Inquest into the Death of Norman Leslie BALE

Contributing factors

• unseaworthy vessel with broken welds and structural defects
• defective outboard motor jammed in forward gear
• refusal to wear approved life jacket despite regulatory requirement
• lack of safety equipment (no EPIRB, flares, radio, or personal floatation devices)
• overloaded dinghy sitting low in water with poor stability
• rough weather conditions with 14+ knot winds and 2.5-metre seas
• travelling alone at night without informing authorities of destination
• deteriorating health (rheumatoid arthritis affecting balance and strength)
• previous hand injury compromising grip and motor control
• vessel operator standing at stern without proper seat, at risk of falling overboard
• impulsive and overconfident personality with history of reckless boating practices

Coroner's recommendations

1. Emphasis on compliance with Navigable Waters Regulations requiring approved life jackets and safety equipment for vessels operating outside protected waters
2. Promotion of wearing life jackets at all times when navigating unprotected waters, particularly for solo operators of vessels under 4.8 metres
3. Encouragement of boating operators to inform friends, family, and local volunteer marine rescue groups of intended destination and expected return time before departure
4. Consideration of compulsory wearing of life jackets in certain high-risk circumstances such as navigation in unprotected waters, open areas, alone, or at night
5. Review of safety equipment requirements for recreational vessels in Western Australia to be conducted by Department of Transport