Gordon Moffat, from Buckhaven, in Fife, died on the Magellan rig in October 2000.

He had been an assistant derrickman on the rig - operated by Global Santa Fe - which was working in the Franklin field 130 miles east of Aberdeen.

The accident happened when Mr Moffat, 41, was working on a winch.

He was pulled into an area described as the "mousehole" - a space of only 10 inches in diameter - and was crushed to death.

In his inquiry determination, Sheriff Kieran McLernan said there were significant failures in the system of work which directly contributed to the cause of the accident.

Learn lessons

The primary cause was the almost total lack of proper supervision.

The sheriff noted that Global Santa Fe had implemented new procedures but said a complete change of attitude was needed.

He said consideration must be given to reviewing the whole supervisory system.

Reacting to the report, Mr Moffat's father Tom said the family were still extremely angry at the failures which led to their son's death.

However, he hoped the industry would now learn lessons which would prevent similar tragedies.