Overview of the findings and recommendations of the April 16 tragedy internal review committees
August 22, 2007
On May 9, 2007, Virginia Tech President Charles Steger directed three internal reviews in the wake of the April 16 tragedy on the Virginia Tech campus. He directed the chairs "to look at strengths and weaknesses of our existing systems/infrastructure and how they may be improved or augmented to address emergency situations that might arise in the future."
These reviews are internal in structure and focus and not intended to be forensic in nature. Says Steger, "I asked for the creation of two different, but concurrent review processes. The external review commissioned by Governor Kaine is essentially investigatory in nature, while ours is a forward looking review of university policy, resources, and infrastructure through the prism of April 16."
The Security Infrastructure Group was charged with examining the university’s existing security systems and recommending changes that would enhance the university’s ability to respond quickly and effectively in situations where the safety of the campus community is jeopardized. This group was also directed to identify strategies that might decrease the probability of such situations occurring, looking at both technological and behavioral aspects.
The Information and Communications Infrastructure Group analyzed and inventoried the communication infrastructure and information systems used during the crisis period, evaluated their performance, and identifies tactics and strategies for improvements.
The Interface Group evaluated the relationships between the university’s student counseling services, academic affairs, judicial affairs, and the legal system. It was charged with examining the existing systems and the interface between them and determining what constraints, legal or otherwise, hamper effective interactions in order to respond to and support at-risk students.
Security Infrastructure Group
Among its findings the security infrastructure group found good cooperation and sound agreements between Virginia Tech and local police, fire, and EMS jurisdictions including ongoing training exercises; sound emergency communications; robust communications infrastructure; a sound emergency preparedness plan; engagement of the leadership in campus emergencies; and a nationally accredited campus police department.
The security group recommends enhancements in physical infrastructure, emergency communications, emergency preparedness, and selected protocols.
Infrastructure recommendations include modification of building door hardware, installation of locks on general assignment classrooms, evaluating the utility of centrally controlled electronic key card access to key academic and administrative facilities (such as the system currently in place on all residence halls), constructing a public safety building combining the university police and rescue squad, and evaluating installation of centrally monitored video surveillance cameras.
Communications recommendations include mass notification techniques within classrooms and other locations, message board in key or high profile public areas and along major vehicular thoroughfares, a people locator system, and further articulation of the recently adopted VT Alerts notification system.
Emergency preparedness recommendations include updating the emergency preparedness plan, more frequent emergency exercises or drills, creation of building coordinators for emergencies, and identification of backups for the policy committee (university leadership with oversight of an emergency).
Protocols include increased education of the university community about appropriate emergency response actions and creation of a comprehensive security master plan and campus security committee.
Read the full Security Infrastructure Group report (PDF; requires Acrobat Reader 7.0 or higher)
Information and Communications Infrastructure Group
Broadly defined, telecommunications comprises the university’s data network, telephone systems (university and/or vendor owned), cable TV, educational systems, and centralized information services. They were dramatically stressed but performed adequately during the crisis. The university on-campus phone system was not degraded but was affected by external problems. External cellular telephone systems and the Public Switched Telephone Network (hardwire telephone systems off campus) experienced huge demand increases and experienced some blocking of calls during the initial periods of the crisis on April 16.
Other university systems experienced some loading, which were quickly identified and rectified, and performed well with no significant problems. For example, the university website www.vt.edu saw a 3,000 percent increase in traffic on April 16, Virginia Tech Police dispatch experienced 450 percent increase, and the university switchboard experienced a 300 percent increase in calls.
Emergency Responder Radio Communication continues to suffer nationally and locally from “interoperability” issues because they use a variety of radio systems and frequencies. Radio systems typically do not support mobile data, encryption, GIS, or other advanced capabilities. Indicative of relatively common signal penetration problems in large buildings, emergency responders reported that radios did not work in some areas of Norris Hall.
This group provides a series of strategic and tactical recommendations. The full report details more than 120 tactical recommendations. Two major strategies emerge:
- Installation of a new fully integrated digital campus architecture for all telecommunications functions based on Internet Protocol (IP). The new system, based on a diverse optical core and including wireless and wired access, would fully integrate all telecommunications functions including voice, video, data, entertainment, and educational systems. This system could remediate every problem and enable every innovation identified by the study committee.
- Make selected research and administrative IT capabilities available to local first responders to improve radio communications capabilities. In addition to improving interoperability problems, the new systems would be integrated with IP based information architecture allowing new applications such as GIS, identity management, sensor networks, location awareness, high-speed links to criminal information databases.
Read the full Information and Communications Infrastructure Group report (PDF; requires Acrobat Reader 7.0 or higher) ››
The Interface Group looked at policies, procedures, capabilities and interdepartmental relationships and communications for the selected areas related to identifying and supporting at-risk students. By its nature the system was found to be logically connected and responsive. The Division of Student Affairs is at the core and supported by and interacting with law enforcement, the academic enterprise, and other university resources offices.
Consistent with the national findings of the federal report commissioned by President Bush, the Interface Group found some confusion about applicability and interpretation of privacy laws among some offices or faculty. To some extent, this created internal silos and feedback problems preventing some offices from having salient information on students at risk. The "system may not be robust enough to provide the kind of analysis that is warranted by more complex, high risk cases… with need for significant mental health services."
The committee makes a series of recommendations under three broad themes:
Expanding Capacity in the System
- Refining and expanding the Care Team, a key SA group that identifies and responds to students at risk (among other responsibilities), including addition of VTPD to standing membership and connecting academic personnel to deliberations where appropriate.
- Creating a Threat Assessment Team charged with examining the most complex cases of distressed students and empowering it to act quickly, when necessary.
- Expanding Case Management Capacity by adding case managers to the Dean of Students office and Cook Counseling Center to improve follow-up with students and to improve information flow through appropriate units about students at risk.
Improving Communications in the System
- Improve Communications in the Systems with particular emphasis on privacy law education throughout the university, clarifying policies for communications with external agencies, establishing a central university contact with a clear picture of distressed students.
Connecting Strategies for Identifying and Supporting at Risk Students to the Broader University Plan for Campus Safety
- Expanding Training of Administrators, Faculty, and Staff in Violence Prevention recognizing the campus safety is the province of all university employees to some extent.
- Extending the University-wide Violence Prevention Policy to integrate the numerous university-wide efforts to enhance campus safety.
- Building Community to Promote Individual and Community Well Being Virginia Tech has a strong, supportive, and vibrant community which is essential in creating a safe campus environment with very good policies and support systems. However, it is recommended that a more systematic approach be instituted with campus well-being as a goal.
Read the full Interface Group report (PDF; requires Acrobat Reader 7.0 or higher)
Read the formal statements regarding the reports: