleeding on the ground and he swiped for entry into Building 2 2nd Floor East Engineering South.

Between 4 p.m. and 4:16 p.m., the attacker shot Mary Loise Gayle, Alexander Mikhail Gusev, Katherine Nixon, Michelle Langer, Ryan Cox, Robert Williams, Christopher Rapp, Tara Gallagher, Laquita Brown, Richard Nettleton, Herbert Snelling, Joshua Hardy, and four other victims.

At 4:06 p.m. dispatchers received the first 911 call and it lasted four minutes and 59 seconds. The caller reported seeing a body on the ground with blood, hearing gunshots, seeing a black man with a blue shirt running into Building 2, hears more shots near his office and ends the call.

At 4:08 p.m. a call is dispatched about a man in front of Building 2 who is possibly shot and the first description of the shooter is reported as a Hispanic man on the second floor. The dispatcher can hear gunshots in the background. The shooter then swiped into the 2nd Floor West Side Business Unit of Building 2.

At 4:10 p.m. a second suspect description is sent out referring to a bald black man in a blue polo shirt. Shortly after that, the first officers enter Building 2 and K9 units and plainclothes detectives arrive at the scene.

At 4:11 p.m. the Virginia Beach Fire Department arrives at the scene.

The shooter swipes his card for entry into the Building 2 2nd Floor West Side Business Unit at 4:12 p.m.

A minute later, dispatchers send out a third suspect description referring to a six-foot-tall clack man with a blue shirt and a gun silencer.

At 4:15 p.m. the Virginia Beach Fire Department sets up a command post and the Virginia Beach Police Department establishes an on-scene commander.

Seven seconds later, the shooter swiped his card for entry into Building 2 2nd Floor East Side Engineering South.

All available SWAT team members arrive at Building 2 at 4:18 p.m. and a minute later the name of the shooter is dispatched.

At 4:20 p.m. there is a police radio broadcast that an officer is shot.

Dispatchers identify that the shooter is isolated and actively shooting on the east side of the second Floor at 4:21 p.m.

At 4:22 p.m. the Human Resources Communications Coordinator sends an email to all city employees to shelter in place at the municipal center until further notice. The email said:

We have an active shooter at the Municipal Center, supposedly in or around Building 2. Please Shelter in place. Lock your doors. We'll communicate when it's safe to leave. Thank you. 

SWAT teams enter Building 2 at 4:26 p.m.

At 4:43 p.m. police report that the shooter is in custody. Another transmission that the shooter is in custody goes out at 4:44 p.m.

At 4:54 p.m. the Human Resource Communications Coordinator sent another email that read:

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!

First responders attempt to set up a Family Reunification Center at United Methodist Church at 5:30 p.m., but the church is occupied. The center is then established at Princess Anne Middle School.

The shooter was pronounced dead at Virginia Beach General Hospital at 5:32 p.m.

At 5:34 p.m., Building 2 is secured and there is no one else injured in the building.

Police find the shooter's backpack and more guns on the second floor at 5:36 p.m.

Explosive detection K9s started searching the parking lot at 5:43 p.m.

The Human Resources Communications Coordinator sent another email at 5:55 p.m. that read:

Today’s situation is ongoing but the suspect is in custody. It is now safe for Municipal Center employees to leave the area. However, those who work in Bldg. 2 must remain here until further notice. Police/fire officials will inform Bldg. 2 employees when it’s safe to leave. Please drive safely when leaving. Thank you.

The Family Reunification Center opened at Princess Anne Middle School at 6 p.m.

There was an explosive sweep of Building 2 at 6:09 p.m. and was finished by 7:18 p.m.

The building was ready for forensics teams and detectives at 7:19 p.m.

Death notifications began at 9:00 p.m. and the last local death notification is made at midnight.

Out of state police officers make the last death notification at 1:00 a.m.

The Family Reunification Center closed on June 2, 2019 when the Family Assistance Center opened at the Princess Anne Rec Center. The Family Assistance Center closed on June 9, 2019.

RELATED: TIMELINE: A break down of the Virginia Beach Municipal Center shooter's last day

Personal Background of Attacker

The shooter was born on October 15, 1978, and died on May 31, 2019, in a shoot out with police after the attack on Building 2.

His parents divorced in the mid-1990s and then his mother remarried. In 1998, the shooter changed his last name to his step-father's last name.

He lived in Virginia Beach and the Hampton Roads Area for most of his life except for when he trained at Fort Sill, Oklahoma for a few months after he joined the Virginia Army National Guard in 1996 and served as a reservist.

He was married in February 2008 until September 2017.

The shooter also kept a low profile. There was no negative press coverage about him until the May 31 attack. Investigators also couldn't find any social media profiles for the shooter.

RELATED: Information about the suspected man behind the gun at the Virginia Beach Municipal Center shooting

Criminal Background of Attacker

Criminal Records

Investigators were not able to find any national federal criminal records, state criminal records or international infractions, like watch lists, that named the shooter. He was also not listed on the National Sex Offender Public Registry.

Traffic Records

Between September 1997 and May 2013, the shooter was cited once for reckless driving for going 99 mph in a 55-mph zone, three times for speeding - twice going over 70 mph in a 55-mph zone and once going 63 mph in a 45 mph zone, an HOV violation and a violation for tinting films, signs, decals and stickers on windshields or windows.

Civil Court Records

There were no National Federal Civil records that named the shooter, but there was a State Civil Court record related to his divorce from his wife in August 2017.

Employment History and Workplace Interactions

The shooter began his career as an engineer in May 2002 and had four different jobs before he was hired by the City of Virginia Beach in 2010. During those eight years, the longest job he held lasted five years and he was unemployed once for a four-month period.

Early in his career for Virginia Beach, he was recognized for his work with various awards. His annual performance evaluations through 2017 stated that he "met expectations at work. Those who knew him said he was quiet and reserved and didn't develop close friendships with people at work.

From April 1996 until April 2002, he served in the Virginia Army National Guard and was honorably discharged.

He was a project engineer at Lewis and White Associated from May 2002 until he resigned in May 2003.

From May 2003 until he was laid off in February 2008, he worked as a project engineer at MSA Engineering. During his time there, he complained about the lack of promotion and perceived racism.

He worked as a project engineer III at Draper Aden and Associated from February 2008 until he resigned in July 2008.

He didn't work again until November 2008 when he was hired as an Engineer II for the City of Newport News. A year later, he was given an excellent evaluation from his supervisor and recommended for a raise. He resigned two months later in January 2010.

In February 2010, he was hired by the City of Virginia Beach.

Between 2010 and 2017, his evaluations were rated as "Meets Performance Standards." In 2018, the city changed the term to "Meets Performance Expectations. His 2017 and 2018 evaluations indicated that he had challenges at work.

In September 2012, he received a "Thumbs Up" award for going above and beyond a project where he was a manager. In April 2014 and May 2015, he received "Excellence in Service" awards for going above and beyond on projects where he was listed as a manager. In December 2015 he received a "Class Act" award for managing a project despite facing "significant barriers" presented by a "challenging citizen." 

He didn't receive another award until April 2018 when he got another "Thumb Up" award for providing HR staff a tour of Public Utilities Operations.

Risk Factors

Investigators used the Workplace Assessment of Violence Risk (WAVR-21) to analyze any risk factors that would have indicated workplace violence.

Risk factors are defined as any circumstances, characteristics, or behaviors that would indicate a person would act aggressively or violently. In contrast, there are also protective factors that decrease the likelihood someone would act violently.

Job Performance issues in 2017

Just before 2017, the shooter started to experience challenges at work. According to performance reviews, he had trouble maintaining appropriate financial and contracting records and engaging with citizens and contractors.

In January 2017, he received a letter from his supervisor about not depositing a $50 check from a contractor in a timely manner. An investigation revealed that he allowed 13 checks to surpass their "stale date" of 180 days after the issue date. He was told to contact the firms and request new checks, which he did.

According to the supervisor, it wasn't a letter of reprimand, but a letter to record the incident. It wasn't considered discipline, but it was serious and required corrective action.

Six months later, in June, he was placed on a Performance Improvement Plan for deficits in working relationships, project management and responsiveness to customers.

Despite earning "Meets Expectations" in other areas of the review, he was placed on the Performance Improvement Plan because he was rated as "Improvement Required" for the above areas.

The reasons for the "Improvement Required" areas were the mishandling of contractor checks, making inappropriate remarks to coworkers and demonstrating insubordination regarding instructions from management and avoiding or delaying responses to citizens about projects he was in charge of.

He successfully completed the plan in August but was still not able to maintain acceptable levels of performance when it came to his project management duties. His supervisor also noted that he did not exhibit good judgment.

In July 2018 he received a written reprimand for poor performance. He was cited for failing to perform the assigned duties as an Engineer III and was reminded there had already been several discussions to address the areas where he was lacking.

A "Letter of Performance Expectations" was issued in July 2018 to ensure an understanding of his job requirements. The issues addressed were the same issues mentioned in his earlier Performance Improvement Plan.

In 2018, he received an "Improvement Required-Performance Improvement Plan Required" rating on his evaluation.

He was rated "Improvement Required" in more areas than the year before. Those areas included:

• Working relationships with coworkers, supervisors, the public and outside contacts
• Knowledge of the field
• Compliance with city and departmental policies
• Conflict resolution
• Commitment to exceptional customer service
• Oral and written communication

He wasn't issued a second Performance Improvement Plan, management instead referred to the Letter of Performance Expectations that was already issued.

When responding to the  evaluation, the shooter initially said:

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 submitted a handwritten comment that read:

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, the shooter sent an email to his superiors and copied it to his personal Gmail account. He wrote, in part:

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.

The email went on to detail a seven-point response.

He initiated a formal grievance on the departmental level as part of the HR process. He completed some steps of the process, but after starting Step 3, which would have been with the Department Director, he chose to end the process in September 2018. He did not appeal his grievance to the Personnel Board.

During the discussions about is 2018 evaluation he expressed to his supervisors and managers that he was being treated unfairly and was being held to higher standards than others at his paygrade.

Job Performance Issues Before the Attack

He was working toward complying with the expectations set in his 2018 evaluation. He did not have a 2019 evaluation before the May 31 shooting.

On May 29, 2019, the Finance Officer in the Business Division received an invoice from the shooter for $3,027.48 for work performed on a project and a purchase acquisition for the contractor or vendor for $3,027.48 for work that was authorized in December 2018.

To the Finance Officer, this was perceived as a serious violation of fiscal guidelines because the work was unauthorized and performed before the funding had been approved. It was reported that the shooter had a pattern of not following fiscal policies and procedures.

The Finance Officer noted that the shooter had the most fiscal violations of any engineer and often submitted his documents late. The Finance Officer denied the funding request and told his staff to tell the shooter that he violated multiple sections of the Virginia Public Securities Act, a firable offense. The shooter was also told he would have to get special permission from the City Procurement Officer to have the funding request approved.

A supervisor then tasked a coworker assigned to Public Utilities to tell the shooter that he broke the law and his employment could be terminated. The coworker did not tell the shooter this. Instead, he sent an email to the shooter explaining that he needed to provide full documentation about the invoice and needed to get approval from the City Procurement Officer.

The shooter then sent an email to the City Procurement Officer asking for assistance with expediting the payment to avoid incurring late fees. A few hours later, the procurement officer responded with an email and a voicemail explaining that he signed a contract with a vendor, which he wasn't authorized to do, that all contracts need to be reviewed by the legal department and that his actions violated a city ordinance.

Someone in the Procurement Office also contacted a City Attorney about a $12,115.31 work authorization for a contractor or vendor that was signed by the shooter on how to proceed. The attorney said the work authorization could be processed, but it was ideal for a City Procurement Agent to sign work authorizations. No emails were sent to the shooter about the issue with this work authorization.

In regards to the $3,027.48 purchase order, supervisors said the shooter had a negative reaction to the voicemail from the Procurement Officer and became very upset. The supervisor said the unit management team would handle it on his behalf. 

The shooter then asked a coworker for advice after-hours on May 30. He told the coworker he was busy in December 2018 right before Christmas and forgot to get the purchase order. He said once he realized the issue he tried to request the purchase order, but a coworker said it was too late and the purchasing department was "giving him a hard time."

He claimed to have sent an email to another Public Utilities Contracts employee asking for help when he realized the issue and had 30 days to fix it. Three weeks later the other employee said he never got the email leaving the shooter with only one week to fix it. Investigators could not find the email the shooter claimed to have sent asking for help.

The coworker said the shooter was upset and he encouraged the shooter to address the problem in-person with the purchasing department and discussed paying for the error out of his checking account to correct the mistake.

The purchase order wasn't resolved before the shooting.

A supervisor said the issue would not have led to the shooter being fired and that his job performance was positive for the 2018-2019 year and that he was going to receive a "Meets Expectations" rating on his evaluation that was scheduled for August 2019. But, the review did not happen, there wasn't a draft of the review and the shooter didn't know about upcoming performance evaluation.

In a phone call to his mom the night before the shooting he told her he was suffering from insomnia and was only getting three or four hours of sleep a night. He added he started taking a prescribed sleeping aid, but investigators don't know if the medication was found by the Virginia Beach Police Department or the FBI.

Weapons Skills and/or Access

The shooter received basic and advanced training when he served in the Army National Guard.

In 2016, the shooter started to buy guns. He had at least six.

He also went to local shooting ranges to practice regularly. He usually went alone or with a family member. He also went with a coworker who said he was "comfortable and proficient" with a gun.

The shooter had a concealed handgun permit, a Heckler & Koch USPC 45 ACP Pistol, a Just Right Carbine's carbine rifle, two Glock 21 45 ACP pistols, a gun suppressor, a Bond Arms Backup Derringer 45 ACP pistol, a Ruger rifle and three rifle gun magazines and a rifle case.

He also started to regularly visit gun websites in April 2016, ordered a bullet-resistant vest online and had a collection of knives.

Violent Preoccupations

Between May 2018 and May 2019, he conducted at least five searches on websites that had news about mass shootings. In January 2019, he specifically clicked on a news story about the mall shooting in Orland Park, Illinois.

Pre-Attack Planning and Preparation

Hillard-Heintze investigators had limited access to the shooter's personal devices because of the ongoing criminal investigation.

They were able to find a search for maps of Building 2 and the Municipal Center campus on May 20, 209.

On May 23, 2019, he set up an automatic out-of-office email reply that said he would be out of the office from May 24 until May 28. What he did during this time wasn't available to investigators so it's unclear if any of the time off was related to planning the attack.

On May 31, 2019 between 10 a.m. and 10:30 a.m., he searched for maps of Building 2, Emergency Communication and Citizen Services and the Municipal Center campus map. He then sent a resignation letter to his supervisor at 10:31 a.m.

Entitlement

The shooter kept a series of emails that indicated he felt he was being treated unfairly at work.

In one email that was drafted and never sent, he talked about how one project interfered with his vacation time and asked if that would make him eligible for on-call pay. He also requested a salary evaluation via email because he believed he deserved an increase because of the crucial projects he was assigned and should have been assigned to an Engineer IV.

In another drafted, unsent email the shooter wrote that he felt he wasn't being properly recognized for his work writing:

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 acknowledgment, I mean that in comparison with other engineers at my level. Why don’t I get to select the consultants that I work with?

Anger Problems

Investigators couldn't find evidence that the shooter was physically aggressive towards coworkers or others before the May 31 shooting. Rumors said that he had gotten into a fight at work, but it was revealed that another employee, not the shooter, was involved in the fight. The other employee was fired on May 31. The shooter's drafted emails confirmed that he had real or perceived grievances toward his employer, specifically with managers and coworkers whom he worked with regularly.

Irrationally Suspicious Beliefs

While there was no evidence that the shooter sought mental health treatment or had a clinical evaluation, coworkers described behaviors that the shooter was paranoid or obsessive-compulsive.

Someone close to the shooter described him as shy, introverted and uncomfortable around others. They said he had the type of personality in which he believed that everyone was against him, characterizing him as "paranoid."

That person described an incident at a restaurant when the shooter believed the other people at the restaurant, who he didn't know, were talking about him and wanted to hurt him. They said he "struggled mentally."

The shooter also installed three CCTV cameras at his home. They were inside the home and pointed outside. It's unknown if he did this as a preventative security measure or to relieve the alleged feelings of paranoia.

Workplace Behaviors

His coworkers described him as private, disciplined, organized and, at times, inflexible. They also described some of his behaviors as consistent with OCD discussing how he brushed his teeth in the work bathroom every day at the same time.

Some coworkers said he was distant and reserved while others said he could be engaging, but all of them said that most of their interactions with him were about work and not personal matters.

Investigators did find several email threads about his personal life where he discussed his divorce with two coworkers.

One coworker did say he was frustrated with management passing him over for promotions and that they were choosing people with less time on the job believing race played a role, but investigators didn't find any evidence that he applied for promotions or other vacancies and only found evidence of one formal grievance, which was filed concerning his 2018 evaluation.

Resignation

The shooter learned that a manager talked to others about his resignation when a coworker asked him about it. 

One person told investigators that he was "very upset" that his resignation was disclosed to others, but another coworker who spoke to the shooter on May 31 said he didn't seem to have any negative feelings about other coworkers knowing he resigned.

The shooter told the coworker he wanted to take personal time off before looking for a new job. The coworker then said the shooter shook his hand and thanked him for listening and supporting him while he was getting divorced. He said the shooter got emotional and teared up before leaving the office.

Work Emails

Most of the shooter's work emails were routine, but there were drafted emails, that were never sent, that detail how the shooter perceived his professional relationships.

The emails seem to reflect irrational and suspicious beliefs.

Screenshots from an email written on April 3, 2019 can be read on pages 54 through 57 of the full report attached at the bottom of this article.

The email said, in part, that people don't fight hard when they're comfortable, only when they're desperate and that the harder someone fights the more comfortable you should feel because it means they are near personal defeat.

He wrote, in part: "Now the pattern is first to ingratiate new or remote employees (2 or so contacts) and then have them reject you. Same as usual, but they are running out of employees to reject you. Generally, rejection is the stressor after making you fatigue through sleep deprivation."

The shooter also stated in the email: "...You don't threaten when you actually plan to take action, you just do it by surprise."

Increasing isolation

Investigators discovered that the shooter was sociable when he was young, but it decreased as he got older. He didn't have any close friends within the last decade and became even more isolated before and after his divorce.

He did not engage in work events or socialize after-hours with his coworkers. He contacted his mother consistently until 2017 when it dropped off.

History of Criminality

The shooter had no history of criminal behavior.

Retrospective Analysis

Behavior and Experiences at Work

Many coworkers described the shooter as shy, socially introverted, odd, disciplined, socially awkward, reserved and unfriendly, but others saw him in a more positive light.

Investigators learned that the positive relationships were developed after establishing rapport, that took several years in some cases, and even then the shooter remained guarded and didn't provide a lot of personal information.

He maintained his privacy and his personal like involved conflict at times, like his divorce, that may have affected his work performance, which could be noted in the timeline of his divorce and his annual performance evaluations.

Based on his drafted, unsent work emails it seems he was struggling with issues that included his perceptions that he was a victim of favoritism and racism. He also demonstrated traits that are associated with paranoia.

Investigators believe his grievance was grounded in the way he felt coworkers and supervisors treated him based on his 2018 evaluation where he typed out a seven-point rebuttal where he provided his version and clarified each deficit defending himself from his supervisors and challenging their interpretation of his job performance.

He kept a running record of his beliefs in his drafted emails, which suggest he was becoming more fixated and preoccupied with his perceived grievances.

His supervisor noted that he was making good progress ahead of his next evaluation, but the error from December 2018 regarding the $3,027.48 purchase order surfaced and the shooter thought his job was in jeopardy.

Investigators said that when the drafted emails were viewed collectively it could have provided the rationale to take aggressive action toward those he felt wronged him.

Some of the victims of the May 31 shooting weren't known to the shooter, but others targeted were those whom he had a perceived or real grievance. Survivors also described that the shooter spared them despite having the opportunity to shoot them.

Motivations

On May 31, 16 people were shot in Building 2 at the Virginia Beach Municipal Center and 12 of them died. A police officer was also shot while police and the shooter were engaged in a shootout.

The Hillard_heintze team said based on the information reviewed to date, they cannot definitively say why the May 31 shooting happened. They said the insight into the shooter is limited and while his drafted emails offer a limited window into his thoughts, they are open to interpretation.

In some mass casualty events, the attacker provides a clear path or detailed plan explaining their actions, but the May 31 Virginia Beach Municipal Center shooter did not write a manifesto, create a pre-recorded video to explain to the shooting or reveal his intent to carry out the attack to anyone.

Since his divorce, the shooter remained distant from family and investigators couldn't find evidence of ongoing friendships or relationships that were central to him.

Shortly after his wife moved out in 2016, his work performance declined. Some of his coworkers and his supervisor knew about the divorce.

On the day of the shooting, he submitted his resignation but participated in normal work activities like answering emails. He was also out in the field with two coworkers for about two hours. They had no indication that later that day he would kill 12 of their coworkers and injure four others. One of them left before the shooting, the other was barricaded in his office during the attack.

Hillard-Heintze investigators identified several pre-incident risk factors for the attacker, but they're not high-risk warnings and align with a lot of American citizens.

In their review of what the City of Virginia Beach knew before the shooting, the following risk factors were identified:

• Weapons skills and/or access - the city knew the shooter served in the Virginia Army National Guard and it can be reasonably assumed they knew he had weapons training.
• Recent job problems - The city was aware of his recent deficits concerning his performance based on his past Annual Performance Evaluations, Performance Improvement Plan and Letter of Performance Expectations.
• Personal stressors - Some coworkers and his supervisor knew he had gone through a divorce.

The Shooter's Relationships to the Victims

Based on the shooter's actions, investigators determined he moved with purpose through Building 2 during the attack but didn't leave any indication of why he shot the people he did.

The common relationship between the shooter and his victims was that they were connected to Building 2 in some way.

The victim who did not work for the city was most likely "in the wrong place, at the wrong time" as he was near the entrance when the shooter entered with his guns.

Of the 16 people shot, three were managers within the Engineering Division or Public Utilities. There were interactions and/or emails between the shooter and the three managers who were shot.

Two of those managers were in his direct line of report, and aware that he believed he was being treated unfairly at work. He had only one instance of significant contact with the other manager who was shot.

Investigators believe the three managers were targeted based on their interviews.

The shooter's relationships with the other employees and his reason for shooting them isn't as clear. Based on interviews, he clearly targeted some individuals and he spared others despite having the opportunity to shoot them.

One witness said the shooter approached three people and had his gun clearly pointed, not at the person in front, but at another person further away.

He shot employees he had little or no contact with and for no apparent reason. Investigators couldn't find a significant relationship between the shooter and the victim in the parking lot as well as a few others, including a newer employee who had only recently met the shooter.

Other employees put their lives at risk to warn others and get them to safety.

There wasn't much conversation between the shooter and his victims, but some employees tried to get him to stop.

Investigators said the shooter is the only one who can explain why some people were spared and others weren't, but he also died during the attack.

Investigators said they heard several rumors, but couldn't find evidence to establish them as fact. 

One rumor was that the victims who were shot were part of a promotion board, but the shooter never formally applied for a promotion.

Another rumor was that the shooter sought a relationship with one of the victims, but there was no evidence of romantic interest between the shooter and the victim in his work or personal email.

It's also not known why others were allowed to live. One survivor assumed he was spared because of his work relationship with the shooter. Another believes the shooter walked away from her after pointing a gun in her face because she smiled and said hello to him almost every day when passing him in the hallway.

Could the Attack Have Been Prevented?

The shooter was a private person and did not display any concerning behaviors that are typical in mass casualty events.

The three risk factors listed above wouldn't normally indicate violence towards others. It at least appears this way because no one reported significant pre-incident concerns.

Investigators could not find a clear link to the violence on May 31, 2019 in their retrospective analysis. Also, investigators looked at things that weren't accessible to the city before the shooting.

Based on the limited information the city would have had access to before the shooting, investigators deemed the shooter as a Low-risk potential on the WAVR-21 risk evaluation.

Minutes after the first 911 call, the Virginia Beach Police Department officers were at the scene.

Plainclothes detectives and K9 units also arrived at the scene.

As the first officers entered Building 2, they heard shots on the second floor.

The attack continued for 36 minutes, ending at 4:43 p.m. when the attacker was shot and taken into police custody.

During the 36 minutes, police arrived at the scene, secured the building, located the shooter and took him into custody.

The shooter was pronounced dead at the hospital at 5:32 p.m.

Initial Response to the Active Shooter

As soon as dispatchers were called about an active shooter in Building 2, they immediately sent first responder units. In addition to the Virginia Beach Police Department, the Virginia Beach Fire Department and Virginia Beach Emergency Medical Services were sent to the scene.

Dispatchers from Emergency Communications and Citizens Services Center ensured that the necessary first responders were sent to the active shooter scene.

Initial Communications

First calls and Execution of ECCS Protocols

Emergency dispatchers received the first 911 call moment after the second victim was shot. The caller could see the shooter and gave the first description to dispatchers.

As the volume of calls from people in and around Building 2 came in, ECCS staff escalated the incident to nearby supervisors.

According to investigators the dispatchers were professional and acted efficiently and compassionately.

Incoming 911 calls increased as family members and others with a connection to Building 2 employees called in the information they were receiving by texting people inside.

ECCS protocol ensured an immediate integration of all ECCS operations and expansion to accept and triage the 911 calls.

ECCS was staffed with 13 people dedicated to processing incoming 911 calls and six to answer non-emergency or city service-oriented 311 calls. The team was supplemented by supervisors as the calls increased.

On May 31, 2018, 20 emergency calls were received between 4:00 p.m. and 4:29 p.m. On the day of the shooting, 110 emergency calls were received during the same time frame. Because of the number of calls, some callers weren't able to get through the ECCS center on their first attempt. Others said they were placed on hold before they could speak to someone on the staff.

Calls from Witnesses

The first callers to 911 heard gunshots and saw a victim on the ground at the South Entrance of Building 2. They were able to give a description of the shooter to 911 dispatchers, which was relayed to the police at the scene and headed to the scene.

ECCS staff were also effective in getting relevant and useful information, like where the shooter was and where victims were located, from callers who were struggling to communicate because of personal duress, fear and trauma.

Dispatchers were able to get critical information while they struggled to hear callers who were whispering or totally silent. Callers, despite dear for their safety, were trying to guide first responders and get help as they hid under desks and whispered to avoid attracting the shooter's attention.

The calls were emotionally charged for callers and dispatchers alike. In a lot of the calls, gunshots could be heard in the background as callers tried to share information. In one call that was particularly difficult, a dispatcher received information from a caller before eight loud gunshots were heard and the line went silent.

ECCS Guidance for Personnel Trapped in Building 2

While dispatchers collected information needed by first responders, they also guided and counseled callers who were in Building 2 or were in fear for family and friends in the building.

ECCS staff advised those who were sheltered in rooms to lock doors, hide, remain barricaded and stay quiet until police instructed them to come out.

The also advised callers that when police told them to exit the room to have their hands up and visible and to follow all police commands closely. In circumstances like the shooting, police are trained to maintain high levels of awareness in case attackers try to blend in with victims and gain a tactical advantage in the stream of people or leave the building.

ECCS Text Messages

According to people who were interviewed, Building 2 employees were texting family members updates and the family members called 911 to relay the information, but ECCS only received two text messages during the shooting.

During emergencies, it is common for victims to rely on text messaging to notify emergency responders or to seek help and ECCS employees are trained to handle E911 texts.

Notification Systems

The City uses a range of automated notification systems that deliver text and email notifications. Most of the communication for the shooting was distributed through the "staff alert: system, which doesn't 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 system or pre-programmed response and tasking protocol for critical events like the shooting.

Key operational staff who responded to the shooting said they learned of the event through informal communication channels including social media and phone calls.

SWAT and command members responded based on social media and phone calls instead of from a formal notification system.

Personnel who responded based on informal notification, some of whom were off-duty, were tasked with operational response, including being assigned key functions of the command. Many of the key personnel at the shooting "self-deployed" and responded without command direction or knowledge of their assignment and the location to where they should respond.

Public Safety Serious Incident Notifications, Policy 545

While the shooter was still active, very little coordinated information was shared with key personnel after the initial broadcast by dispatchers.

The policy, which drives information from ECCS to the Public Safety Department's Command Staff, used by the city was put into effect before an independent communications center was established. It relies on internal communication through different public safety branches.

The policy states that once a command member with the impacted department - police, fire EMS or 911 - is notified that department and command member is responsible for any further notifications.

VBPD General Order 11.02, First Responder Notifications

The policy states that first responders are supposed to give notifications to any supervisory members of an incident that concerns the department's liability or is of significant interest to the community and that reports should be made to the chain of command.

With the May 31 mass shooting, and other critical events, this isn't an effective use of resources. When there isn't a VBPD Command Duty Officer at the scene, the commanding officer at the scene is responsible for notifications, but they're also supposed to be engaged. A Centralized Communication Center would be more effective for critical situations like the May 31 Municipal Center shooting.

Early Incident and Subject Information

Some of the survivors, relatives or friends who called dispatchers raised concerns about not being believed by ECCS Operators. On the other hand, 911 operators are trained to ensure that accurate information is going out to first responders.

During the early calls, four different descriptions of the shooter were given to dispatchers and broadcast. Police at the scene were able to get an accurate description from witnesses and broadcast it. 

Inaccurate descriptions of the shooter could be deadly for officers and victims, especially at a mass casualty scene where people may be trying to get themselves away from danger as police arrive.

VBPD Response to the Scene

Emergency Radio Communications

The first 911 call was received at 4:06 p.m. Dispatchers issued an emergency call Priority One Incident over the police radio and included the alert tone prior to reporting details.

Most of the early response was on one radio channel.

ECCS established a second radio channel, but many officers continued to use the primary channel, which resulted in missed communication. Officers were told about the second channel, but there wasn't a timely switchover.

Arrival and Entry into Building 2

Police officers of various ranks and assignments were assigned and responded to a call for shots fired in Building 2. Most of the officers that responded came from the Police Administrative Headquarters and 1st Precinct Building, which is about 800 feet from Building 2.

Records show that two detectives and two k9 officers were among the first at the scene and entered Building 2 at 4:10 p.m to try and find the shooter.

Officers were able to find the shooter because of active shooting they heard while inside the building. The shooter was behind a secured interior door with a window off the main hallway on the second floor. The shooter fired at police and they shot back. The shooter then went down an interior hallway behind another secured door.

Communication between officers inside Building 2 was difficult because of the amount of radio traffic and those inside were involved in a shootout with the suspect.

Movement within Building 2

Officers entered the building through different entrances as employees continued to evacuate the building.

Some officers could not enter Building 2 employee entrances or secured employee entrances to floors until they got access cards from employees fleeing the building.

Not all of the cards allowed officers to access every area of the building. Officers asked ECCS for help with access to interior doors, but ECCS did not have remote access to control doors in Building 2.

Police were also not familiar with the layout or floor plans of the building and, as stated above, communication with officers inside the building was difficult.

Officers were eventually able to get access cards that gave them access to secured employee areas allowing them to go after the shooter and search for victims.

Indirect Notification to Key Personnel

Members of the SWAT team were at the Oceanfront preparing for the Memorial Day Patriotic Festival when they heard about the shooting.

Hillard Heintze didn't find any record that SWAT members were directly notified of the shooting.

SWAT team members said they heard about the shooting from a coworker, through a text message from a friend and through a phone call with an officer who was at City Hall.

SWAT Members Arrive

Records show that available SWAT team members were responding to the shooting at 4:18 p.m. and the first SWAT members were in the building by 4:26 p.m.

Officers inside had already been involved in a shootout with the shooter once leading to an officer being shot. The SWAT team and other officers were able to isolate the shooter and take him into custody by 4:43 p.m.

Recommendations

Hillard Heintze made the following recommendations for ECCS and the police department:

• Refine policies and procedures to include more details about specific roles and responsibilities for responding officers, supervisors and command officers.
• Policies and protocols should also include written checklists, which identify key things dispatchers could do, to use while handling a situation like an active shooter.
• Provide additional training for dispatchers and first responders on the importance of separate tactical and operational radio channels during critical situations and maintaining radio discipline throughout the situation.
• Specific roles should be pre-designated ahead of a critical situation. There should be enough people to report in shifts instead of a mass response.
• ECCS should make it more widely known to the public that they are capable of receiving E-911 text messages.
• Pre-programmed automated notification systems should be used to ensure key personnel and citizens are notified of emergency events.
• Dispatchers should communicate the source of the information they are broadcasting, especially when it comes to descriptions of an active shooter.
• Police officers should have access to all secured areas of city facilities immediately during a critical situation and have the tools to breach doors when necessary.

While the Virginia Beach Police Department took the lead at Building 2, other public safety agencies responded to the scene.

Incident Command System and Key Agency Roles

Active Assailant Training

The ongoing active shooter training by the City of Virginia Beach and the VBPD was valuable in the response to the May 31 shooting.

The officers who entered Building 2 and took the shooter into custody followed current best practices for law enforcement response to an active shooter, and they saved lives.

It is recommended for the city to update its current policies and training to include multiple critical situations.

Incident Command System Hierarchy and Policy

In its evaluation, Hillard Heintze determined that the VBPD and the city could benefit from having a written policy to specifically address an active assailant response.

The Emergency Operation Center is supposed to provide support, drive resources and coordinate decisions, resources and logistics thorough the situation.

To make the Emergency Operation Center effective, there should be a representative from each public safety department to serve as a liaison and provide real-time communication about the incident.

The Emergency Management Agency Director responded to the center and reported it operational, but staff from other public safety agencies did not respond in a timely manner. Key personnel who staff the center stayed at Building 2.

Virginia Beach Fire Department personnel were the first to respond to the center for support, but they didn't arrive until 6:00 p.m.

VBPD and EMS representatives didn't arrive at the center until 7:00 p.m. The Deputy City Manager was the last to arrive. 

The center remained open until 2:00 a.m. on June 1, 2019, an hour after the last family notification was made, in the aftermath of the shooting. There was a briefing on June 1, 2019 at 8:00 a.m. and the center remained open for 12 days to support the investigation and coordinate any follow-up work.

Building 2 Incident Notification and Evacuation

While some employees fled the building, others hid and tried to help victims who had been shot. Many people were unaware of what was happening until they heard about it from other employees or saw it happening.

Building 2 did not have an intercom system and communication from the City about what to do and what was happening was limited.

One employee pulled the fire alarm to try and warn others about what was happening because they thought it was the best thing to do, but pulling the fire alarm could have put people in harm's way as they tried to leave. Pulling the fire alarm also disables elevators.

Early evacuations were also confusing because employees were led to two different locations. Check-in at the muster location was also not available during the early part of the evacuation and other people besides victims and employees entered. A fully-staffed EOC could have made things easier.

Employees who parked their cars in the Building 2 parking lot couldn't access them and some people left their phones in the building. This left employees without a way to get home or communicate that they were okay.

There was also no employee list for responders to validate who was accounted for and who wasn't.

Evacuation Policies and Practices

All city facilities and departments are required to have evacuation plans While the City's HR Department's Occupational Safety and Health Services is responsible for creating the plan, each department is responsible for training their employees and making them familiar with the plan.

The city did not have a consistent active shooter plan as part of its evacuation planning and focus though.

At least one employee said there were challenges with the evacuation plans not being updated or trained.

Police Incident Command

Overall, the report describes poor communication and a lack of effort to establish a unified command on the part of the Virginia Beach Police Department.

The ECCS was not used to assist in directing resources, there wasn't an efficient chain of command and people didn't follow through on assigned tasks.

For example, the Incident Commander assigned an officer to be his scribe, which is common, but the officer broke off leaving a limited ability to track decisions and information like not knowing which officers were in the building and difficulty establishing coordination.

If the VBPD and VBFD worked under a Unified Command Approach, the VBFD could have helped the police with universal key cards that are located in the Knox Box in the basement of Building 2. A VBPD representative at the Emergency Operations Center would have helped with coordination and taken that burden away from those at the scene.

Post-Event Incident Management

The firm determined that the investigation into the shooting significantly drained the VBPD's investigative resources.

The investigation into the shooting is still going on while officers deal with the "normal" workload and it continues to challenge the department.

The Chesapeake Police Department had to assist the VBPD because they did not have enough investigative staff. Midway into the investigation, the VBPD also hired retired officers to help with the investigation and ease some of the burden.

Managing People and City Services

Immediate Aftermath and Business Continuity

While the Emergency Operations Plan includes an overview of the response and recovery responsibilities of different departments, it does not include protocols or actions following an active-assailant event to an event that directly involves city facilities and employees.

The city also did not have a specific Business Continuity Plan for the City or Building 2 employees.

Recommendations

Hillard Heintze made the following recommendations when it comes to multi-agency coordination command and control:

• Roles and responsibilities should be pre-designated for command members at the Incident Command Post and the Emergency Operations Center. Officers should have a pre-planned assignment and be trained for their roles as well as what should happen if someone is not there to fill their assignment.
• There should be specific guidelines and procedures for the VBPD when it comes to identifying victims in mass-casualty events and how the information should be secured when multiple agencies are involved in the investigation.
• Protocols and procedures for a chain of command need to be refined regarding issues with radio communication and discipline, the allocation of resources, operational issues and other concerns.
• Policies regarding a unified command need to be refined and additional training needs to be provided to emphasize the critical role of police commanders.
• Policies need to be improved to ensure next-of-kin notification happens in a timely and professional manner. Specific and ongoing training needs to be provided to supervisors regarding policies on securing the identities of victims in mass-casualty events.
• A case management system needs to be established to track the Emergency Operations Center and Family Reunification Center process both effectively and efficiently. Protocols should identify a role for a scribe so that records are not only maintained but also reviewed and finalized with the closure of both centers.
• When designing future office spaces, planners should consider best practices when it comes to access to exit doors, secured entry and places to hide in the event of an active assailant.
• Specific training to the different possible active assailant events should be provided and should designate specific assignments and responsibilities for each responder.
• Family Reunification Center protocols should be established to provide set-up support, sign-in logs and private spaces for victims' families.
• Support services should be provided to first responders and investigators to address concerns of post-traumatic stress, fatigue and burnout.
• The Emergency Operations Center plan should be tested and supported with full staff once it is established.

Physical and Technical Security Measures in Building 2

City buildings need to ensure open access for the public, but also a secure work environment for employees.

Workplace violence prevention relies partly on building construction, but most buildings aren't designed with active shooters in mind.

Physical and Technical Security

Since the May 31 shooting at Building 2, all departments have been relocated with the exception of the IT Department.

The work by Planning, Public Utilities and Public Works, which were all located in Building 2, required interaction with the public.

There were exterior doors on all four sides of the building. The North and South entrances were the primary entrances for the public and employees and automatically unlocked from 6 a.m. until 6 p.m. There were two emergency stairwells located near the North and South entrances. The East and West entrances remained locked at all times.

An Access Control System card, which was issued by the city was required to open the East and West doors and all other doors once they were locked after hours, on weekends and on holidays.

There are also basement loading dock doors that unlock on a schedule similar to the North and South entrances and two elevators available for employees and the public that went from the basement to the third floor.

Security officers were not at their assigned posts before the May 31 shooting.

The city does not have a formal written minimum-security standard for city-owned buildings and different department heads are responsible for requesting, planning and funding security improvements.

The doors in Building 2 are equipped with Acess Control System controls, which include magnetitic door-position switches. The switches are designed to detect forced entry or if a door is left propped open.

There are no panic or emergency buttons in Building 2.

Access Control System

All Virginia Beach employees and others with recurring work with the city are given photo ID cars with their names and department when hired. The badges are required to be worn on city property and each employee's supervisor specifies the level of access each employee needs to complete their job functions on the ID request form.

When someone is fired or resigned or when a vendor completes their work with the city, it is the manager's job to get that person's ID card since they no longer need it.

The shooter submitted his resignation with a two-week notice on May 31. His ACS card would not have been deactivated until his last day, which he confirmed was June 14.

The Building also had unrestricted access in public areas due to the public's need to access different departments in the building. Only two departments in Building 2 used ACS to limit public access. Those departments were the IT Department and Public Utilities on the second floor, which is where the shooter worked.

Key and Lock Control

Authorized personnel looking for access require an ACS card instead of hard keys.

The Facilities Management Office, Building Maintenance Division keeps master keys for all keyed doorways and makes keys for departments that request keys to buildings they occupy, but there is no record of how many keys have been made and who has them.

Building 2 also has doors with different lock systems like key-operated locks or push button locks. This could have delayed the response of first responders.

Security Cameras

The city's security technology systems aren't integrated for automatic video display of an active alarm or activity alert. The security cameras on most city buildings are not actively monitored.

If something occurs in an area that is covered by security cameras, those who need to access the footage can review the stored footage after the event.

AS far as Building 2 is concerned, Security Camera footage is limited to the IT Department and the hallway in the basement that leads to the department. There were no cameras on the upper levels.

Fire Line Safety

As mentioned earlier, an employee pulled the fire alarm during the attack. When the alarm was pulled, the Virginia Beach Fire Department was dispatched, but the department was already at the scene and they knew it wasn't a fire.

The ACS controlled doors on the second floor did not release when the alarm was pulled and it's not required for them to release because they do not restrict access to emergency evacuation stairwells. 

The review states that door security is critical to prevent an attacker from getting inside by pulling the fire alarm.

The City's HR Department's Structure and Operational Model

Virginia Beach's HR department is decentralized. Staff within different departments are tasked with HR-related duties but are not trained in HR.

Hillard Heintze could not find any information that the HR Department knew ore received information from employees of any concerns about the shooter's behavior.

The HR department is split into four divisions, but most of the employee HR engagement is done by unit managers and staff, who aren't trained to deal with problem employees.

Hillard Heintze stated that the city's approach is not conducive to employee management. The lack of ongoing, structured and direct engagement with managers and HR liaisons leads to gaps in information.

The HR liaisons perform a lot of the HR duties at the unit level, but in practice, the liaisons rarely interact with the HR Department, they report to unit managers, leading the HR functions to be driven at the unit level without professional HR guidance.

The liaisons are city employees who have other duties and report directly to individual department management, not to HR. In addition, unit managers, not the city's HR Department, are responsible for dealing with employee decisions including disciplinary suspensions.

Due to the structure, the city's HR Department has poor visibility into the progression of an employee's performance and is not engaged to identify early warning signs of possible workplace violence. The lack of visibility prevents the HR Department from identifying strategies to mitigate situations and address behaviors.

This structure also leads to confusion for employees, conflicts of interest for managers and HR liaisons, concerns that there is no resource to assist employees facing challenges with their managers, managers not feeling supported, and HT staff not feeling engaged or able to support the needs of managers and employees.

The City's Policies Related to Workplace Violence Prevention

Recruitment, Hiring and Background Investigations

Hillard Heintze stated that, based on what they were able to examine, the shooter didn't exhibit any apparent issues before the city hired him that would have raised concerns and prompted additional investigation or not to offer him a job.

Recruitment through background investigation is the earliest chance the city has to prevent future violence. The process helps ensure the city is hiring candidates who meet the requirements of a position and well-adjusted individuals who would be a good fit for the city.

Violence prevention programs can also include education from HR professionals and security and legal counsel on cultivating a workplace culture of caring within the organization. When implemented properly, the programs can help promote courtesy, respect and safety in the workplace.

The city's current policy includes a training process for supervisors that covers incorporating behavior-based questions in the interview questions and techniques.

The HR Staffing and Compensation Division and the hiring department or manager coordinate the hiring process so it follows the city's Equal Employment Opportunity policy.

The policy dictates that each person who receives a conditional offer of employment is required to do a background check performed by the Virginia Beach Police Department and that HR personnel must call the candidate's references while the hiring manager verifies the academic history, licenses and certifications.

Code of Conduct

A Code of Conduct provides specific notice to employees of required and acceptable workplace behaviors. The city doesn't have a stand-alone Code of Conduct, it instead relies on different policies and protocols that address employee conduct.

The city has a Code of Ethics, but it's focused on expectations of public integrity more so than conduct or behaviors.

An example where a Code of Conduct would have been helpful in relation to the shooter would be the $3,027.48 payment order. The Finance and Purchasing Department told the shooter that it was a legal violation, but his managers told him that it wasn't a problem and they would handle it. A Code of Conduct would have identified expectations and possible outcomes.

A Code of Conduct is key in ensuring workplace behaviors which is crucial in preventing workplace violence, identifying appropriate standards of conduct and allow consistent, impartial and timely efforts to address prohibited behaviors. It also allows an employer to address inappropriate behaviors with consistent and fair consequences.

Grievances

The attacker felt he was being treated unfairly at work and perceived he was not being treated with the same level of fairness as others with his same job description.

After he received a written reprimand in July 2018, the shooter started the formal grievance process, but after getting to Step 3 he decided to end the grievance and did not appeal it to the Personnel Board.

The grievance policy gives employees the ability to grieve employer actions they believe are unfair or if they believe the employer has not recognized all the facts. This allows for a consistent, documented and impartial process and provides a level of checks and balances over employee responsibility and management authority.

Discipline

The review by Hillard Heintze confirmed that there were no significant disciplinary actions taken against the shooter.

An employer should address concerning behaviors as early as possible, but also discern between prohibited behaviors, like fighting or direct threats, and concerning behaviors, like signs of depression and disruptive behaviors that cause fear.

Early intervention and redirection of concerning behaviors should be the focus of the City HR Department including corrective measures. When employees consistently engage in concerning behaviors then discipline is appropriate, but it should be proportional and equitable to the behavior. This allows for consistent standards in the workplace and keeping other employees safe.

The city's discipline-related policies are well-documented. The process requires that supervisors investigate any complaints and reports before imposing disciplinary action, but supervisors aren't trained to conduct employee investigations. Having untrained supervisors conducting investigations could result in conflicts of interest or bias in an investigation.

Termination of Employment

The shooter didn't have any performance issues that would have resulted in him being fired, but the issue with the $3,027.48 pay order indicated that he was concerned about being fired.

Another employee was fired the day before the shooting and many believed that the fired employee was the shooter. They had concerns that the fired employee could carry out an act of workplace violence and felt the issue wasn't properly addressed by management.

Firing an employee is a form of discipline that requires a more formal practice and approach. It can create a risk factor for difficult employees and can create the potential for violence if an employee isn't well-adjusted.

If an employer is terminating an employee they need to follow legal guidelines, reduce the risk of retaliation, ensure a consistent and humane approach and that the employee understands the actions and reasons for the employee's termination.

Departments are required to consult with the City's HR Department before firing an employee. Once it is decided that the employee will be fired, managers must provide 24 hours written notice to the employee of a pre-disciplinary meeting advising the employee of the termination and why they are being fired. Many employees said that notice is synonymous with termination.

The letter requires the employee to return to their unit manager for a final notice, which could present a contentious situation and increase the risk of workplace violence. 

Full-time employees do have the right to grieve their termination if it's because of misconduct or unsatisfactory work performance.

Managers and supervisors aren't trained to recognize and report individuals who exhibit concerning behavior as early as possible or before taking disciplinary action against the employee and there is no formal process for making and handling requests for police or other security for a meeting with a concerning employee.

Substance Abuse, Drug Screening and Testing

While there was no evidence that the shooter had a substance abuse problem, these policies are important given the effect of substances on behaviors.

The city's policy is focused on the health, safety and well-being of employees. The policy determines when employees should be screened and there is a process for determining reasonable suspicion.

Employees do need to disclose if they're using a prescription medication that could impair their work ability, but they do not need to disclose the medication or why they are taking it. The city also encourages voluntary engagement with the Employee Assistance Program.

Workplace Harassment

Hillard Heintz did not find any evidence that the shooter was engaged in or the victim of workplace harassment.

The city does have a workplace harassment policy that prohibits harassment based on someone's sex, race, color, religion, national origin, disability, age, pregnancy or childbirth, genetics, military status, sexual orientation or gender identity. It also prohibits discrimination and harassment in all interactions with citizens, vendors, contractors, clients and customers.

The policy is in best practice with the private and public sectors and promptly investigates complaints of unlawful discrimination and harassment. 

Complaints are made to HR liaisons who do not work for the city's HR Department and are not trained to identify harassment behaviors.

Employee Assistance

There is no record that the shooter used the Employee Assistance Program following his divorce nor was he referred to the EAP by a manager.

There isn't evidence that this would have made a difference in the shooting, but EAP personnel have expertise in handling the emotional, psychological and financial challenges of a divorce.

An EAP is an important component in a workplace violence prevention program. Not only can it be an effective first step in disrupting any inappropriate workplace behaviors and a pathway to violence, but it also provides unbiased advocacy and support for employees and a valuable resource for managers and supervisors.

EAP counselors do have a duty to warn in case of threats made by employees, but they are not trained in behavioral threat assessment.

Privacy and Information Sharing

There wasn't evidence that sharing private information was a factor in the shooting, but there was evidence that other people knew about work issues the shooter was having.

Some employees said there was a lack of concern for privacy and confidentiality with regard to HR issues. Many coworkers were aware of work issues that the City HR Department was perceived as not successful in addressing.

Discretion and confidentiality are paramount in maintaining a civil work environment. Managers' actions must be unbiased, impartial and appropriate in dealing with employee's behaviors. And allowing rumors to spread around the office is inconsistent with food workplace practice and can contribute to an unhealthy work environment.

Policies should be clear that reporting concerning behaviors is not an invasion of privacy.

The city does not have a comprehensive policy for addressing employee information, privacy and disclosure. It needs to provide clear guidance through policies, protocols and processes for recognizing and reporting issues regarding concerning behavior to ensure no gaps or omissions in addressing employee issues.

Criminal and Administrative Charges and Convictions

A background check of the shooter did not show any criminal activity that would have prevented him from working for the city.

Criminal behavior can be an indicator of workplace violence. Employees should advise their employer of any ongoing criminal offenses and advise their employer about the charge and if they are detained. Employees should also notify their supervisor after they are released.

City policy requires all full-time and part-time employees, volunteers and temporary service employees to uphold the highest standards of conduct and follow the law to ensure public trust.

If an employee is arrested, the City HR Department convenes a Charge and Conviction Panel to review all misdemeanor and felony charges and then makes a recommendation for suspension, restriction on service delivery or termination of employment.

Requiring employees to self-report criminal charges is a standard in policy, but it does present an overreliance on the employee's integrity. Reporting to a direct manager is also challenging in a work environment that doesn't prioritize employees' privacy and discretion.

Resignation of Employment

The shooter resigned voluntarily on May 31 and told his manager that his last day would be on June 14.

A resignation policy allows employers to have visibility as to why the employee is leaving and to help ensure security with sensitive work documents, access to facilities and a timely resolution to any gaps in service.

Employees are required to submit a written resignation with the date and time that the resignation will be effective and to submit a signed copy to the HR Department.

Resignation can sometimes be a risk factor for workplace violence and managers and supervisors need to be trained to recognize and report andy warning signs.

Workplace Violence Prevention

The shooter did not display any risk factors that would have suggested he was going to commit an act of workplace violence, but employees have not been trained to identify warning signs and there was no program in place to report concerning behaviors.

The city appears to define workplace violence as someone with a gun or weapon physically harming another employee, but there are more levels of workplace violence.

Being disrespectful and rude is concerning and could escalate to mild bullying, which is an early warning sign. That could then escalate to angry outbursts and stalking and domestic violence all before a targeted attack on the workplace.

If those issues are addressed early enough then the situation can de-escalate.

The current policy in place was established in July 2001 and hasn't been updated since. It addresses prohibited behaviors like direct threats and physical harm but puts the responsibility on all employees to report potential violations to the policy and the existence of protective orders.

The policy does not refer to warning signs and employees aren't trained to identify any warning signs. Instead of taking a proactive approach, it focuses on waiting for threatening behaviors to manifest.

The policy directs supervisors to investigate any suspected workplace violence, take disciplinary action and notify the City's HR Department, but it doesn't say when the supervisor should notify HR.

This is a vulnerability for managers, especially those who aren't trained in detecting workplace violence.

Zero Tolerance

The city lists prohibited behaviors in its workplace prevention policy that it considers unacceptable and subject to disciplinary action, but it doesn't contain all actions that would be deemed concerning nor does it identify whether the behavior is prohibited only if it's at the workplace or nearby.

The city should not only define prohibited behaviors but also focus on reporting and managing behaviors and situations of concern.

Without a process in place to handle low-risk, concerning behaviors, it could contribute to untreated mental health issues.

Weapons

The shooter left the building, got guns from his car and went back into the building where he proceeded with his attack. 

The city has a policy of no weapons in the workplace to prevent attacks like this, but employees argued that if they were allowed to have weapons, they could have prevented the harm done in the attack.

Policies should identify expectations of privacy and highlight areas subject to search for weapons in the event of a report that an employee might have weapons in the workplace. Policies should also consider the breadth of restrictions, if there is a weapons ban, and ensure that employees are trained on how to report knowledge of a coworker having a gun at work.

The city has a zero-tolerance policy for weapons at work, while acting as a representative for the city, in a city-insured car, or on city property. There are two exceptions and they are if the possession or use of a weapon is a condition of the employee's job, providing a city service, or has been authorized by a supervisor or if a lawfully owned gun is kept in a locked, private car while on city property.

The policy goes on to state that anyone who knows or has a reason to believe someone is violating the policy should immediately report to the supervisor.

Visitor Management

The shooter was an employee of Building 2 and had free access to the secured employee floors so the visitor management policy was not an issue.

The building was used by the public so the main entrances were unlocked during business hours. There was no formal reception area or security desk on the main floor. People could enter freely and do not have to show ID or a building access pass until they reached an employee-only area which would require the use of an access card, which turned out to be an issue for police response.

The city should consider taking more physical security measures in buildings that are open to the public like a security desk, sign-in sheets and/or a do-not-admit list.

Meeting with Difficult Employees

The shooter never filed a formal workplace grievance, but his managers and supervisors were aware of his feelings of unfair treatment through his performance evaluations, the grievance process and emails related to the grievance process and performance evaluation on his view that the work reprimand was not fair.

Conflict management is key for supervisors and managers and so is knowing when and how to engage an employee or report a concern.

There is no clear policy or guidance in place for engaging or conducting meetings with difficult employees nor does the city provide managers with training in this area.

The city has an open-door policy, which is a best practice in most situations and can help ensure the success of a workplace violence prevention program. Bit, the city's policy places a burden on employees who must contact every level of supervision in their chain of command when using the open-door policy, furthermore, it's already been stated that employees don't feel as though the city values privacy and discretion in the workplace. Any policies should ensure employees that they won't face retaliation when it comes to reporting a concern.

Termination/Separation Checklist

The shooter submitted his resignation via email on the day of the attack via email and management responded, but didn't take any other formal action that day.

The use of a checklist is key in a successful workplace violence prevention program, especially on the employee's last day.

A checklist would help provide consistency which would improve security over property and documents, employee wellness and appropriate management actions.

The City HR Department should continue to handle resignations and terminations and managers should share any information about a resignation in a timely manner.

Need to Establish Workplace Violence Prevention Programs

The City of Virginia Beach's investment in workplace violence prevention before the May 31 attack and now is limited to its violence prevention policy. There are no established workplace violence prevention programs.

Hillard Heintze outlined key elements the city needs to incorporate to establish a successful workplace violence prevention program.

Leadership: The Importance of Championing Workplace Violence Prevention

The city has a violence prevention policy but has not actively focused on workplace violence prevention as a component in addressing the risks to personnel and operations.

Under an effective program, city leaders are vocal champions for workplace violence prevention and management can communicate goals and objectives clearly and often by acknowledging risks of workplace violence and demonstrating their commitment to building a foundation of consistent reporting, risk assessment and program development.

While city leaders aren't directly involved in the day-to-day operations of workplace violence prevention, they need to provide leadership that makes it clear to everyone that they're committed to safe workplaces.

Behavioral Threat Assessment: The Capability to Identify, Assess and Manage Risk

Behavioral threat assessment is the process of collecting and analyzing relevant information about someone who poses a threat to the organization's staff or assets.

Research into workplace violence shows that the person usually displays warning signs or attack-related behaviors as they plan or prepare for an attack.

The City of Virginia Beach is currently limited in this with its decentralized HR Department as the department is not actively engaged in managing employee performance issues.

While the shooter's reported behaviors would not have risen to a formal review, there was another employee who demonstrated a significant threat to the workplace.

That employee said, shortly before the shooting that it would not be surprising if "someone came in and shot the place up."

Many employees felt that management's response to this was inadequate.

That employee was fired on May 30 and many people originally believed he was the shooter on May 31.

This incident is an indicator of managing risk in the workplace for long-term safety, workplace health, employee confidence in management and the ability to redirect inappropriate behaviors.

Threat AssessmentTeams: A Critical Component of the Behavioral Threat Analysis

There is no single entity in the city responsible for tracking and analyzing employee behavior holistically and as a matter of workplace violence prevention resulting in a significant gap in the workplace violence prevention capabilities.

The city needs to establish an interdisciplinary team to identify, assess and manage potentially concerning behaviors to help address escalating behaviors and prevent a future incident.

The Threat Assessment Team should have formal documentation that includes team processes, structure, meetings and recordkeeping guidelines.

A combination of investigative skill and multi-disciplinary collaboration with a systematic approach can help gather the evidence and information necessary to make a comprehensive assessment of the threat someone may pose to the organization and help develop an informed mitigation strategy.

Because of the Virginia Tech shooting, Virginia Law states that each public institution of higher education can establish policies and procedures to prevent violence on campus including assessment and intervention of individuals whose behavior poses a threat to the safety of the campus community. This law provides the opportunity for the city to develop a team that can readily address workplace violence concerns.

The team could include representatives from HR, legal and facilities, a manager with knowledge of the situation, and the department's HR liaison. Other members could be added to include senior leadership. EAP Personnel, threat assessment experts 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 and each would bring a different perspective that allows an informed, holistic response to potential workplace violence risks.

Complaint Categorization: The Need for a Central, Standardized System

There is no centralized database for interactions involving city employees and this vulnerability is further exacerbated by a decentralized HR process.

A centralized system that helps track information and complaints in a consistent, standardized manner across all departments within an organization can facilitate early intervention and help prevent any escalation of violence.

A documented case file with base-line behavior information helps identify any escalation behaviors and successful de-escalation practices.

CATEGORIZATION

There isn't a system to trace warning behaviors or actions taken in support of workplace violence prevention. Furthermore, the City's HR Department does not ensure consistent identification and reporting of HR matters using categorization codes.

Employee behaviors span a range of actions and little is done to ensure consistent identification of the issues and a consistent response and appropriate outcome.

The following categories are suggested when conducting an assessment that may pose a threat to the workplace:

• Inappropriate Behaviors or Communications: this involves intimidating words or gestures, harassment, emotional distress, confrontation, phone harassment, obscene phone calls, stalking, verbal abuse and any other actions that make someone fear for their safety.
• Domestic Violence: this includes incidents involving individuals who have or have has an intimate relationship that has become hostile or volatile.
• Physical Violence: this includes any physical contact resulting in minor or serious injuries including induced fear and apprehension of physical threat or harm to another person.

INVESTIGATIVE SUBJECTS: THREE TYPES

The program should include various categories of people who may pose a threat to the workplace

• Employee or Contractor: a current or former city employee or one of its contracted service providers.
• Resident with Domestic Situation: someone with a personal relationship with a targeted employee that does not have an established relationship with the workplace.
• Visitor or Resident Seeking City Services or Information: someone who is not an employee and is seeking a city-provided service or information or has another reason to be on the premises.

TRACKING

The city has various employee record-keeping systems for documenting HR activity, but they are incomplete, stand-alone and often focus on risk rather than risk prevention.

The system does not document or track behaviors of concern unrelated to discipline, including knowledge of personal crises and behavioral warning signs, like those treated for mental illness.

Most employee interaction, including discipline, is maintained within individual departments. These records are paper-based and kept in file cabinets. Some managers, HR liaisons and HR Department staff keep notes on paper or on their computers and may not be entered into the official HR records.

No one is assigned to record-keeping duties which can make creating a comprehensive employee file challenging.

The city needs to aggregate its data and be more efficient with record-keeping.

The City HR Department should be involved in the early stages of discipline to ensure consistency in the review of employee behaviors across the city.

A consistent record-keeping practice would assist in creating a database that HR employees and HR liaisons can access before interacting with employees.

TRAINING AND EDUCATION

The city does not train employees to identify concerning behaviors and information that can help prevent an act of workplace violence.

Training employees at all levels is vital to implementing and sustaining an effective workplace violence prevention program. 

Employees should also be educated to understand that the primary goal of the program is to enhance safety not discipline, arrest or punish individuals.

The training should be instructed by expert researchers and practitioners on the background and fundamentals of threat assessment with a key focus on four critical functions:

• Identify those who pose a threat
• Investigate and uncover all facts surrounding those who pose a threat
• Assessment of facts to determine whether the threat is valid
• Management of those who are assessed as possibly posing a risk

Training should be customized for different groups. The general workforce, managers and supervisors and the internal threat assessment team should have different training.

Survey Conducted of City of Virginia Beach Stakeholders

Several different stakeholders for the City of Virginia Beach were surveyed to gain insight into the city and the events of the May 31 shooting.

Building 2 employees were surveyed to gain insight into workplace issues and the opportunity to provide their opinions, comments and concerns to the Hillard Heintze team.

Some of the questions addressed workplace violence issues.

Twenty-one percent of respondents said that managers have engaged them with how to address workplace violence and 29% said they felt prepared to handle a threat or threatening situation, but 66% said they didn't know the process for reporting concerning situations, incidents or threats.

Less than 20% of respondents said they were informed of their department or unit's violence prevention policy for handling potentially violent situations while 34% of respondents said that prior to the May 31 shooting the city had clear policies and practices concerning workplace violence.

Only 17% of respondents knew about the standard procedures in place to identify, evaluate and inform workers about specific high-risk clients, situations or locations.

Nearly 90% of respondents agreed that employees should have training on workplace violence prevention while 3% disagreed and 8% didn't have an opinion.

Twenty-two percent of respondents reported that they were trained to engage with hostile or poorly performing employees, and 20% reported being trained on workplace violence prevention.

In regards to being treated with dignity and respect from other employees, 77.5% agreed, 9.5% disagreed and 13% were neutral.

As far as being treated by respect from managers, 68% agreed, 21% disagreed and 11% were neutral.

More than half of respondents, 55%, said city managers and executives treated them with dignity and respect, but 25% disagreed and 20% were neutral.

Fifty-five percent of respondents said they believed their manager would act in a timely and appropriate manner when reports of workplace violence were made and 20% disagreed, but only 42% believed city executives would react in a timely and appropriate matter while 40% disagreed with that statement.

Most respondents, 71%, said they were comfortable reporting situations, incidents or threats of violence to their manager, but only 48% said they were comfortable reporting the same situations to the City HR Department.

When asked about how secure they felt in the workplace 55% of respondents said they did most of the time, but that number increased to 71% when they were asked how secure they felt at work before May 31, 2019.

The two most common concerns raised were a lack of physical security to prevent unauthorized access to non-public office areas and the lack of secure infrastructure to protect them from an active assailant.

A majority of the respondents from the Engineering department felt secure in their workplace before May 31, 2019.

Almost 74% of respondents who identified as supervisors said they were not trained in workplace violence prevention and over 55% have not been trained to monitor or regulate the activity of others, 68% said they weren't trained to engage with hostile or poorly performing employees and almost 82% said there were no procedures in place regarding high-risk clients, situations or locations.

While nearly 78% of respondents who identified as supervisors said they were able to effectively engage with their employees since May 31, 2019, but 74% said that they hadn't received any additional support in helping to manage employee issues since the shooting. However, 60% of these respondents said management provided additional support to address work challenges since the date of the attack.

Due to an overwhelming outcry of a toxic work environment and retaliation against any employees that spoke out, Hillard Heintze contracted People Element to perform a completely independent survey.

The independent survey found that in the areas of value and ethics, communication, training and development, work environment, recognition and leadership all decreased in overall satisfaction.

The areas of lowest perception were leadership and recognition.

One of the most common concerns for employees was trust and whether or not the City's HR Department and others were capable of acting quickly and effectively to any internal workplace concerns.

Many employees referred to "toxicity" in the workplace, unfavorable treatment regarding policy and practices and their interpretation by various government offices and whether individual and inter-office issues were being handled properly.

Many employees reported that guidance provided from HR liaisons was inconsistent and depended on the person consulted and the issue at hand among other factors. There were also reports of confusion when it came to HR and many people believed the current reporting structures are unhelpful.

Other Issues Outside the Scope of Review

There were other issues raised at public meetings that fell outside the scope of the review.

Those included:

• Mistreatment and bullying, retaliation and humiliation by supervisors, managers and department leadership.
• A toxic work environment.
• Mistrust of city leadership, most notably the former city manager.
• 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 on ombudsman, empowered with addressing, investigating, mediating and resolving employee issues.
• Concern that the City HR Department was disconnected from what was occurring in divisions.
• Mistrust in the findings and confidentiality of the city's findings in surveys, data collection and confidential employee files.
• Concerns regarding the city survey findings being linked back to their unique ID/work emails and retaliation potentially occurring based on honest feedback provided.
• Concerns about racism and the lack of hiring and promotion opportunities afforded to employees.

These issues were not raised to the same level in surveys of employees as they were in public meetings.

Recommendations

Hillard Heintze made the following recommendations for the city when it comes to workplace violence prevention:

• The city should set up a specific department with qualified staff that is responsible for physical and technical security for City facilities. 
• Develop minimum security technology standards for all buildings and departments that should address security camera coverage.
• Develop a 24-hour monitoring capability for the integrated security technology platform.
• Mark all access control locations and doorways with information reflected in the monitoring platform so first responders can request the release of specific floors while leaving other doors locked to constrict and retain a shooter.
• Integrate security technology systems to improve the overall level of security for city-operated facilities.
• Develop Knox Box go-bags for each City Building and ensure all first responders are aware of them and have access to them.
• Improve controls over the keys in distribution.
• Replace magnetic locks with electric strikes or electric lock sets that are not required to open during a power failure or fire alarm activation.
• Incorporate panic or emergency alert buttons.
• Develop strategies to improve employee and citizen enrollment in emergency alert platforms.
• Apply an all-hazards approach to emergency mass notification messaging
• Establish policies and protocols for when departments believe there is a concern regarding any actions or meeting with an employee.
• Restructure the HR Department to achieve a centralized approach to HR functions.
• Establish consistent standards for hiring and train all hiring managers and persons with responsibility for hiring on these standards.
• Ensure the City government leaders champion and support the violence prevention program.
• Establish a Code of Conduct or Employee Handbook that identifies for all personnel the organization's behavioral expectations in the workplace.
• 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 to provide distance between the employee's original workplace and colleagues.
• Restructure how the City HR Department addresses negative performance by an employee.
• Include HR in every case involving disciplinary action with an employee.
• Enhance applicable policies and protocols to address validation of references, licenses, certifications and requirements independent of the HR review.
• Develop an employee manual for employee investigations with consistent standards for all city units.
• Establish a centralized database with access controls determined by and under the authority of the City HR Department.
• Establish an Interdisciplinary Threat Assessment Team to handle behavioral assessment and management.
• Develop a widespread campaign throughout the organization emphasizing the EAP referrals can compassionate, are always confidential and will not jeopardize an employee's career or job status.
• Have the City HR Department and management work with the Legal Department to clarify privacy expectations and identify how privacy rules can be applied to the City's work environment.
• Assign HR the responsibility for the workplace violence prevention program and designate an Employee Relations Manager as the Threat Assessment Team Leader.
• Modify the City's HR policies to incorporate a more caring tone to encourage employees to report concerns.
• Revise policies to require the reporting of protection orders that include the workplace to ensure the implementation of appropriate security protocols.
• Establish a centralized system and process to examine all potential sources of information about employee misconduct and inappropriate workplace behaviors.
• Implement an awareness campaign on issues affecting employees like substance abuse, domestic violence and workplace harassment that provides focus on support offered by the city and information on seeking help.
• Give HR the responsibility to investigate reported or suspected violations and concerns related to violence
• Ensure HR professionals and departmental managers collaborate to provide the opportunity for privacy on sensitive issues to reduce internal gossip and facilitate information-sharing between departments and HR.
• Establish a team comprised of legal counsel, HR and law enforcement personnel to develop a plan for information sharing with exception to public safety.
• Establish enhanced information sharing with the Employee Assistance Program through policies and procedures to facilitate formal reports when threats of violence are indicated.
• Develop a centralized system for tracking potential workplace violence incidents.
• Require that HR is notified and can review the discipline of any employee that results in time off.
• Ensure that all employees are made aware of the workplace violence prevention policy through training and have a basic understanding of violence prevention basics and warning signs.
• Implement workplace violence prevention training for managers and supervisors that focuses on understanding early warning behaviors and working with the HR Department to manage difficult employees.

Hillard Heintze's full report can be read below.

The executive summary to the full report can be read below.