Investigations into the death of a paper mill worker uncovered "crucial failings" in risk assessment, the Health and Safety Executive (HSE) said.
Dean Thomas, 42, was crushed to death at the former JR Crompton plant in Lydney, Gloucestershire, on 3 May 2003.
The company has since gone into administration and been bought by a firm unconnected with the death.
After a court case, in which the former owners were fined £200, the HSE said many safety issues had been overlooked.
Home-made tools
Mr Thomas was re-setting a machine which rolls paper, when an untrained co-worker pressed the wrong button, causing an hydraulic table to close on him.
The HSE said the company had not carried out a suitable and sufficient assessment of the risks of using the machine.
Inspectors also found home-made tools which workers used to reset the machine when they were inside it, a practice done with the full knowledge of the management.
"Given the frequency of access, the company should have realised that they were putting their staff in danger and altered the machine to prevent it working if anyone remained inside the enclosure," the HSE said.
At the court hearing, the judge told the former owners the fine would have been £250,000 had they still been in business.
A spokesman for R J Crompton said the company was unable to comment.
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