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

Hillard Heintze released a 262-page report on the results of its investigation into the Virginia Beach mass shooting. 13News Now took a closer look at that report.

Amanda Johncola

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On May 31, 2019, 12 people were shot and killed and four more were injured after a lone gunman opened fire in Building 2 of the Municipal Center.

After push back from the victim's families, delegates and others city council began to discuss an independent investigation into the shooting.

On July 2, Virginia Beach city council approved a resolution for an independent investigation into the shooting and by July 17, Hillard Heintz was chosen from 15 other firms to conduct the investigation.

Hillard Heintz sent an 11 person team to look into the mass shooting. The investigation began on July 22.

The following information comes from the full report released by Hillard Heintz on November 13, 2019.

What the team set out to do:

The Hillard Heintz team set out to understand what happened in Building 2 of the municipal center on May 31 and why. This included creating a timeline leading up to the shooting highlighting the shooter's work history and interactions.

The team also set out to "review city policies, procedures and practices around facility security, prevention of workplace violence and alerting employees and responding to active shooter notifications" among other things and offer recommendations for improvement.

The team was hoping to identify anything that might have helped prevent the tragedy or "mitigate its consequences."

The final goal the team set was to "recommend strategies, tactics and countermeasures that the City needs to implement" to ensure that nothing like this happens again.

What the team did:

The team's review of the shooting included a continuous on-site presence from July 22 through November 4. During this time, the team interviewed people involved, made observations and looked over the evidence.

The team talked directly to employees and community members through interviews, group discussions and public forums to ensure everyone affected by the tragedy had a voice in the process.

The point of the listening sessions and forums was to explore the community's concerns and use that feedback in the review and final report. The team processed 187 emails and 85 calls from the public as well as conducted more than 230 interviews with witnesses, city employees, family members of the victims and the shooter, responding officers and supervisors.

Investigators met with 10 of the 12 victims' families and reached out through liaisons provided by the city and Catholic Charity to schedule interviews with the other two families to ensure everyone's voices were heard.

Other city and county employees like representatives from the City's HR Department, Virginia Beach Police Department, City Auditor's Office, Magistrate's Office, Virginia Beach Fire Department, Office of Emergency Management, Virginia Beach Emergency Medical Services and Facilities Management Office were also included in the review.

There were also two surveys conducted. One was for the entire workforce and the other was specifically for Building 2 employees.

The investigators did a walk-through of Building 2 and the entire municipal campus.

The Hillard Heintz team also created a timeline on the police response with 911 calls and Virginia Beach Police Department and Emergency Medical Services radio dispatch recordings related to the attack.

The team was able to review and analyze "policies, crime reports, evidence, data and electronic records" related to the shooting. This included 335,000 emails and 6,500 documents that came primarily from the shooter's "work-related electronics and personal data that was provided."

Social media sites and public records for information relating to the shooter and his motives were searched and reviewed.

Investigators were able to perform a "retrospective threat assessment" using the data they collected throughout the investigation.

Key findings:

The independent investigation uncovered six key findings identified by the Hillard Heintz team.

City employees and first responders acted courageously

The first key finding was that the City of Virginia Beach employees, police and first responders were courageous in a life-threatening situation. Their actions prevented more casualties.

The report said that city employees in Building 2 acted heroically placing themselves in danger to save their coworkers. It also said that the Virginia Beach Police Department worked quickly and effectively following best practices and professional tactics to isolate the shooter and take him into custody before he died from injuries.

Virginia Beach firefighters and emergency medical crews who responded were able to take those who were hurt to treatment and others to safety as well as protect everyone who was traumatized. 

No warning signs

According to the full report, the attacker didn't show any warning signs or prohibited behaviors that would have given the City of Virginia Beach a chance to intervene ahead of the shooting on May 31.

Before the attack, the shooter's actions, behaviors and communications didn't include and pre-incident risk factors that are signs of workplace violence. 

The review by Hillard-Heintze did show personal risk factors that went unnoticed before the shooting, but those risk factors weren't elevated to the point that they would have warranted intervention nor do they provide a definitive motive for the attack.

The shooter never talked about any violent intentions he may have had with anyone before the tragedy. He didn't seem preoccupied with violence or reveal any violent thoughts or fantasies, but he may have been interested in other mass-casualty and active shooter events. 

He did buy multiple guns over the past three years and bought a suppressor and body armor before the shooting. He also reviewed maps of Building 2 and used his ID card to access other parts of the building than where he worked. The city did not know this before the attack.

The shooter didn't have a known history of mental health care and treatment.

He also did not leave a detailed plan or manifesto about his intent of the attack.

In the two years leading up to the shooting, he did receive feedback from his supervisors about deficiencies in his job performance. In the days before the attack, he found out about another, potentially significant, mistake in his work that could have caused increased stress that may have been made worse by insomnia.

He was described as reserved, socially withdrawn and didn't really show emotion, but no one described him as aggressive or violent. The coworkers that were interviewed did not think the shooter posed a threat or would commit a violent act.

Improving the city's workplace violence prevention programs and policies

City leaders, managers and employees didn't fully embrace the requirement of the policy against workplace violence before May 31. The city's commitment to workplace violence prevention was restricted to its policy and civilian response to active-shooter training. The city's active-shooter training is a voluntary program with limited availability.

The Hillard-Heintze team said the city needs to formulate a clear policy that gives guidance to supervisors, managers and employees including how, what and when to report any behavior that seems suspicious, what to do when someone violates the policy, handling domestic violence matters at work and include intervention strategies and resources for those who are struggling.

The city also needs to create a mandatory workplace violence prevention training.

It should focus on education about the issues surrounding workplace violence and what to do if there is an active threat. Managers and supervisors should also be trained to identify early-warning behaviors.

All employees should be trained in violence prevention basics, how to recognize early warning signs and understanding the importance of reporting. Employees should also be trained routinely in what to do for different events.

The city's HR department needs to be involved in the management of difficult employees. The HR department needs to play a vital role in leadership and provide intervention assistance and ongoing training.

A Threat Assessment Team would improve the city's ability to identify and prevent workplace violence.

The team should include members from Human Resources, Legal Counsel and Security. Its duty would be to collect and review information about people who may be a threat. The tea, would establish, document and follow a formal process when investigating possible threats.

Restructuring the city's HR department

There should be unit-level HR liaisons that are trained in HR resources and have the experience needed. These liaisons should have the support of the city's HR department.

The city should also create a centralized database of all employee performance and workplace issues.

In addition, employees need to be aware of the resources available to them through the city's Employee Assistance Program.

A Public Advocate's Office should be created to give employees an independent channel to voice concerns about issues at work.

Improving the city's critical incident response protocols

The city does have a mass-notification system, but it's voluntary and its enrollment did not give Emergency Communications and Citizen Services confidence to use it on May 31.

This system could have provided timely information during the attack.

The city has invested in Incident Command System training, which helped first responders with the attack, but not all first responders followed the training.

The city's main communications center roles were not clearly established. While Emergency Communications has been updated, it still relies on response protocols from when it was managed by the police department.

There should be guidelines and requirements for emergency communications and response to different situations.

Training for different responses should include post-event issues.

Improvements to physical and technical security

The city needs to develop a plan for security including a formal minimum-security standard for all city-owned and operated buildings. Department heads should not be responsible for requesting, planning and funding security improvement because they do not have the expertise for it.

First responders did not have access to all areas of Building 2. They should have had access through a master access card or Emergency Communications should have had remote control of the doors to assist the police.

The security cameras are also not actively monitored and most of the security control systems are not integrated for automatic video display of an active alarm or system activity alert.

The security cameras in Building 2 were limited to IT and did not capture any part of the attack.